EBB 2 – What is Evidence Based Care?

Dr. Rebecca Dekker – 00:02:10:

Hi everyone, in this video, I’m going to answer the question, what is evidence-based care? Welcome to the Evidence Based Birth® Podcast. My name is Rebecca Dekker, and I’m a nurse with my PhD and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details. So welcome to this episode of the Evidence Based Birth® Podcast, episode number two, what is evidence-based care? In the very first episode, we talked about how I started Evidence Based Birth® and how I got into writing about the research on childbirth. Now today we’re going to answer the questions, what is evidence-based care? Is evidence-based care a specific way of giving birth? Is it a checklist? Can you even define it? What is it and what is it not? 

Well, first, let’s talk about the old way of doing things in medicine. It used to be, in the old days, that medicine was practiced entirely on a doctor’s clinical opinion, their experience as a doctor, and their unsystematic observations. I’ll give you an example of something that I read from a 1950s obstetric journal. A physician was writing an article about how he decided to manually remove a woman’s placenta. In other words, after the woman gave birth, he physically reached up with his hand into the woman’s uterus and removed the placenta with his hand instead of letting it be delivered naturally. He said, this went well, so I decided to do it with all of my patients. 200 births later, he wrote, quote, “This is a safe and beneficial practice,” end quote. This clinical decision that he made to remove the uterus with his hand was based on his opinion, his experience, and his really unsystematic observation. Because although he said everything went really well, he did not actually record the complication rates that happened with this practice. And he did not compare this practice with the health outcomes of other women who did not receive the same practice of manual removal of the placenta. We now know today that this practice, manual removal of the placenta, is not something that should be done with a normal, uncomplicated birth, as it is extremely painful and can cause complications. 

Now, before you think this kind of practice was exclusively in the realm of doctors, we also used to see similar things happening in midwifery. For example, some of the older midwifery textbooks talk about giving women enemas, giving them something to make them have a bowel movement at the start of labor. And so this was something that was done just based on opinion and unsystematic observations, not based on the research. Another example that we still see today is when a hospital system might require everyone who’s having an induction to have their membranes ruptured or their waters broken early on in the induction process. And they may say, well, this is to keep you and your baby safe without specifically digging into the clinical research on how often does this cause infections? How often does this cause complications? So, whenever people are using kind of non-recorded clinical experience as their, quote, rationale for why they’re doing something, instead of also looking at the research evidence or even looking at their own statistics to see if they are doing this safely. 

The term evidence-based medicine was first used in the year 1990 in a residency training program for new doctors in Canada. However, although doctors were the first to use the term evidence-based medicine, I want to point out that Florence Nightingale, the legendary nurse who started using statistics to help base medical and nursing decisions, was back in the 1850s. When Florence arrived at a British military hospital in Turkey in 1856 during the Crimean War, the mortality rate for soldiers who were injured was sky high. Florence Nightingale began documenting the statistics, and she used the evidence she collected to show that the poor sanitation in the hospitals and the poor sanitary practices were the reason for so many deaths during that war. And she ended up using that evidence to guide changes in practice that saved many lives. While we’re talking about Florence Nightingale, I also want to acknowledge her peer, Mary Seacole. So many people, when they’re asked to name the most famous nurse in history, they will mention Florence Nightingale’s name. But Mary Seacole, a Jamaican nurse and doctoress, also paved her own way to the Crimean Front after being told, we don’t need you here. She also did a ton of work to save lives during that time. And she was well-loved during her time period, but ignored by historians until about the 1980s. Many people scoffed at her work because she published a memoir instead of research pamphlets like Florence Nightingale did. 

Making matters more complex, Mary, as a multiracial woman, showed colorism against those who were darker skinned than her. One article that has really helped me over the years as I dive deeper into evidence-based care is Tima Okun’s article on white supremacy culture found at dismantlingracism.org. Okun explains that part of white supremacist culture is, quote, worshipping the written word. In other words, if it’s not in a memo, it doesn’t exist. Florence Nightingale published extensively her research, while Seacole did not. But just because Mary Seacole did not publish extensively on her nursing practice does not mean that it did not exist or was not impactful. This type of toxic culture also values either-or thinking, categorizing people as either good or bad. In other words, it would be easier for historians to acknowledge and celebrate Seacole’s work as a care provider if she did not have a complex existence as a human in her time period. Rather than engaging with that tension, people have ignored Mary Seacole altogether. One of the critiques I’ve seen of evidence-based care is that it ignores the type of knowledge, wisdom, and skill that Mary Seacole brought to wartime nursing care. But I think one of the amazing things about evidence-based care is it brings together both the science, the data, and the art of human healing together. And I’ll talk more about that in a minute. 

