Midwives have, until recently, been fairly passive when it comes to engaging with the evidence based agenda. Although not all midwives can or should be researchers, all midwives can have a role in strengthening midwifery knowledge and subsequent practices. Below is a list of ways through which midwives can play their part.
• All midwives should be involved in contributing to auditing practice. This can be on an individual or unit level. If we look at the Children’s NSF (DH 2004), for example, midwives should be auditing their own current practice and that of their organisation to identify which recommendations they currently fulfil, which areas need to be improved and what targets need to be set. Supervisors of midwives may play a pivotal role in auditing practice and should support individual midwives with self-auditing.
• A fundamental problem in midwifery appears to be the inability of some midwives to access the evidence, determine its appropriateness and critique its quality. Midwives need to learn to critique the evidence as opposed to relying on others who may interpret the data differently. A classic example of this would be one midwife saying that home birth is more dangerous than hospital birth, and another midwife saying that home birth is as safe as hospital birth. The quality of evidence in this area is poor and therefore is easily misinterpreted.
• Midwives need to challenge practice and guidelines when the evidence is weak, as opposed to being covert about not following unit protocols. The evidence around labour definitions and progress (Lavender et al. 2005b) provides a classic example. When a woman has been fully dilated for an hour without an urge to push, a midwife should state her rationale for watchful waiting as opposed to pretending that there is still a rim of cervix present. Knowing the strength of evidence related to such practices may give midwives the courage to overtly defend their care.
• Midwives should remember that much of the evidence is based on population based outcomes, as opposed to individual outcomes. As a consequence, one has to remember that there will always be exceptions to every rule. We may, for example, support the evidence (Royal College of Obstetricians and
Gynaecologists 1993) that it is unnecessary to provide continual electronic fetal monitoring for women with straightforward pregnancies and uncomplicated labours. But, if a woman requests this and would be anxious without it then the midwife needs to make a decision based on the balance between benefit and harm. However, if the evidence does appear strong, it would be in the midwife’s best interest to discuss alternative practice options with senior colleagues prior to implementation.
• Midwives must not rely solely on other health professionals to gather the evidence that they need to support and guide practice. Different professionals have different perspectives, and although all maternity professionals have the common goal of improving outcomes, different models of care lead to different research priorities.
• Midwives should not shy away from local and national research and practice forums as they have an important contribution to make.
• Midwives should aim to be ‘thoughtful users’ of evidence (as outlined previously).
Conclusion
There is clearly a wealth of evidence, both empirical and tacit, but this evidence will never be complete. Midwives need to know not only what evidence does exist but also where the gaps in the evidence are. One must accept that in a changing profession such as midwifery, which is influenced by policy, organisa-tional constraints and societal expectations, there will probably never be enough empirical evidence on which to base practice. As one piece of knowledge is uncovered, another question will be asked. Midwives must therefore draw on all types of evidence to give unbiased information to women and provide care that is appropriate for the individual. However, when empirical evidence is available, midwives need to be able to access and appraise that evidence to determine its suitability. Furthermore, midwives should engage with a reflective practice approach to critically analyse their own daily use of evidence.
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