INTRODUCTION

Some ways of knowing have traditionally occupied spaces at the edge of the dominant vision, the same kinds of spaces as are filled by the lives and experiences of the socially marginalised, including women. Thus, neither methods nor methodology can be understood except in the context of gendered social relations. Understanding this involves a mapping of how gender, women, nature and knowledge have been constructed both inside and outside all forms of science (Oakley 2000, p 4).

Inquiry is based on the recognition of certain connections. It is important always to be mindful that separating the knower from what is known implies a separation of one’s self from another person and also implies the separation of the researcher from the subject of research (Reason 1988). The connection between understanding in the scientific and biological domain, and the experience we bring from our family, our practice, our social and political contexts, together with our use of language, is the reason we can expect to have different and multiple understandings of the world. We make sense of facts and select and organise all our observations based on the influences of previous learning and practice. Drawing stories from our reservoir of experiences and social contexts connects us through language and metaphor to understand the science behind midwifery. Understanding biological systems depends on a multiplicity of understandings, explanations and connections (Fox Keller 2002).

SEEKING TRUTH

Although there are several methods of seeking truth that may conflict or coexist with each other at various times, it is generally accepted that, in midwifery as well as medicine, some ways of arriving at the truth are more acceptable than others. The following examples will help provide you with an understanding of how many of the interventions and actions in practice have been arrived at. After reaching the end of this chapter, I hope you will return to this section and be able to discern whether or not the following methods are entirely acceptable.

Let’s look at the safety of believing in something or having faith in an authoritative expert opinion. For example, many women and midwives believe that having an epidural during labour is both safe and effective. They believe that if the departments of anaesthesia and obstetrics so wholly endorse the procedure, then it is unlikely that having an epidural will have any adverse side-effects. Similarly, having a continuous CTG monitor running and recording the baby’s heartbeat for the whole of labour will surely be seen as the safest way to detect anything going wrong as soon as it happens. Both these procedures were introduced as routine interventions without prior scientific validation, and are still supported by the fact that because so many women like them and they are so comforting, there seems little reason to question their routine use and safety.

Then there is the feeling that something is right. For years, midwives have done certain rituals because they had a gut feeling it was the right thing to do. How does this come about? For many it is the wisdom gained through the experience of looking after many women in childbirth. It may be something as simple as recommending a salt bath for the relief of the perineum, or wanting to give a baby extra fluid to complement the mother’s milk supply when it seems that neither can settle happily. These are interventions that for some just feel like the right thing to suggest, even though the midwife may have no knowledge of the benefits or safety of such measures.

Very close to the feeling that something is right is the knowing through personal experience that this is the way to do something. We have seen something or heard it so often that our personal experience of the event leads us to believe it must be true. In both midwifery and obstetrics, much of what is practised is based on personal experience and learning from past mistakes. Personal experience is often characterised as being anecdotal, ungeneralisable and a poor basis for making scientific decisions. However, it is often a more powerful persuader than scientific publications in changing clinical practice. In fact, midwives constantly use their personal judgement to affirm what they believe to be true in certain situations—the non-scientific ‘rule of thumb’. This is also one of the most contentious areas in which to change attitudes and practice because it challenges one of the most strongly held methods for seeking truth—the knowledge gained through the personal experience of doing things a certain way.

Legal methods of arriving at the truth need little explanation. Here something is deemed to be true because it can be substantiated through authoritative testimony. The expert witness is seen as an authority and an expert in the subject under examination. Up until the past 15 years we were familiar with the use of the word ‘evidence’ in relation to legal method. However, with the widely accepted move in medicine to evidence-based medicine (EBM), the word ‘evidence’ has taken a much more prominent position in the scheme of things. Box 5.1 walks you through an ethical argument in addressing the question: ‘Is evidence the same as research?’

One of the most widely accepted methods of searching for truth in midwifery is through scientific method or research. Searching for truth using scientific research methods involves the systematic study of phenomena and the relations between and among phenomena using agreed rules or accepted methodologies. The systematic collection, analysis and interpretation of data minimises the contamination of results from external factors (known as bias) (Kirkevold 1997).

There are two main schools of thought on how scientific method should proceed.

Both these strategies are used to develop the knowledge of midwifery.

Whichever method we use to try to find answers to a certain problem or situation, there are certain things that help us measure how successful the research is in answering our question. Research is measured in terms of its rigour of scientific inquiry by concepts known as reliability (the repeatability of the research) and validity (the extent to which the instruments measure what they set out to measure).