So fast forwarding to the 1990s, and doctors in Canada at a medical residency program were using the term evidence-based medicine in their informational document. The first time they used the phrase, they said, quote, the goal is to be aware of the evidence on which one’s practice is based, the soundness of the evidence, and the strength of inference that the evidence permits, end quote. In 1991, these same physician educators in Canada linked up with physicians in the United States to form the first international evidence-based medicine working group. Together, they published an article that described evidence-based medicine, and they said that this was a complete shift away from the traditional way of practicing medicine. In the traditional way of practicing medicine, intuition, unsystematic experiences, and understanding the physiology of the body are how all medical decisions are made. None of these are bad things in and of themselves. But the shift towards evidence-based care means that we now also understand the importance of using evidence from scientific research. Now, doctors and midwives and nurses can still use their intuition and their clinical experience. They just now also include research evidence in their practice. 

In 1996, Dr. David Sackett, an American-Canadian medical doctor and a pioneer of evidence-based medicine, published a classic book about evidence-based medicine. In this book, which is about the size of my hand, but it packs a really big punch, Dr. Sackett writes that evidence-based care is the integration of best research evidence with clinical expertise and the patient’s values. So this means evidence-based care is like a triad or like a three-legged stool. It includes number one, access to the best research evidence. Number two, access to an experienced care provider who has experience and expertise. And number three, the patient’s goals, values, and preferences. And you need all three legs of these tools to make evidence-based care. In other words, evidence-based care is having full, accurate information, evidence-based information that helps you make decisions, being cared for by a trained provider who pays attention to that evidence, and care that is tailored to you. So let’s take a look at the first leg of that three-legged stool, and that is research evidence. One of the important things that a lot of people don’t realize is that there are different levels of evidence. And if you’re watching on YouTube, I will show you an image of one person’s rendition of those levels of evidence. Researchers have tried to rank evidence in order from highest level to lowest level. And these rankings are a little controversial, but in general, systematic reviews tend to be considered the highest level of evidence. Although these reviews are filtered through someone’s viewpoint, somebody has to decide which studies go into the review. So systematic review is when a researcher combines information from many different research studies. And if the data are also combined and a statistical analysis performed, then that kind of systematic review is also called a meta-analysis. 

The pros of this kind of study are that it can be much more powerful than individual studies because we can get a bigger number, more people to look at, especially when we’re studying rare conditions. The main con of the systematic review is it’s only as good as the studies it includes. One saying is garbage in, garbage out. If a meta-analysis included a rotten apple or two in the combined data analysis, then the overall results might be rotten. Now, usually the author will rate the quality of the studies that they included so the reader can know up front the quality of the studies that went into the systematic review. However, I will say that here at EBB, sometimes when I’m reading a systematic review, if I have questions about how deeply the researchers reviewed the research, sometimes I’ll pull the original studies that they put into the review, and I may find major quality issues that the reviewers missed. Sometimes I don’t, but sometimes I do. And in that case, you can’t really trust the results of the systematic review. I give an example of a scenario like this in episode 216 of the EBB podcast when I look at research on the evidence on prenatal perineal massage for preventing tears. And in that episode, I give examples of how fraudulent studies made their way into a systematic review. The next level of evidence comes from randomized controlled trials. Now, in a randomized controlled trial, it’s an experiment. And in this experiment, typically one group receives usual care or some kind of placebo. And the other group receives a new treatment. Now, the participants in these studies are randomly assigned into one of those groups. So it’s sort of like flipping a coin. And you don’t know ahead of time which group each person is going to put into. And then the researchers can compare the two groups before and after the intervention was given. The fact that people were randomly assigned to the groups controls for potential differences between the groups. 

