How to Present Evidence-based Midwifery Care Like a Pro

by Melissa Garvey, ACNM Writer and Editor

This week we launched an exciting project that has been in development for more than a year. Evidence-Based Practice: Pearls of Midwifery is a professionally developed presentation featuring nearly 100 fully referenced slides to assist midwives and their advocates (expectant moms, active dads, other health care providers, everyone!) in explaining the science and art of the midwifery maternity care model. Designed to showcase the evidence-based foundation of midwifery practice, Pearls of Midwifery emphasizes the proven benefits of physiologic labor and childbirth for mothers and their newborns.

Pearls of Midwifery is a long-overdue resource. In the words of ACNM President Holly Powell Kennedy, CNM, PhD, FACNM, FAAN, “Despite the recent plethora of information on evidence-based maternity care practices, there continues to be an underuse of many beneficial interventions while some harmful practices persist. We must continue sharing the evidence with our clients and other health care providers to ensure that all women receive the safest and most effective maternity care.”

Evidence-Based Practice: Pearls of Midwifery includes suggested speaking notes for each slide and a checklist that can be printed and shared.

Pearls of Midwifery is free to ACNM members and available for nonmembers to purchase in the ACNM Live Learning Center for just $69. Where do you plan to use this new resource?

ACNM Responds to ACOG’s 2010 VBAC Recommendations

On July 21, 2010, the American College of Obstetricians and Gynecologists (ACOG) released a revised practice bulletin on vaginal birth after previous cesarean section (VBAC). Today, ACNM released its response to the revised practice bulletin. Read on for an excerpt from the response, or read the full statement here [PDF].

ACNM’s philosophy is that all women—including those who have had a prior cesarean birth—should have access to information, counseling and birthing options provided by vigilant, skilled clinicians within a coordinated maternity care delivery system. While integrated resources should be made available in all settings, immediate access to emergency delivery solely to safeguard against the potential risks associated with TOLAC (trial of labor after cesarean) should not be the focus. Rather, risk associated with TOLAC should be considered within the spectrum of perinatal benefits and risks associated with nulliparous women in labor. Uterine rupture, a rare, often unpredictable complication of both trial of labor after cesarean as well as repeat elective cesarean delivery, is a primary factor underlying the ACOG recommendations. Yet the risk of uterine rupture associated with TOLAC is similar statistically to that of other obstetrical emergencies for a woman experiencing her first birth. Furthermore, it should be noted that the benefits of labor and vaginal birth are often omitted from this discussion. The focus is exclusively on risk, which does not yield a complete picture. Provided with the latest evidence and comprehensive counseling, women must be allowed to make decisions regarding TOLAC and give birth in the settings that best meet their individual needs. It is unclear how these fully informed women will be at liberty to choose a TOLAC when facilities continue to refuse them this option, claiming compliance with the 2010 ACOG guidelines.

ACOG’s 2010 practice guidelines may help to expand access to TOLAC for women with certain clinical presentations. However, ACOG’s continued recommendation that TOLAC be undertaken at facilities capable of immediate emergency deliveries virtually assures that the 2010 guidelines alone will fail to appreciably increase access to TOLAC and VBAC in the U.S. The NIH VBAC consensus statement recommends that “hospitals, maternity care providers, health care and professional liability insurers, consumers and policymakers collaborate on the development of integrated services that could mitigate or even eliminate current barriers to trial of labor” (p. 37). Only a long-term, system-wide, concerted effort based on quality evidence and further research in all settings will accomplish this goal. ACNM welcomes this important and necessary collaboration.

Read more [PDF]

Access to Midwifery Care Improves Maternity Outcomes

by Tina Johnson, CNM, MS, ACNM Director of Professional Practice & Health Policy

The Patient Protection and Affordable Care Act will bring millions of newly insured citizens into the health care system. In order to meet the country’s needs, leaders are calling for high value, evidence-based solutions. Let’s start with the health condition that affects 100% of all Americans...childbirth! How can we provide high quality, high value maternity care for all women and families? The answers are in the evidence: midwifery care improves maternal and newborn outcomes and patient satisfaction, reduces health disparities, and saves money and resources.

The U.S. grossly outspends every other nation per capita on health care, yet our maternal and newborn outcomes lag far behind those of other developed nations. Childbirth is the number one reason for hospitalization, and its related hospital charges surpass those of any other health condition. Resource-intensive interventions like labor induction, epidural analgesia and cesarean section are overused, often without indication or consideration of alternatives, resulting in increased risk of maternal and newborn harm.

Cesarean section is the single most common operating room procedure in the U.S., and the rate is steadily climbing. Incredibly, in 2007, nearly one-third of American women delivered their babies by cesarean section. Maternal mortality has risen dramatically, and glaring racial disparities in maternal and neonatal outcomes persist.