Seeking truth through empirical research involves both experimental and non-experimental research. In non-experimental designs, the observations are recorded without having first manipulated the variables. In contrast to this, in the experimental method there is a systematic manipulation of and control of variables. Evidence-based healthcare, or the practice of basing clinical decisions on the best available scientific evidence, is predominantly derived from experimental method. All research, whether inductive or deductive, follows the broad pattern of the research cycle.

Regardless of the method of research, this basic formula sets out the cycle of events that occur in a research process (Fig 5.1).

Figure 5.1 The research cycle

QUALITATIVE RESEARCH METHODS

Qualitative research contributes to the understanding of social aspects of health issues, through direct observation of the nuances of social behaviour (Green & Britten 1998; Pope & Mays 2000). Qualitative research can investigate practitioners’ and patients’ attitudes, beliefs and preferences, and the whole question of how evidence is turned into practice. The value of qualitative methods lies in their ability to pursue systematically the kinds of research questions that are not easily answerable by experimental methods. Rigorously conducted qualitative research is based on explicit sampling strategies, systematic analysis of data, and a commitment to examining counter-explanations. Ideally, methods should be transparent, allowing the reader to assess the validity and the extent to which the results might be applicable to their own clinical practice. Qualitative research does not usually produce numerical rates and measures (Green & Britten 1998). Researchers who use qualitative methods seek a deeper truth (Greenhalgh & Taylor 1997). They aim to make sense of, or interpret, phenomena using a holistic perspective that preserves the complexities of human behaviour (Black 1994). The research often provides us with a picture of ‘behind the scenes’, how people are feeling, or what other forces are at work that may not be discovered in a quantitative investigation of facts.

An example of the ‘behind the scenes’ behaviour that affected the introduction of evidence-based leaflets into maternity hospitals in the United Kingdom was recorded by Stapleton et al (2002) when they undertook a qualitative study beside a randomised controlled trial (RCT) by O’Cathain et al (2002). In the experimental study, the researchers concluded that in everyday practice, evidence-based leaflets were not effective in promoting informed choice for women using maternity services (O’Cathain et al 2002). The qualitative study (Stapleton et al 2002) mounted alongside this RCT provided a rich insight into what was happening with the information leaflets, and found that the way in which the leaflets were disseminated affected promotion of informed choice in maternity care. The qualitative study provided the evidence for ‘behind the scenes’ and the bullying and coercive behaviours that had become a normal way of doing things in these maternity units. The culture into which the leaflets were introduced supported existing normative patterns of care and this ensured informed compliance rather than informed choice (Stapleton et al 2002).

EVIDENCE-BASED PRACTICE

The aim of evidence-based practice, to quote Professor David Sackett, is ‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients … the integration of individual clinical expertise with the best available external clinical evidence from systematic research’ (Sackett & Cooke 1996, p 535). In other words, it is the combination of clinical judgement and clinical practical experience with information we gather to help us learn.

The following five steps in putting evidence into practice are based on the work of Sackett et al (1996):

In The New Midwifery, Professor Lesley Page describes evidence in terms of ‘a process of involving women in making decisions about their care and of finding and weighing up information to help make those decisions’ (Page & McLandish 2006, p 360). The five steps to evidence-based midwifery (Box 5.4) were adapted by Professor Page from the original work in this area undertaken by Sackett and colleagues in 1996 (Sackett et al 1996).

In step 3, seeking and assessing evidence, the original authors added that it is important to decide how valid something is. In other words, how close to the truth is it? It is also important to find out how useful it is—that is, how applicable to practice is the evidence? One thing to remember is that evidence-based midwifery should never be a ‘cookbook’ approach to what we do. The evidence that we bring to practice from the literature or from research should only ever inform our practice, not replace it; and it should always be taken along with a woman’s individual preference for a clinical decision (PageMcLandish 2006; Sackett & Cooke 1996).

One of the ways of checking whether a research paper addresses the area of inquiry you are interested in is to see whether the question the research seeks to answer applies to the area of interest. To do this, we divide the question into its components to make sure it is relevant. For example:

This is known as the PICO method (see Box 5.5). The appendix at the end of this chapter lists questions to ask in evaluating a clinical guideline.