For example, randomized control trials on doula care, this is an important example of why we need control. Some people may say, “Well, people who choose to have a doula are more likely to have a vaginal birth because they’re more motivated to have a vaginal birth.” And that may be true in the general population. But in a randomized control trial, people were randomly assigned to have a doula or not. So their preferences and their motivations should be equally balanced between the two groups. Another thing to know about randomized trials is that often they’re blinded. Blinding in a randomized trial means that the patients or the clinicians or the researchers, or sometimes all three, don’t know which group each person was assigned to. And the code isn’t broken until after the study is over and the data have already been analyzed. This helps lessen bias in the study. However, it’s not always possible to blind people to which group they’re in because some treatments are very visible. For example, it is quite obvious if you were assigned to get into a tub of water or not. You can’t blind someone to that condition. There are some drawbacks to randomized controlled trials, although they’re often considered the gold standard. There are many childbirth interventions that simply cannot be randomly assigned. For example, people may have very strong feelings about whether they want a home birth or a hospital birth, and so they would never agree to be randomly assigned to give birth at home or in a hospital. Other researchers may have difficulty getting ethical approval for a study on a certain topic in childbirth because that treatment is already standard practice. Some randomized controlled trials are also too small to look at rates of rare complications, or they may be carried out in carefully controlled research settings that don’t translate to real-world settings, or the protocols that were followed in the research study might not be followed in a typical hospital setting in the real world. 

The next level of evidence moving down on the hierarchy is observational studies. As I said earlier, a lot of things in maternity care cannot be randomly assigned, and in those cases, we often turn to observational studies. A stronger type of observational study is a prospective study. That’s when you enroll someone in their pregnancy, and you follow them throughout labor and birth and hopefully afterwards for a while to find out what happens to them. You can remember this as pro meaning moving forward. So prospective study means we’re moving forward in time and following people through time. Now, although prospective studies are considered the highest quality of observational research, you might not always have a comparison group. For example, maybe there is a prospective study on water birth, and some of them don’t have a good comparison group because you have the water birth group, and then you might have the group that got out of the water. You could try comparing these two groups, but the group that got out of the tub might have done so because they were having complications or an extra long labor or a higher risk birth. So if you compared the water birth group to the group that did not give birth in the water, it’s like comparing apples to oranges. Today, researchers often use special methods to match people in one group to very similar people in another group, trying to make each pair of people very similar, except for the one thing that you’re trying to study. Retrospective studies are considered a lower quality of observational research. Retro means going backwards. So in this time, you’re looking backwards in time. Often these might be birth certificate studies or medical record studies. So you’re looking at a whole bunch of records to see what happened to a large group of people. The main drawback with retrospective studies is that limited data are available. For example, you might be trying to figure out, like, did this certain thing result in a higher number of babies being admitted to the NICU? But it might be difficult for you to understand exactly why they were admitted to the NICU because maybe those data were not collected on that specific medical record. So you’re limited by the data that were collected a long time ago. 

Another example of this is with birth certificates. When researchers use birth certificates in the United States to look at newborn health outcomes, the problem with this is that our birth certificates are not verified. There might be mistakes on them. Things might be miscategorized. They’re also typically anonymous. So you can’t go pull the medical record from the hospital to get more details about what happened. Going below observational research come case reports. And case reports are considered one of the lowest forms of research evidence. A case report is typically a report of a single event. Sometimes there’s more than one event. It’s typically a rare condition. And it might be something like a letter to the editor in a medical journal, or it could be a formal written case study where a provider writes up everything that happened to a specific patient and publishes it in a journal. I’ve seen case reports that are very good quality and some that are very bad quality. Some case reports are very useful. They’ll include a whole literature review of that subject so you can learn a lot from reading it. And they give a lot of details about what happened to that specific patient. It helps you learn more about that rare event and maybe how to prevent it in the future. One of the main drawbacks with case reports is that there’s no denominator. So what do I mean by that? Well, there’s a numerator. There’s the one case that happened. But we don’t know how common it is because we don’t know if that case was one out of a thousand or one out of a million. Then finally, we have medical opinion. Technically, medical opinion is considered medical evidence. However, it is the type of evidence that is most likely to be biased. It can be right and sometimes it can be wrong. And that’s because there is a certain amount of uncertainty in medical decision making. And although a doctor or midwife’s opinion is helpful, it’s not infallible. So like I already said, a provider could be right or they could be wrong. In this illustration, they also put medical guidelines at the top of the pyramid above systematic reviews. And although medical guidelines from professional organizations can be very helpful, you also have to remember that they’re filtered through the bias of the group that put together that guideline. So as a researcher, I never take the guideline as the truth. I see, what studies did they cite? What studies did they leave out? And I often will go and pull the actual studies that they used in their guideline to create their guideline and make sure that they were citing it appropriately. So these guidelines can be useful, but I don’t rely on them as certain truth. 

