Making childbirth safer: Promoting Evidence-based Care

Name of presenter

Prevention of Postpartum Hemorrhage Initiative (POPPHI) Project

Session Objectives

By end of session, participants will be able to describe/define:

• The global maternal health situation

• Evidence-based care and rationales

• Objective for using clinical evidence

Maternal Mortality and Morbidity: Scope of Problem

• 180–200 million pregnancies per year

• 75 million unwanted pregnancies

• 50 million induced abortions and 20 million unsafe abortions

• 600,000 maternal deaths/year (1 per minute), 99% of which occur in developing countries

• 30 maternal morbidities for every 1 maternal death

Deaths Worldwide from Complications of Pregnancy and Childbirth

Principles of Basic Care

• Based on evidence

• Given by skilled providers in functioning healthcare system

• Provided in manner respectful of woman, her newborn and family, and their culture

• Individualized to meet unique needs of woman, newborn, and family

Objectives of Evidence-Based Care

• Promote practices based on best available evidence

• Encourage clinicians to:

• Value evidence above mere tradition or habit—“We’ve always done it this way.”

• Access and evaluate new clinical data as it becomes available

• Incorporate evidence into daily clinical practice (i.e., modify practices accordingly)

Objective of using clinical evidence

• To promote care based on best available evidence

• To encourage practitioners to develop their skills in obtaining, evaluating and incorporating evidence into daily clinical practice

In order to achieve that, practitioners should understand and intellectually evaluate new clinical data as it becomes available

In an ideal world…

• The most effective care for every condition is known

• Every clinician has access to and understands most up-to-date evidence

• Every clinician practices most effective care s/he knows

In the real world

• Much of what should be known is not known

• Much that is known, is not known by most clinicians

• Clinicians often fail to practice what they know to be the most effective form of care

Evidence-based medicine is the systematic, scientific and explicit use of current best

evidence in making decisions about the care of individual patients.

Evidence-based medicine

Levels of Evidence and Grades of Recommendations

Grade of recommendation

Level of evidence

Interventions

1a Systematic review of randomized controlled trials A

1b Individual randomized controlled trial

2a Systematic review of cohort studies

2b Individual cohort study

3a Systematic review of case-control studies B

3b Individual case-control study

C 4 Case series

D 5 Expert opinion without explicit critical appraisal or based on physiology or bench research

Importance of Rationales

• Practices should be based on firm rationales

• Provider should know why practice is important:

• What condition can be detected by conducting this part of examination?

• What condition may be prevented by giving this supplement?

• Understanding rationales helps provider focus assessment and care provision

Meta Analysis

• Is one tool that may allow useful information to be obtained from multiple studies

• Is systematic evaluation of collection of several studies which are similar in design, study populations and outcomes examined

• Combines data appropriately to find answer to important question in cumulative information in literature

• Is systematic review of medical literature

Measures of Statistical Significance: 95% Confidence Interval

• Confidence interval: Range in which true effect size can be found

• 95% chance that true effect size lies within 95% confidence interval

• If confidence interval overlaps 1.0, then there is a > 5% possibility that observed outcome difference is due to chance

• Very wide – results less believable

• Very narrow – more believable

0.01 0.1 1 10 100Odds Ratio

No Difference

Confidence Interval

Results consistent with chance

Reduced Risk Increased Risk

Measures of Statistical Significance: p Value

• Conventionally set as 0.05

• Equivalent to 5%

• Difference is significant if p value is less than 0.05 (< 0.05)

• Means that there is less than a 5% chance that the result obtained is due to chance, or

• 95% certain that result obtained by the intervention is true

Summary

Quality basic care is:

• Based on evidence and rationales

• Evidence-based medicine should be used to set a standard of care

• New data should be evaluated critically to determine whether to change standards

• Given by skilled provider in functioning healthcare system

References

Hulley SB and SR Cummings. 1988. Designing Clinical Research: An epidemiological approach. Williams and Wilkins: Baltimore, Maryland.