EPIDEMIOLOGICAL METHOD

The foundation and primary focus of evidence-based care is within the specialty of medical epidemiology, ‘to ensure the practice of effective medicine, in which the benefits to an individual patient or population outweigh any associated harm to that same patient or population’ (Muir Gray 1997, p 3). The underlying belief is that meaning can be discerned from population patterns and that a relation exists between mathematics and material reality. The epidemiologist’s focus of study is the whole population, in which outcomes are described in averages and percentages, rates and risks. Then the science of chance is applied in the form of a statistical framework that gives the reader an indication of the measurement error or the uncertainty with which the result is believed to be true. This is better known as the ‘confidence interval’ (Jolley 1993). Epidemiology seeks to provide answers through the analysis of accumulated results of hundreds or thousands of comparable cases in population samples. The language of mathematics is used to describe the findings in terms of ‘probability’ and ‘risk’. Such answers, arrived at through studying population samples in randomised trials and cohort studies, cannot be mechanistically applied to the individual. ‘In large research trials the individual participant’s unique and multidimensional experience is expressed as (say) a single dot on a scatter plot to which we apply mathematical tools to produce a story about the sample as a whole’ (Greenhalgh 1999, p 324).

In other words, the answers that we gain from doing research at a population level tell us about the general population in averages and frequency measures. They do not tell us the story of the individuals who took part. In asking ‘What works?’, we are suggesting that research will show us how to do things the best way. The danger here is that we may unwittingly focus on very narrow ‘evaluative’ studies—that is, studies that demonstrate the effectiveness of an intervention, such as the randomised controlled trial (RCT), when in fact information from a whole range of types of studies, answering a variety of questions, may be more useful. (See the story of the information leaflets earlier.) In reality we practise within a complex and mostly unpredictable reality in which learning from trial and error may be an important way to make progress.

At the turn of the 20th century, epidemiological research began to explicitly incorporate social science perspectives related to health data that could inform public policy. One of the first substantial prospective epidemiological analyses to be undertaken was a study of the socioeconomic and nutritional determinants of infant mortality in the United States in 1912, by Julia Lathrop (Kreiger 2000). As sociologist Ann Oakley pointed out, the history of experimentation and social interventions is ‘conveniently overlooked by those who contend that randomised controlled trials have no place in evaluating social interventions. It shows clearly that prospective experimental studies with random allocation to generate one or more control groups is perfectly possible in social settings’ (Oakley 1998, p 1240). The usefulness of the population-based results of an RCT depends on the translation of the concepts and measures used to describe groups of people into a language that can inform the decisions of an individual (Steiner 1999).

The RCT is currently considered to be the orthodox and ‘gold standard’ scientific experimental method for evaluating new treatments. The ethical basis for entering patients in RCTs, however, is under debate. Some doctors espouse the uncertainty principle whereby randomisation to treatment is acceptable when an individual doctor is genuinely unsure which treatment is best for a patient. Others believe that clinical equipoise, reflecting collective professional uncertainty over treatment, is the most sound ethical criterion (Weijer et al 2000). The scientific principles that are applied to the design and conduct of primary research, such as the RCT, are also applied to secondary research, such as the systematic review (Chalmers et al 1992). Many regard epidemiology as ‘an arcane quantitative science penetrable only by mathematicians’ (Grimes & Schulz 2002). However, it must be pointed out that ‘statistics is at most complementary to the breadth and judgement’ of the knowledge gained from epidemiological research (Jolley 1993, p 28).

Figure 5.2 outlines the kinds of studies you will encounter in the scientific literature, both medical and midwifery, that are based on the epidemiological method.

Figure 5.2 Types of epidemiological studies

In order to find where the ‘best evidence’ is to support our practice we are encouraged to give research studies a ranking from the highest level, or the ‘gold standard’, to the lowest level of research evidence. These rankings are made explicitly on the ranking of research methods from the most reliable to the least reliable. This ‘evidence hierarchy’ provides an initial screening test as to whether data from research studies are derived from methods that are more likely or less likely to guide readers towards truthful conclusions (Gupta 2003). (Further discussion

on this topic, and current debates, definitions and controversies, can be found on the Centre for Evidence-Based Medicine website at www.cebm.net/.)

Experimental trials are limited when the study size is too small to detect rare or infrequent adverse outcomes, or when the outcome of interest is long term and the trial would need to continue for an improbable length of time. In all these cases, observational studies may be considered more practical (Black 1996). Observational studies may be most valuable where randomising people to an intervention is inappropriate (Black 1996)—for example, randomising women to having water for birth or to having an elective caesarean section is inappropriate and also disregards the ‘effect that choice itself has on therapeutic outcome’ (McPherson 1994).

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