So that is the first leg of the three-legged stool, research evidence. Research evidence is really important. And as you could probably tell from our name here at Evidence Based Birth®, we love gathering and reading research evidence. But I want to give you a really important caveat about evidence-based care and research. And that is evidence alone is never enough to make a decision about your health care. When you’re making a decision about your care, you need to look at a variety of things, including the potential benefits, the potential harms, the costs, the convenience or inconvenience, and your values, goals, preferences, and intuition. You can also look at the expertise and skills and knowledge offered by your provider. 

And that’s that second leg of the three-legged stool. In my opinion, it’s so helpful and important to have a trustworthy care provider who is experienced in applying this research evidence to the specific situations of their client. And this leg of the evidence-based care is often ignored, either because people can’t find a care provider they trust or for whatever reason, they’re not open to talking with their care provider about the information that they’re gathering. Or perhaps they’re not open to talking with their care provider about the information they’re gathering during pregnancy. For example, a lot of people today think they can just use AI or social media to learn about pregnancy, childbirth, and postpartum, and they make decisions based on what they’re reading on these platforms. Or maybe they’ll find a citation to one specific research study, and they use that to make a decision about their health care. One of the reasons I love it when somebody has a trusted care provider they can talk with is because you can take what you’re reading online and the info you’re considering, and a good care provider would help you make sure that that information applies to your unique situation and that it is good quality information. They can also take it into context, including your holistic assessment of what’s going on with you and your body and your pregnancy at this time. Also, newsflash, AI can hallucinate. I have seen it make up birth info online, and now we also have a problem with fraudulent research being generated by AI and then being cited by AI when it’s giving people answers. So having a human being on your side who knows you and your clinical condition and can help you understand and verify research is invaluable. 

For example, even if you’re looking at information on the EBB website, maybe you look at the Evidence Based Birth® article all about the evidence on big babies, and you think, “Oh, I don’t need to do an ultrasound at the end of pregnancy to check for a big baby because that’s not evidence-based. That’s unnecessary.” But what if you have gestational diabetes and maybe it’s not under the best control with your diet? In that case, if you talk with your care provider and show them the evidence you’re looking at, they might be able to clarify, “Hey, the research that you’re looking at doesn’t apply to those with gestational diabetes.” So they can help you look at and gather research on gestational diabetes that’s more specific to your situation. 

Finally, the third leg of the evidence-based three-legged stool is the patient’s values, goals, and preferences. As I’ve already said several times, one of the core principles of evidence-based medicine is that evidence alone is not enough. And that’s because when evidence is used alone without any input from the patient that it’s impacting, it can become like a bad dictator. For example, if a hospital publishes a policy that says everybody needs to have high-dose pitocin, everybody needs to have their membranes ruptured as early as possible in an induction, and they don’t include alternatives or reasons why you might want to decline that and have a slightly different path in an induction, that is an example of misusing evidence. That’s because there’s no one single right decision for everybody, and everybody’s situation is slightly unique. Another example would relate to epidurals for pain management. Research has shown that epidurals are the most effective form of pain management during labor. However, for some people, their values, goals, and preferences or a unique medical condition might mean that they should try to avoid an epidural if at all possible unless it truly became medically necessary. Or you might have somebody who absolutely needs an epidural during labor based on their unique situation or their preferences. And you also might have some people who fall into a gray area where they need to weigh the pros and cons, and decisions may differ depending on who they are and what they have going on in that moment. Also, everyone has underlying biases that can affect our decision making. And a lot of the time, we’re not even aware of our own biases. There’s a great book out there called Your Medical Mind by Dr. Jerome Groopman and Dr. Pamela Hartzband. In their book, they describe the difference between doubters and believers, minimalists and maximalists, and naturalists and technology lovers. Some of you right now might be categorized more as a medical doubter. You might approach medical treatment or medical advice with skepticism. On the other hand, you might be a believer where you believe that there’s always a medical solution from your doctors for your problems. And a lot of times I have found that this type of underlying bias may come from experiences you had as a child, teenager, or young adult, where your personal experiences with the healthcare system either reinforced your belief in medical treatments or your doubts. 

