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2020 Tour: What do we mean by evidence?

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  • There are five top-level themes of the NCT strategy.‘Confident parents’ and ‘High quality information’ are the two themes most closely related to our commitment to be parent-centred and evidence-based.
  • Why does any of this matter? Let’s put into historical context the current state of knowledge about pregnancy, birth and maternity care, and why evidence-based information (and maternity services) are important. Some ideas from previous centuries or generations seem positively dangerous; others (such as some of the less invasive; more holistic approaches) seem surprisingly modern.All examples are taken from the chapter by Ann Oakley in the book cited, which is a really interesting read.
  • Maternity care as we know it today has a remarkably short history.One of the key drivers for providing antenatal care was to improve the quality of the army as a fighting force (not concern about mothers or babies). Developments have occurred in a number of developed countries at around the same time.All information taken from the chapter by Ann Oakley in the book cited.
  • There is some evidence of (a struggle between)different paradigms for care, associated with generally female professions of nursing/midwifery and male profession of medicine (social versus medical model), and in the 1920s between traditional community services and new antenatal clinics.Assumptions were made based on the dominant care paradigm. Research and examination of evidence enables us to question (and challenge) assumptions to develop services that meet strategic and policy objectives.There is evidence that some people felt that women should be consulted about maternity services as long ago as the 1930s. Yet the idea of ‘woman-centred care’ did not emerge as a mainstream government policy concept until the 1990s. Sixty years gestation!All information taken from the chapter by Ann Oakley in the book cited.
  • All information taken from the chapter by Ann Oakley in the book cited.
  • As well as the rise in medical antenatal care, the midwifery profession in the UK became protected by act of parliament (unlike in the USA where midwifery became illegal in many states during the 20th century)The creation of the NHS meant that all women could access care. Gradually major improvements in health were seen. General improvements in health and reductions in family size made a big impact, as did the introduction of sulphonamides and antibiotics. See Has the medicalisation of childbirth gone too far?The transfer of birth from home to hospital (assumed by the Peel and others) to improve outcomes, is still the subject of new research and debate. Information taken from:1] Ann Oakley (1982) ‘The Origins and development of antenatal care’ in Enkin M and Chalmers I (eds.) Effectiveness and satisfaction in antenatal care. Spastics International Medical Publications2] Johanson R, Newburn M, Macfarlane A. Has the medicalisation of childbirth gone too far? BMJ 2002;324(7342):892-5.3]Birthplace in England Collaborative Group. Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ 2011;343:d7400. http://www.bmj.com/content/343/bmj.d7400 
  • The idea is to use published, high quality, scientific evidence alongside the knowledge of the practitioner and the values of the person receiving the service.This applies to education services as well as to clinical care.
  • There needs to be a balance between the use of scientific evidence - from social science and medicine, epidemiology or other clinical studies - and the practitioner’s knowledge and judgement about how evidence on populations of people might apply to local circumstances and individual parents/patients.
  • The evidence-based medicine movement started as a radical, critical movement which challenged established medicine. It has become more mainstream but it is fundamentally progressive as it is based on questioning and asking how do we know, what we believe to be knowledge. However, it does believe that it is possible to establish useful and reliable evidence about the nature of the world, and that some forms of knowledge are more robust than others.
  • The randomised controlled trial is a robust way of assessing the effectiveness of ‘interventions’, such as screening programmes or treatments (surgery, drug treatments or some talking therapies). Complex social interventions such as education or support programmes, or self-hypnosis can be assessed with RCTs but there are more methodological challenges. RCTs can also involve qualitative research to explore the experiences of people receiving treatment/care – and/or of the staff providing care.
  • Iain Chalmers, is a good friend of NCT and spoke at several of our conferences in the 1980s and 1990s when he was working on Effective care in Pregnancy and Childbirth.NCT researchers have been involved with the National Perinatal Epidemiology Unit at Oxford ever since, and have links with many other researchers and research units.The Cochrane Collaboration is now the home of reviews of evidence not only for maternity care and but all aspects of healthcare, aspects of social care and education.Sir Iain has gone on to set up the James Lind Alliance.
  • Transcript

    • 1. What do we mean by evidence? Mary Newburn Head of Research and Information, NCT
    • 2. NCT 2010-2020 Strategy themes Confident parents Supportive services Positive image of parenthood High-quality information An efficient organisation.
