Onderzoek ontmoet praktijk Evidence meets practice Helen Spiby Mother and Infant Research Unit University of York, UK 11 th December 2007

Where evidence meets experience PLAN Overview EBP process Identifying research questions from midwifery practice Early Labour Support & Assessment trial Suggest ways to increase midwives’ involvement in evidence based practice

The three elements of evidence-based health care Evidence-based healthcare

Evidence Based Practice in Midwifery Why? Best possible care & outcomes Ethical imperative Reduce variations in practice Efficient use of finite resources Professional accountability Women & families as partners

Alternatives to Evidence Based Practice Opinion-based practice Custom Interventions implemented/ practice changes without a strong evidence base

Procedures : evidence of harm/mixed effects/no clear evidence/evidence applied inappropriately Supplementation with formula for breastfed babies Routine rupturing of membranes Not suturing second degree tears Placing babies prone to sleep

Overview of the EBP process Identifying questions from practice Locating the evidence Critically appraising the evidence Utilisation in practice Evaluation & reflection

Identifying questions from practice Formulating the question: PICO Population Intervention/exposure Comparison Outcome

Identifying questions from practice: PICO Population - description of a similar group of women/babies

Identifying questions from practice: PICO Intervention –treatment –therapeutic intervention –screening –diet

Identifying questions from practice: PICO Comparison –alternative option –control/current treatment

Identifying questions from practice: PICO Outcome –clinical : wellbeing enhanced –organisational –economic

Relating questions to research methods Effectiveness of treatment: systematic reviews/ randomised controlled trials Effect of environmental factors on health: cohort & case control studies Women’s experiences : qualitative (interviews) & quantitative (questionnaire surveys)

Locating the evidence: Evidence Based Healthcare: Resources Pre-synthesized information E.g. systematic reviews, evidence summaries; higher quality clinical guidelines (NICE); Practice Standards (KNOV) Cochrane Reviews Individual studies

Critical appraisal Was an appropriate research method used to answer that question? Is the research described comprehensively? Was the context relevant? Resource: CASP

Critical appraisal Is there a clear focus to the research question? Appropriate allocation between groups? How were outcomes measured? What is the risk of bias? How are results presented? Valid conclusions?

Identifying questions from practice: some examples Are there midwifery practices that prevent perineal trauma ? What are women’s experiences of labouring in water ? Should women in early labour receive midwifery care at home ?

Practices: impacts unknown & evidence required When should support start once women are in labour? What information do women need in early labour? What is the appropriate schedule for vaginal examinations in early labour?

Asking questions about effectiveness Impacts at individual level Improvements in physical/ emotional wellbeing Consequences/ side-effects Uptake/ acceptability

Identifying & measuring outcomes Clearly defined & interpreted consistently Valid & reliable methods of measurement Risk of bias minimised

The Early Labour Support and Assessment trial (ELSA) Funded by: NIHR Service Delivery & Organisation of Care programme Conducted by: a midwifery-led multi- disciplinary research team

Arriving at hospital early- more intervention during labour; higher rate of instrumental & operative births 10-33% women admitted to a delivery suite are not in labour 97% births in UK in hospital Caesarean Section rate 22%: national concern 40%-50% first babies born by CS/ instrumental birth in Yorkshire in 2001 Background (1)

Critical appraisal of existing research: Methodologically prone to bias Settings unrepresentative of current UK maternity care Home visits not tested as a single intervention Background (2)

Aim & Research design To determine the effect of offering home visits by a midwife to nulliparous women in early labour Using A multi-centre randomised controlled trial with cost-effectiveness analysis

Intervention Offer of a home visit by a community midwife ( ) Advice & support, assessment of wellbeing & progress Control Group Standard care - telephone contact with labour & delivery suite; advice to attend for assessment

Outcomes Primary: Caesarean section in labour & instrumental vaginal birth Secondary: Impacts on labour: length, pain relief, procedures Maternal & neonatal complications Breastfeeding Women’s emotional wellbeing & experiences of care Health professionals’ views & experiences Economic analysis

Timetable & progress Recruitment August 2004 – July participants; 11 clinical sites in England Analysis in progress; Final report March 2008 Active dissemination to all stakeholders Conference September 2008

Workshops Please divide into 4 groups Work in small groups Identify a writer, work through the task; hand notes to facilitator

Workshops Identify an issue from practice that you encounter nearly every day with your students & develop a research question- Using the PICO framework Which type of research would answer that question?

Challenges to EBP in midwifery Access to & quantity of evidence Providing women with evidence Changing professional practice

Consistently effective: Educational outreach visits Manual/computerised reminders Multifaceted interventions Interactive educational meetings Haines A. (2001) Getting research into practice. 2nd ed. London: BMJ

Changing professional practice Mixed effects: Audit & feedback Local opinion leaders Local consensus processes Patient-mediated interventions

Evaluation & reflection Evaluation - early, under-resourced, methodologically weak Reflection- individual & system-based approaches

Evidence based practice in midwifery: making it happen Throughout midwifery –policy, education, practice; avoid divisions Education & skills Building capacity Infra-structure support

Core skills & attitudes for EBP in midwifery Formulating questions about practice Ability to locate evidence Skills in critical appraisal Ability to collaborate & lead research Implementation knowledge

Evidence based practice in midwifery: making it happen Build capacity by creating opportunities Secondments- clinical midwives join research teams ; mentorship Joint appointments – shared funding between academic & practice settings Academic midwifery practices How do we involve midwifery students?

Evidence based practice in midwifery: making it happen Build capacity by creating opportunities Career pathways Academic development funding streams What opportunities are there for you ?

Opportunities- in the Early Labour trial Midwifery Research Fellow –PhD Local Midwifery Co-ordinators – 10 midwives, part –time, working in practice Midwives : investigators, all Trial Committees & working groups 2 Midwives seconded into MIRU working on the trial

Evidence based practice in midwifery: making it happen Infrastructure support Identify existing systems that could foster EBP e.g. Journal clubs ; academic assessments Information specialists Link activity to policy, professional & public health priorities Develop skills in acquiring funding National & international collaborations

Evidence based practice in midwifery: making it happen Identify support systems Engage stakeholders Set achievable goals, celebrate early success Evaluate & disseminate all experiences