Evidence can be a powerful tool, and like any tool, if used incorrectly can be hazardous. However, similarly, ignoring the available evidence can also be dangerous. Midwives are in a very powerful position, having the ability to use the evidence or ignore it, when caring for individual women. Although it is true that all midwives will not know all the evidence at any given time, my own research (Lavender and Chapple 2004) and clinical observations suggest that there are five main types of midwives, in terms of empirical evidence utilisation: (i) non-users, (ii) reluctant users, (iii) selective users, (iv) rigid users and (v) thoughtful users.
Non-users
‘Non-users’ describes the midwife who, despite having knowledge of the evi-dence, chooses not to use it. This group of midwives includes, for example, those
who continue to carry out episiotomies or use continuous external fetal monitor-ing because that is the way they have always practised. These midwives are likely to have had a negative impact on intervention rates in the United Kingdom. More subtly, it also includes, for example, those who encourage women to labour on their backs and those who fail to provide women with evidence regarding risk factors prior to commencement of an oxytocin infusion.
Reluctant users
Reluctant users are those who use the evidence only if they are pressurised to do so either by colleagues or by organisational protocols. This group of midwives includes those who will practice only in a certain way when a particular shift leader is working and those who will use the evidence only if formally instructed to do so. Examples of reluctant users include the midwife who withholds routine amniotomy on particular shifts where her actions will be questioned and the midwife who cup feeds, as opposed to bottle feeds, a baby on night duty only when working alongside an infant feeding adviser.
Selective users
Selective users make up the largest category and often have a combination of positive and negative attributes. There are midwives (i) who use empirical evidence only retrospectively, (ii) who use evidence to negotiate practice and (iii) who use evidence only to justify their personal beliefs.
Those who use empirical evidence retrospectively
Midwives, who use evidence only retrospectively, do so usually in an attempt to justify their own actions. For example, a midwife who carries out an amniotomy without any clinical rationale may select a particular finding within a piece of research, such as reduction in labour length, to justify the action. Much criticism has been directed to this approach, some suggesting that the term sister says has been replaced with research says. It is certainly my experience that some midwives do say ‘research says’ without a comprehensive understanding of either the extent or the strength of the evidence.
Those who use evidence when negotiating
Some midwives use evidence when they find themselves in a situation in which they feel that they need to negotiate. In a number of clinical scenarios, I have witnessed midwives skilfully utilising their knowledge of the evidence to prevent unnecessary labour interventions. On many occasions, when obstetricians or midwifery shift leaders have instructed the midwife to transfer a woman from low- to high-risk care for augmentation, for example, experienced midwives have quoted the limitations of the evidence related to the duration of the first stage of labour to prevent this from happening. Situations such as this, however, rely on a midwife who is confident in her ability to draw on other forms of evidence, such as clinical expertise and intuition. However, the importance of knowing the
evidence base of maternity care is particularly highlighted when peers or women quote evidence at the attending midwife to encourage her to care for her in a way that she may not think as appropriate. All midwives should be using empirical evidence for negotiation, even if the negotiations are with oneself. Debating the evidence and relating it to a particular woman, the social setting and cultural and personal beliefs can establish a clear rationale for the care provided.
Those who use evidence only if it justifies their personal belief
Some midwives may provide women with a certain amount of information on which to base their decisions. A typical, and all too common, example of this is a midwife who provides a woman with the evidence around effectiveness of epidural pain relief, believing that to have one would be in her best interest. This same midwife, however, may fail to provide the woman with the evidence around side effects of epidurals.
Rigid users
Rigid users are often as dangerous as those who fail to utilise the evidence at all.
These are the midwives who insist on commencing an oxytocin infusion because the woman’s progress has crossed the partogram action line, despite having strong, regular contractions. A further example is encouraging a woman to give birth in the upright position, when her preference would be to adopt a left lateral position.
Thoughtful users
Thoughtful users are those who select appropriate evidence depending on an individual woman and her environment. Midwives in this group can identify when the evidence is most appropriate and can say ‘I know the evidence but for this individual woman it is not right!!’ As Davis-Floyd (2005) rightly states,
We need to hear the voices that insist that the deviation can be the norm for this woman and this baby at this time in this place.
But these midwives are those who can also gain the woman’s trust so that she listens to the evidence provided to her and the accompanying rationale for why it should or should not be used. It may be that, for example, the woman does not wish to have regular vaginal examinations, despite the hospital guideline recommending this practice. The ‘thoughtful user’ will know the paucity of the evidence and will be able to relay the pros and cons to the woman and negotiate an outcome that is right for the individual. This midwife may practice differently, however, according to the individual woman.
Although I have defined specific types of midwives, many midwives will see themselves within more than one category as how the evidence used is complex and multifaceted. However, by recognising the different categories, one can reflect on their own use of evidence in practice and make appropriate changes.