For midwives practising in many settings, there is a burgeoning quantity of research available, and methods to disseminate it depend increasingly on the use of information technology. The past 10 years has seen a significant increase in the quantity of web based information and Sinclair’s contribution alerts readers to that and offers guidance to midwives in achieving publication. Her appendix to this volume reminds midwives of the importance of disseminating their scholarly activity as the first step in allowing that evidence to be subject to critical appraisal and encourages discrimination in the appraisal and use of evidence.
This sentiment is echoed by Bick in a cautionary note reminding midwives of the importance of appraisal ‘before changing practice overnight’ (Bick 2006). This is demonstrated by Vadeboncoeur’s account of the interpretation of evidence and its impacts on the availability of vaginal birth after caesarean in Canadian settings.
However, it must be noted that some midwives will still not have easy access to web based information for reference during clinical practice; this is particularly the case for community based midwives.
The chapters by Shallow, Amelink and colleagues reflect the interaction between guidelines and practice standards on midwives’ work and experiences. This has altered significantly during the past 10 years. In the UK context, the work of the National Institute for Health and Clinical Excellence encompasses health technol-ogy appraisals, evidence based clinical guidelines and public health guidance for
use in providing care for childbearing women in England and Wales. Guidelines should provide a means of ensuring that an evidence based approach to care is offered and a significant amount of evidence synthesised to a level that would be impossible for most practitioners. However, whilst generally accepted as a positive contribution to care and a cornerstone of service provision, potential impacts on individual midwives’ engagement with evidence based practice must be considered. The provision of pre-synthesised information, with versions for both practitioners and service users, provides a contemporary resource that may facilitate discussion between women and midwives. However, the widespread availability of guidelines raises questions about midwives’ engagement in the full cycle of activity that is defined as evidence based practice (NHS Public Health Resource Unit 2002). This cycle includes formulating research questions, search-ing and appraissearch-ing evidence to inform clinical practice, utilisation and evaluation.
It could be argued that, with the widespread availability of guidelines that cover most aspects of maternity care, midwifery involvement is relegated to a more pas-sive role in following pre-set guidelines. This may mean that skills in components of the evidence based practice cycle that midwives acquire during training may be lost through under-use and consequently a less critical approach may be taken in consideration of the evidence. The impacts of this on individual midwifery practi-tioners and their practice is an area that may benefit from empirical enquiry. The opportunity to exercise skills in accessing evidence still exists; women and their families will continue to raise questions about the appropriateness and effects of different care that are not yet included in guidelines. The evidence should still be presented to women and discussed in the context of their situation and needs.
There will always be women, who despite meeting the clinical criteria encom-passed by a guideline, find that its contents hold little relevance or appeal to their situation. Perhaps there may be additional or different skills that midwives need to develop in the context of guideline-led care?
Despite a slow start to involvement in guidelines (Spiby 2001), there are welcome signs that midwives are increasingly engaged in this area at both a national and local level, through stakeholder involvement, as described in the chapter by Paeglis and contributing to Guideline Development Groups and the associated difficulties (Rogers 2003) or in criticising and getting guidelines changed if they are not right. The National Institute for Health and Clinical Excellence (NICE) Intrapartum Care guideline is one example. In addition, Richens (2007) identified key issues when considering the implementation of the postnatal care guideline.
These debates are taking place in journals, widely accessed by midwives from a range of roles.
Other debates can be located in this text and the wider midwifery literature. In her chapter, Lavender encourages an open and honest reflection of the potential influence of midwives’ own views and perceptions in their interpretation and selective use of evidence. This is echoed by Walsh (2008) and Sandall (2008).