How can we reverse these disturbing trends? Ensure that all women have access to maternity care providers and practices that support the normal processes of birth. Labor support, freedom of movement, intermittent monitoring, alternative birth settings, vaginal birth after cesarean...all have been identified as evidence-based practices that are underused.

Midwives truly are the experts in supporting healthy vaginal birth in all settings. Midwives caring for low-risk women improve infant mortality rates in both hospitals and birth centers when compared with physicians caring for equally low-risk women. Midwife-led models of group prenatal care reduce preterm and low birthweight rates and improve patient satisfaction. Birth centers provide improved outcomes for even the most at-risk women, reducing preterm birth, low birthweight and cesarean section rates, and reducing costs to our health care system. Skilled midwifery care is the gold standard among nations with the best maternal and neonatal outcomes, and has been identified as essential to reducing maternal mortality worldwide.

It’s time to bring that message back home. The time is now to promote and support midwifery in America—and to follow the evidence.

This post was originally published on the the Center to Champion Nursing in America (CCNA) blog. Visit CCNA to join more conversation about this post.

Evidence in Action at Midwife Connection

by Melissa Garvey, ACNM Writer and Editor

We’ve been pretty silent at Midwife Connection lately, but this week we’re getting back to normal. Yolanda Landon, our communications manager, is back from maternity leave with baby Kennedy in tow (yes, ACNM has the best mother-friendly, baby-friendly work policies I’ve ever encountered!), and we’re gearing up for the ACNM 55th Annual Meeting scheduled for June 12 – 16 right here in Washington, DC. In honor of this year’s theme—Midwifery: Evidence in Action—let’s kick off the week with another post in Andrea Lythgoe's excellent “Becoming a Critical Reader” research series.

Becoming a Critical Reader: The Five Basic Questions

by Andrea Lythgoe, LCCE (Originally published on Science and Sensibility for Lamaze International)

Since it has been a while since we’ve had any articles in this series, you may want to refresh your memory by rereading the first and second installments in the “Becoming a Critical Reader” series. I promise it won’t be so long of a gap before the rest of them!

OK, having reviewed and identified your own personal biases, you are ready for the second read-through, where you can more critically read the article. We’ll spend the next few posts in this series going through the various types of articles and the things you’ll want to consider when doing this more critical reading. Some questions will be pretty universal, no matter what type of article you are reading. Others will be more specific to the various types of articles. We’ll cover those specific questions over the next few posts.

The basic questions to ask as you read:

1. What did the authors set out to do? Hopefully you’ve already figured this out in your preliminary run through. If you’re not clear on that, make that the first thing you look for. When you find it, write it down so you don’t lose sight of that aim in the remainder of your reading.

2. Did the article really do what it set out to do? Look for the “conclusions” or “results” sections to see what the authors say about a study. Sometimes what is written here will have nothing to do with their original intent. Not that this makes the conclusions invalid, because sometimes studies do make important and interesting discoveries in tangential information. Ideally, the authors should at least address the original aim of the study, even if it was to say “we did not find what we expected to find.”

NOTE: This question is NOT the same question as “Did the study show what I think it should have shown” or “Did the study look at what I wanted it to study?” Sometimes I hear people disparage a study by saying “They looked at the wrong thing! Instead of studying ‘when is the best time to do an induction?’, they should have studied whether to do them at all!” This is unfair. The study is no less valid because it addresses a different issue than you would have chosen to research. The question is “Did they do what they set out to do?”

3. Did the article use appropriate methodology? Some methods might not be a good way to study a particular question. Other methods might be a better approach. While some are fond of saying that only a double-blinded, randomized controlled trial can give you sufficient answers, it’s not always realistic or ethical to do research in this way. We’ll go more into detail on that in our next series on methodology, so don’t worry if you don’t know enough to make a good judgment on this aspect right now.

4. Did the author show undue bias or influence? Many studies will have a disclosure on the first or last page of a study that tells who paid for the study or if the researcher has any conflicts of interest. While I wouldn’t necessarily dismiss a study because of a potential conflict of interest, I certainly would be using a VERY fine-toothed comb in my perusal of the study!

5. Do the conclusions match the data? Sometimes there is a pretty obvious mismatch between the two. I once read a study where the author concluded that a vaccine for GBS would save lives. However, the aim of the article was to find out if prenatal screening for GBS would reduce the incidence of serious GBS infections. Vaccines were not mentioned anywhere in the article, except in the conclusions area. It seemed an obvious mismatch to me.

Sometimes the mismatch might be more subtle. This is why you’ll want to jot down that answer to the initial question, “What did the authors set out to do?” At this point, go back and see if both their data and conclusions answer that.

These five questions are a good place to start as you review articles. I suggest that you take some time this week to find the full text of a study and read through it, answering these questions as you go.