2020 Tour: What do we mean by evidence?

What do we mean by evidence?

Mary NewburnHead of Research and Information,

NCT

NCT 2010-2020 Strategy themes Confident parents

Supportive services

Positive image of parenthood

High-quality information

An efficient organisation.

High-quality information

NCT 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

Confident parents

NCT 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…

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.

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

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

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

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

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.

Evidence based medicine

The last 20 years has seem the development of the ‘evidence-based medicine’ or ‘evidence-based healthcare’ movement.

‘Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients’

Evidence based medicine: what it is and what it isn'tDavid 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

Good medical practice

‘Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough.

Without clinical expertise, practice risks becoming tyrannised by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient.

Without current best evidence, practice risks becoming rapidly out of date, to the detriment of patients.’

Evidence based medicine: what it is and what it isn'tDavid 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

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 isn'tDavid 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

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."

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.

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’.

Sir Iain Chalmers

Sir Iain Chalmers Why 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

‘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.’

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)

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.

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: women's satisfaction with the early labour telephone component of the All Wales Clinical Pathway for Normal Labour. J Adv Nurs 201144

‘train and meet’ sessions

An opportunity for

consultation - about NCT workers’ views about, and commitment towards, the aim of being both parent-centred and evidence-based.

Thank you – It is good to know that there is an overwhelming commitment to this approach.

‘train and meet’ sessions

An opportunity for

evidence-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 workers

Thank you and watch this space. … To find out about journal club contact [email protected]

‘train and meet’ sessions

An opportunity for

training – • sharing experiences and

good practice among the delegates

• introduction to different types of scientific evidence and what is meant by ‘effectiveness’.

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 [email protected] or [email protected]