    • 3. High-quality informationNCT aims include:• To create and provide more parent-centred information about the transition to parenthood• To ensure our public health information is evidence-based, non-judgemental and user- friendly
    • 4. Confident parentsNCT aims include:• To publicly champion the benefits of well-supported and informed parents.• To improve our social and geographical reach…• To tailor our multi-channel support, including web- based and telephone services, to ensure that parents get the information they need, when they need it.• To enhance our baby feeding information and services providing information focused on parents’ needs…
    • 5. This talk includes• A look at the history of maternity care and the use (or otherwise) of evidence.• What is ‘evidence-based medicine’ or evidence- based healthcare, or education?• Midwifery and social science research• Feedback form the ‘train and meet’ sessions• Opportunities to find out more about evidence.
    • 6. History• Antenatal care is less than 100 years old. J W Ballantyne: ‘founding father of antenatal care’ interested in ‘the prevention of monstrosities’• 18th C spearmint and opium were prescribed for vomiting. Laxatives and keeping the feet warm also popular remedies. Meat was considered dangerous. Cheerful disposition important for optimal fetal development.• 19th C external palpation of the uterus during pregnancy first reported in The Lancet (1858). ‘Bleeding’ - ‘it is by no means rare for women to be bled six or eight times during the latter months’ (Playfair 1898).• 19th C One vaginal exam for the wealthy in the 7th month – opiates ‘and her labia rubbed with opium tincture and softened with linseed or starch fomentations’.Ann Oakley (1982) ‘The Origins and development of antenatal care’ in Enkin M and Chalmers I(eds.) Effectiveness and satisfaction in antenatal care. Spastics International Medical Publications
    • 7. History• Concern about the ill-health of the infantry. Only two-fifths capable 1902 Major General Maurice, ‘a matter of imperial importance’.• First British antenatal outpatients clinic opened in 1915 by Dr Ferguson in Edinburgh. The fetal heart was first heard in 1918 (through a corset, while listening for splashing!).• First antenatal clinic in Australia 1910 and the US in 1911.Ann Oakley (1982) ‘The Origins and development of antenatal care’ in Enkin M and Chalmers I(eds.) Effectiveness and satisfaction in antenatal care. Spastics International Medical Publications
    • 8. History• The Boston Lying-in Hospital offered extensive home visiting during pregnancy, every 10 days, initiated by the Instructive Nursing Association in 1901.• Sylvia Pankhurst lobbied for services that did not involve ‘the inevitable long wait’, ‘amidst a crowd’ (1930).• ‘In the development of the maternity services there is a special need for a close study of the woman’s point of view’ (Royal Commission on Population, 1949)• In 1915 an ‘incalculably small’ number of women received antenatal care but by 1935 this had risen to 80% of women (place not stated. Implies UK or England and Wales). But this care, lobbied for by the women’s movement after securing the right to vote, was based largely on assumptions. ‘(It was ) taken for granted that more medical care would reduce mortality’.Ann Oakley (1982) ‘The Origins and development of antenatal care’ in Enkin M and Chalmers I (eds.) Effectiveness and satisfaction in antenatal care.Spastics International Medical Publications
    • 9. Historical evidence on antenatal care • Positive step forward: The first ‘embryonic confidential enquiry’ on Maternal Mortality was published in 1924 by Dr Janet Campbell. • Assumption: Only 21% of women who dies had received any antenatal care and it was asserted that this would improve outcomes (i.e. reduce maternal mortality). • Progress? Later reports (1927, 1930, 1932) repeated the assertion about the importance of antenatal care, and the need to expand the antenatal work of maternity centres. • Evidence: ‘in 1933 the maternal mortality rate was seven per cent higher than in the previous year and 15 per cent higher than 20 years previously’ (Holland 1935). Use of induction of labour and caesarean section had increased and often led to poorer outcomes for women. ‘Antenatal supervision in many cases simply transfers mortality from one column to another’ (Browne, 1932). Ann Oakley (1982) ‘The Origins and development of antenatal care’ in Enkin M and Chalmers I (eds.) Effectiveness and satisfaction in antenatal care. Spastics International Medical Publications
    • 10. Historical evidence on antenatal care • The Midwives Act 1902 ‘to secure the better training of midwives and to regulate their practice’. • From 1948 the services of a midwife and a doctor were available; without charge. • Hospital birth rate 35% in 1937, 65% in 1957, about 95% today.