Another category is the minimalist versus maximalist. So a minimalist is someone who would prefer to avoid medical treatment if at all possible, and they fall under the category less is more. So one example of a minimalist would be somebody who wants to avoid a labor induction if at all possible and would only induce if there was like an important health reason for an induction. On the other hand, a maximalist might be someone who wants to control risk as much as possible saying, “Do whatever you can to lower my risk to the lowest level.” So a maximalist might be somebody who would gladly accept an elective induction at 39 weeks in order to prevent the very rare risk of stillbirth, even though this has not been proven in clinical trials. And then you have naturalist versus technology lovers. A naturalist might be someone who believes that nature knows best, that you should leave the body alone and trust the inherent wisdom of the body, and that medications are unnatural and dangerous. Whereas a technology lover would believe that science, modern medicine, and technology are the answers. An example of a naturalist might be someone who believes that vitamin K is dangerous to their baby, even though the evidence does not back that up. A technology lover example might be someone who believes that continuous electronic fetal monitoring could save their baby’s life during labor, even though the evidence doesn’t back that up either. 

So as I’ve been talking, maybe you’ve been thinking about where you are on the spectrum. If you are pregnant or if you’re a birth worker or healthcare worker, where are you and your clients on the spectrum? Do your clients tend to be more doubters or believers, minimalists or maximalists, naturalists or technology lovers, or do most people fall in the middle? I’ve heard from a lot of people that they personally might be a maximalist or love technology in their personal life, but when it comes to birth and pregnancy, they have more of a minimalist or naturalist perspective. No matter where people are on their medical mind spectrum, it’s important for us to remember the three-legged stool. And remember that we still need to be providing people with evidence-based information. And respecting and valuing good quality evidence is something that I think most of us can find common ground on, no matter what our underlying biases are. Also, it might be important to think about whether or not your mind and your healthcare provider’s mind are a good match or a good fit. If you find yourself really falling strongly on the minimalist, naturalist side and your doctor is a maximalist technology lover, then it might not be the best fit when you get into a childbirth situation. 

So in summary, we’ve talked about evidence-based care being a three-legged stool. It’s having the most up-to-date, high-quality research evidence. It’s being attended by a care provider who pays attention to the evidence. And it’s about your care being tailored to you. And with that third leg of the stool, we have to keep in mind that everyone has biases. And it might be helpful to know your biases up front, as well as those of your care provider. What is evidence-based care not? Well, evidence-based care is not cookie-cutter care. It’s not assembly line care. It’s not everybody has to follow this policy care. It’s not having a care provider who ignores your individual situation or your preferences. It’s not having a care provider who practices based on worries of legal liability or ignoring the research evidence and just going with what they prefer because that’s how they’ve always done things. Evidence-based care is not when inaccurate information is given to you. And it’s not the overuse of treatment that, when used unnecessarily, have been shown to increase harms. And this is really important. I want to stress that there is no single right decision for everyone when it comes to pregnancy, birth, and postpartum care. There is no universal checklist you can use to create the perfect evidence-based care experience. Each and every one of us who enters pregnancy and birth is an individual, and the best course of action may vary from person to person. The answer to what do we do in this medical situation during pregnancy or birth is specific to you. The individual answers to your questions may depend on the research evidence, on your provider’s clinical expertise and the input they can provide, and your unique preferences both as an individual and someone who’s part of a family. 

And yes, your intuition matters in evidence-based care. You can hire experts to support you in birth, but also always remember that you are the expert on your own body. Now, hopefully you are all on board with this concept of evidence-based care, and you think it sounds like an awesome idea. I know I love the evidence, but here’s the problem. Very few people around the world are actually getting evidence-based care as they’re entering childbirth. And that’s because we have something called the evidence-practice gap. So in the Evidence Based Birth® Podcast number three, we will dive into the evidence-practice gap and talk about how it can be so difficult for some of us to access evidence-based care, and maybe what are some solutions to this problem. In the meantime, I hope you enjoyed this episode all about what is evidence-based care, and I’ll see you next time. Thanks. Today’s podcast was brought to you by the Evidence Based Birth® Professional Membership. The free articles and podcasts we provide to the public are supported by our professional membership program at Evidence Based Birth®. Our members are professionals in the childbirth field who are committed to being change agents in their community. Professional members at EBB get access to continuing EdGovX courses with up to 23 contact hours, live monthly training sessions, an exclusive library of printer-friendly PDFs to share with your clients, and a supportive community for asking questions and sharing challenges, struggles, and success stories. We offer monthly and annual plans, as well as scholarships for students and for people of color. To learn more, visit ebbirth.com/membership.