Toward More Evidence-Based Practice

Abstract

Childbirth educators are responsible for providing expectant parents with evidence-based information. In this column, the author suggests resources where educators can find evidence-based research for best practices. Additionally, the author describes techniques for childbirth educators to use in presenting research-based information in their classes. A sample of Web sites and books that offer evidence-based resources for expectant parents is provided.

Evidence-based practice is a key phrase in medicine, today. Doctors espouse it. Nurses have developed several models of research utilization designed to bridge the theory/practice gap. In order to guide caregivers in best practices, medical books and journals have added meta-analyses from The Cochrane Library and the Agency for Health Care Policy and Research. And evidence-based information is the foundation for Lamaze International. Yet, Lamaze educators still find it difficult to present research-based information to expectant parents. The first challenge is getting the information. As you can see in the boxed text from the Lamaze Institute for Normal Birth (a new, virtual site for normal birth information), Lamaze International is committed to disseminating the evidence to its educators. The next challenge is developing effective techniques to present this information in childbirth education classes. This column discusses both of these challenges.

Evidence-based information is the foundation for Lamaze International.

Resources for Evidence-Based Information

Lamaze educators and doulas feel frustrated when they hear normal-birth, evidence-based information at conferences or workshops and then return home to practice in medical facilities that do not seem to have heard the same information. They are frustrated with the lack of knowledge women have about birth, pain, and interventions and with the number of pregnant women who circumvent that education and choose interventions that will give them controlled or pain-free births. How can childbirth educators use the vast resource of research to improve birth outcomes for expectant parents? How can we get this information?

Educators and doulas are not all research-oriented and do not subscribe widely to research journals. Lamaze educators have the benefit of receiving The Journal of Perinatal Education and subscribing to BIRTH at an affordable discount through Lamaze International. The development of the Lamaze Institute for Normal Birth was the result of our educators' frustration, which was communicated to the Lamaze International Board of Directors. The organization's six care-practice papers were developed for use by both educators and expectant parents (Lamaze International, 2003, 2004). The higher reading level was designed to inform educators so they could provide the information to their class participants. Plans are under way to develop more accessible literature appropriate for many expectant parents. Lamaze educators can present this information with the confidence that it is evidence-based and supported by Lamaze International.1 These care practices are only a beginning.

The Lamaze Institute for Normal Birth (www.normalbirth.lamaze.com) publishes quarterly summaries of the latest peer-reviewed research that supports normal birth practices. Lamaze International position papers—as well as those adopted from other sources such as the Coalition for Improving Maternity Services (CIMS)—are included on the institute's Web site. Resources are available for direct connection to other sites where evidence-based information is presented. Although the site is new, pending revisions and updates will present even more information for childbirth educators and expectant parents.

Box 1. The Lamaze Institute for Normal Birth Statement of Purpose.

We believe that women who are fully informed, confident, and supported will want normal birth, and that caregivers should respect the birth process and not intervene without compelling medical indication. The Lamaze Institute for Normal Birth has developed six evidence-based practice papers. Adapted from the World Health Organization, these practices promote, protect, and support normal birth and form the foundation of our work.

1. Labor begins on its own

2. Freedom of movement throughout labor

3. Continuous labor support

4. No routine interventions

5. Nonsupine (e.g., upright or side-lying) positions for birth

6. No separation of mother and baby after birth, with unlimited opportunity for breastfeeding

Lamaze International conferences and workshops are also geared toward providing educators with up-to-date information. The organization's education council retired its previous workshop on evidence-based information, “Childbirth Education in the 21^st Century,” and now provides a new, updated workshop on the latest research and innovative teaching strategies: The latest workshop is titled “Mission Possible: A World of Confident Women Choosing Normal Birth” and is available in many areas. The staff at Lamaze International's administrative office is easy to work with when you want to schedule a workshop for your area (call toll free at 800-368-4404).

Presenting Evidence-Based Information in Class

Let's say you attend Lamaze International's annual conference, loaded with evidence-based teaching strategies, or one of the Lamaze workshops, updated yearly to provide the latest evidence-based information. You return to your class and are faced with expectant mothers who have heard from other women that being a martyr in birth is not necessary. You teach expectant parents who will give birth in a facility that limits food, fluid, and freedom of movement. Are you expected to add to the chaos and stress of birth by telling expectant parents that no evidence indicates these practices improve birth outcomes and, furthermore, these practices may send parents sliding down a cascade of interventions that is not beneficial (Amis & Green, 2000; Hotelling, 2004)?

As Lamaze educators, we are responsible for presenting expectant parents with evidence-based information. There are many ways to disseminate that information. One is by student-directed curriculum. Birth issues have been discussed in the media and in social and work settings. Expectant parents who attend our classes are not oblivious to the conflicts, but they lack the information to make educated decisions. During the classes, within the context of the topics you are focusing on, participants can be offered the freedom to discuss conflicting information. The first night, expectant parents can identify the topics they find most important to cover in class. These topics can be written on sticky notes placed on a poster and used for sharing and for future reference.

As Lamaze educators, we are responsible for presenting expectant parents with evidence-based information.