    • 11. Evidence based medicineThe last 20 years has seem the development of the ‘evidence-basedmedicine’ or ‘evidence-based healthcare’ movement.‘Evidence based medicine is the conscientious, explicit, and judicioususe of current best evidence in making decisions about the care ofindividual patients’Evidence based medicine: what it is and what it isntDavid L Sackett, William M C Rosenberg, J A Muir Gray, R Brian Haynes, W Scott RichardsonBMJ 1996. http://www.bmj.com/content/312/7023/71.full
    • 12. Good medical practice‘Good doctors use both individual clinical expertise and the bestavailable external evidence, and neither alone is enough.Without clinical expertise, practice risks becoming tyrannised byevidence, for even excellent external evidence may be inapplicable toor inappropriate for an individual patient.Without current best evidence, practice risks becoming rapidly out ofdate, to the detriment of patients.’Evidence based medicine: what it is and what it isntDavid L Sackett, William M C Rosenberg, J A Muir Gray, R Brian Haynes, W Scott RichardsonBMJ 1996. http://www.bmj.com/content/312/7023/71.full
    • 13. Individual clinical expertise involves…. ‘…thoughtful identification and compassionate use of individual patients predicaments, rights, and preferences in making clinical decisions about their care.’Evidence based medicine: what it is and what it isntDavid L Sackett, William M C Rosenberg, J A Muir Gray, R Brian Haynes, W ScottRichardsonBMJ 1996. http://www.bmj.com/content/312/7023/71.full
    • 14. Prof Archie Cochrane • The evidence-based medicine movement started as a radical, critical movement which challenged established medicine. • "I knew that there was no real evidence that anything we had to offer had any effect on tuberculosis, and I was afraid that I shortened the lives of some of my friends by unnecessary intervention."
    • 15. Prof Archie Cochrane • His advocacy of randomized controlled trials eventually led to the development of the Cochrane Library database of systematic reviews, the establishment of the UK Cochrane Centre in Oxford and the international Cochrane Collaboration.
    • 16. Sir Iain Chalmers • Effective care in Pregnancy and Childbirth (Chalmers, Enkin and Keirse, 1989) and the Guide to Effective care in Pregnancy and Childbirth • Founder of the Cochrane Collaboration, now with 30,000 volunteers contributing . • James Lind Alliance, ‘aims to identify the most important gaps in knowledge about the effects of treatments’.
    • 17. Sir Iain Chalmers ‘Decisions to use or withhold interventions in health care, social care and education should take account of findings in systematic reviews of relevant and reliable research evidence. Continued failure to do this will result in continued avoidable suffering and death, and waste of resources.’Sir Iain ChalmersWhy are systematic reviews of research on the effects of policies and practices so important?Tuesday 28 September 2010, Old Sessions House, North Holmes Campus, Canterbury
    • 18. Prof Mary Renfrew • There are also midwife researchers who have made a major contribution to knowledge about the transition to parenthood and topics of prime importance to NCT. Professor Mary Renfrew is one example. • Breast feeding and child behaviour in the Millennium Cohort Study (2011) • Men and Infant Feeding: Perceptions of Embarrassment, Sexuality, and Social Conduct in White Low-Income British Men (2011) • Factors influencing the infant feeding decision of socioeconomically deprived pregnant teenagers: The Moral Dimension (2010) • Breastfeeding promotion for infants in neonatal units: a systematic review (2010)
    • 19. Prof Jane Sandall • Professor Jane Sandall is another. • Individual or group antenatal education for childbirth or parenthood, or both, In: Issue 3, The Cochrane Library (2007) • Understanding the social organisation of maternity care systems: Midwifery as a touchstone, Sociology of Health and Illness, 27,6:722-737.
    • 20. Professor Jo Green • Professor Jo Green is a social scientist whose contribution to knowledge on maternity care and the effects of behaviour has been considerable. • Screening for postnatal depression - is it acceptable to women and healthcare professionals? A systematic review and meta- synthesis. Journal of Reproductive and Infant Psychology 2010; 28(4): 328-3 • Converting policy into care: womens satisfaction with the early labour telephone component of the All Wales Clinical Pathway for Normal Labour. J Adv Nurs 201144
    • 21. ‘train and meet’ sessionsAn opportunity forconsultation - about NCTworkers’ views about, andcommitment towards, the aimof being both parent-centredand evidence-based.Thank you – It is good to knowthat there is an overwhelmingcommitment to this approach.
    • 22. ‘train and meet’ sessionsAn opportunity forevidence-gathering regarding• NCT workers’ competence and confidence in using evidence in different circumstances• Perceptions of individual’s strengths and barriers• Opportunities and the obstacles in the organisation• Training and support needs of NCT workersThank you and watch thisspace. … To find out aboutjournal club contactselina.nwulu@nct.og.uk
    • 23. ‘train and meet’ sessionsAn opportunity for training –• sharing experiences and good practice among the delegates• introduction to different types of scientific evidence and what is meant by ‘effectiveness’.
    • 24. What does NCT mean by evidence-based?NCT plans to• Set standards and develop guidance for the NCT group regarding the quality and range of evidence, and key evidence sources, which should be used.• For further information contact research@nct.org.uk or nctlibrary@midirs.org.uk