Reconsidering Evidence: Evidence-based Practice and Maternity Care in Canada
Van Wagner, Vicki
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Evidence-based practice (EBP) has been widely adopted as a scientific and objective approach to health care. Enthusiastic acceptance of EBP within maternity care appears to have had unexpected effects on the care of childbearing women. This qualitative study of an interprofessional group of maternity care providers explores EBP from a critical science studies perspective to understand the social inside the science. A literature review and interviews with family physicians, midwives, nurses and obstetricians were analyzed for themes. Initial hopes for EBP were high and often contradictory. Although many had hoped EBP would help limit rising rates of intervention in childbirth, informants noted that interventions, such as induction of labour and caesarean section, have continued to increase. Informants described patterns of uneven application and misapplication of evidence. They described how some evidence is applied quickly while other evidence is resisted. The rapid uptake of the findings of a single trial about breech birth was frequently contrasted with reluctance to implement evidence in favour of auscultation rather than electronic fetal heart monitoring. My findings reveal patterns of over application, for example, when research about post-term pregnancy is used as a rationale for induction of labour earlier than the findings justify. Informants described under interpretation when multiple or ambiguous interpretations are ignored and over interpretation when evidence is generalised to populations beyond its relevance. Informant interviews reveal underlying reasons that evidence is oversimplified and unevenly applied. Care providers are influenced by belief systems, powerful cultural trends to technologic solutions, discomfort with uncertainty, a focus on risk avoidance, and structural issues including payment systems and limited resources. Many informants expressed concern that the adoption of EBP has unexpectedly undermined support for physiologic birth. They described a profound sense of loss, including loss of skills, access to care and choices for women. Informants advocated reconsideration of EBP, calling for a conscious and reflective approach which acknowledges that scientific evidence alone cannot set goals and objectives of care. My findings are evidence of interprofessional interest in open dialogue about interpretations of evidence and revisions of EBP in the care of childbearing women.