Health-care professionals’ (including midwives) use of evidence was investigated in Marshall’s (2004) doctoral research, in the context of breastfeeding support for new mothers. The concept of selectivity in using evidence was again identified;
this may be appropriate, as midwives select the evidence that is most appropriate for the care of an individual woman. However, care is needed to ensure that
midwives do not choose to use the evidence they agree with, whilst disregarding evidence that does not accord with their prior beliefs. The importance of listen-ing to women to hear what advice worked at particular times or in particular situations was regarded as very important. Evidence congruent with existing beliefs and integration of information from a wide variety of sources was identi-fied in health-care professionals’ support to women. The fact that few health-care professionals had the skills to appraise research evidence was noted but instead, they utilised general messages from evidence sources. Research-derived knowl-edge was considered to ‘find its way into practice in indirect ways’ (Marshall 2004, p. 183) but did not provide certainty. These findings offer important directions in planning future education for evidence based midwifery.
The extent to which midwives are asking questions about evidence, its utilisa-tion and methodology appear to be increasing. In the context of caesarean secutilisa-tion on maternal request, Kingdon and Lavender (2008) encourage midwives to debate the relevance of Cochrane reviews when there are no trials available. When con-sidering evidence related to management of the third stage of labour, Soltani (2008) asks questions about clinical and statistical significance in the context of using evidence in different health settings.
Vadeboncoeur observes that policy can be based on disconcertingly low levels of evidence. This may be due to a range of factors: the limitations of the evidence may be neither understood nor acknowledged. One of the most significant impacts of this is on women, who may be denied choices without being made aware of the limitations of the evidence behind policy. The extent to which the wider midwifery community is aware of this is unclear in the contemporary climate.
The availability of pre-synthesised information for several aspects of maternity care may provide a spurious sense that evidence exists in all areas and that there remain few unknowns; however, this is not the case.
In our earlier chapter, we raised questions about the appropriateness and limitations of hierarchies of evidence in the context of midwifery practice. Such hierarchies also have limitations in particular aspects of evidence, for example, those related to public health guidance. Hierarchies do not foster consideration of feasibility when considering the implementation of evidence and do not support the incorporation of the views of practitioners and services users. The latter are acknowledged as significant factors in the implementation of evidence and yet are often not formally recognised or addressed; an example of this is provided in a paper by Renfrew et al. (2008) in the context of public health guidance related to breastfeeding.
For many years, methodological debate in midwifery research focused on the relative benefits of the quantitative and qualitative paradigms (Walsh 2007) with proponents of each defending their position. The value of mixed-methods approaches to answering research questions is now widely accepted (O’Cathain and Thomas 2007), although further exploration of appropriate use of mixed methods is required. Lavender suggests that midwives may feel that there are tensions when it is population based outcomes that are reported in much published research but individual situations that are encountered in practice.
Midwifery practice requires consideration of different types of evidence and the
importance of the philosophical alignment of the evidence source with midwifery practice was raised in our earlier chapter and echoed by other contributors (Walsh, Amelink and colleagues). Work in guidelines and practice standards depends upon utilisation of a wide range of literature; this was demonstrated in the context of developing a practice standard for anaemia by Amelink and colleagues, who also comment on the importance of bringing the range of literature together to provide a coherent and complete view, rather than by considering the results of individual studies that leave unanswered questions about certain aspects of the area of practice.
Lavender provides a mixed review of midwives’ activities related to evidence based practice. She suggests that greater levels of involvement could be achieved in audit and in improving critical reading abilities. However, she sees a significant potential contribution to the national research agenda and in contributing to filling gaps in the evidence. Proctor and Renfrew (2000) identified the need for programme funding to allow research programmes to develop; this is important in achieving security and in building a body of knowledge. The NHS Research and Development programme provided a strong foundation but has now been trans-formed; significantly more research funding is now being coordinated under the auspices of the National Institute for Health Research (NIHR) (www.nihr.org.uk).
Programme funding is now available, as is substantial funding for capacity building. As components of the NIHR, the Health Technology Assessment pro-gramme is internationally respected and the Service Delivery and Organisation of Care programme is now established. Midwives are accessing these sources of funding but this remains predominantly at the level of the individual project rather than programme grant. In the United Kingdom, midwifery is contributing to activities that support research commissioning through both research councils and the NIHR.