At the first session of my classes, I present a ping-pong paddle with “Fact” written on one side and “Opinion” on the other. This technique allows me to introduce the evidence-based nature of the class. Additionally, I can demonstrate the idea that not all interventions and medications can be tested ethically on humans; thus, observational information is also presented in class. Furthermore, this technique alerts expectant parents to the fact that their caregivers and I may have biases based on personal experience.

Some educators have told me that they assign controversial topics, such as medications or interventions, for parents to present at the next class. This approach not only introduces expectant parents to Web sites and literature they can refer to for other questions, but also gives them the chance to address the conflicts. If you wonder whether class participants will actually do the homework, you can hand out copies of Lamaze International's six care-practice papers or the CIMS Mother-Friendly Childbirth Initiative2 for references. See Box 2 for a partial list of reading and Web-site resources that offer expectant parents evidence-based information about common birth practices and interventions.

Box 2. Web Sites and Books That Present Evidence-Based Information for Expectant Parents.

Web-Site Resources for Expectant Parents

Coalition for Improving Maternity Services

• www.motherfriendly.org

Lamaze International

• www.lamaze.org

Maternity Center Association

• www.maternitywise.org

Medline

• www.igm.nlm.nih.gov

PubMed

• www.ncbi.nlm.nih.gov/pubmed

The Cochrane Library

• www.cochrane.org

The Society of Obstetricians and Gynaecologists of Canada

• www.sogc.org

International Cesarean Awareness Network

• www.ican-online.org/

Books for Expectant Parents

Gaskin, I. M. (2003). Ina May's guide to childbirth. New York: Bantam Books.

Goer, H. (1999). The thinking woman's guide to a better birth. New York: Perigee.

Simkin, P. (2001). The birth partner: Everything you need to know to help a woman through childbirth (2nd ed.). Boston: Harvard Common Press.

Simkin, P., Whalley, J., & Keppler, A. (2001). Pregnancy, childbirth and the newborn (4th ed.). New York: Meadowbook Press.

Amis, D., & Green, J. (2003). Prepared childbirth the family way (6th ed.). Plano, TX: The Family Way.

Designing learning tasks that involve small groups will help spark class discussion on questions about provider and facility practices. When class participants are allowed discussion time, they have more freedom to chat about information they have heard from other parents and their providers. Small groups introduce topics into follow-up discussion with the entire group; thus, ideas and perceptions that would never have surfaced in the larger setting emerge.

How does an educator correct misinformation without demoralizing or embarrassing students? With all the misinformation circulating, it is a difficult task. One way is to acknowledge misinformation as the current trend or practice and to add that new information is available. Although centuries old, this “fresh” information is new to many caregivers, so you are not really fibbing.

Doulas and Lamaze educators know that convincing caregivers or expectant parents to try less invasive techniques in order to achieve the desired birth outcome means we must assure them that there is something in it for them. The evidence simply is not enough in many cases. We have to provide expectant parents and caregivers with incentives to change unnecessary, high-tech practices into high-touch practices that yield better outcomes. For example, in presenting the risks of cesarean birth and the downsides of not breastfeeding, educators can point out that excellent fact sheets are available from both the Lamaze International and the CIMS Web sites.

Educators as Change Agents

There are many ways to encourage parents to seek normal birth with the confidence of evidence. Yet, a real dilemma occurs when the educator functions within a hospital setting where procedures are not evidence-based and do not follow the six care practices. The childbirth educator may be restricted in providing the information she presents in class, and her job may be threatened if she crosses the lines set by her administrator. Many educators have been “called on the carpet” for presenting information that physicians do not want expectant parents to discuss with them. Advocacy is a part of the childbirth educator's responsibility, and we are accountable for the information we present.

Advocacy is a part of the childbirth educator's responsibility, and we are accountable for the information we present.

Dissemination of information is a key element to changing harmful or unbeneficial practices not supported by research. If you are in one of these situations, consider scheduling Lamaze International workshops for your co-workers. Being a change agent is not easy; however, when you have the voice of Lamaze International presenting the knowledge, an increased confidence is conveyed in the message. Change does not happen overnight, but the seeds can be planted and you will witness collaboration in innovative practices aimed toward normal birth.

The Lamaze Institute for Normal Birth (LINB) was created for dissemination of information. You can easily refer expectant parents to the institute's Web site without jeopardizing your position in a hospital setting. For example, the Web site offers information about birth networks. Birth networks are parent-driven support groups for normal birth and parenting practices. If you are lucky enough to have a birth network near you, you can direct expectant parents there for support and information about normal birth. Many birth networks have monthly meetings where parents and professionals participate in dialogue and share resources. If you do not have a network nearby, encourage parents to form one. The LINB Web site provides information on forming a birth network in your community.

Your hospital may offer the Lamaze Parents' Magazine as a benefit to its customers. The magazine's articles and photos are evidence-based and promote normal birth. Refer to this publication and let parents know what it represents.

Remember: Lamaze International—the organization that certified you—is committed to normal birth, and normal birth is supported by research and by organizations such as the World Health Organization, CIMS, and the Maternity Center Association. Redirect your inquiring, expectant parents away from the trauma/drama births in the media and toward research-based information.