Evidence Based in

Health Care
(Midwifery)
Dwi Izzati Budiono, S.Keb, Bd., MSc
Learning outcomes

• Evidence Based Health Care

• What is it?
• Why do we need it?

• Steps involved in EBHC

• Hierarchy of evidence

• Where do we go to find evidence?

• Very basic searching
Evidence Based Health Care

What is EBHC?
 Evidence Based Practice

Evidence Based Practice (EBP) is a

problem-solving approach to the delivery
of care that incorporates the best evidence
from well-designed studies in combination
with a clinician’s expertise and patients’
preferences within a context of caring

Sackett et al 2000
Evidence Based Practice

Evidence based practice provides a framework

and process for the systematic incorporation
of research evidence and patient preference
into clinical decision making at the level of the
individual practitioner and the healthcare
organisation

Newman and Papadopoulos 2000

 Evidence Based Practice

Evidence Based Practice (EBP) is a

problem-solving approach to the delivery
of care that incorporates the best evidence
from well-designed studies in combination
with a clinician ’s expertise and patients ’
preferences within a context of caring

Sackett et al 2000
Evidence Based Practice

Evidence based practice provides a framework

and process for the systematic incorporation
of research evidence and patient preference
into clinical decision making at the level of the
individual practitioner and the healthcare
organisation

Newman and Papadopoulos 2000

 Needs and preferences
of patients and clients

Evidence-based
health care

The professional’s
The best available expertise, skills and
evidence judgement
‘Research’ vs. ‘evidence’ based practice

• Evidence based practice is about using research,

applying research to clinical problems and
integrating research into organizational policy to
inform processes and guidelines

• Evidence based practice provides a framework and

process for the systematic incorporation of
research evidence and patient preference into
clinical decision making at the level of the individual
practitioner and the healthcare organisation

(Newman and Papadopoulos 2000)

 Why is
evidence based
practice
important?
 In the past!

• Apprentice type system

• Anecdotal evidence

• Others’ personal experience

(could be unreliable/biased?)
• Recent development
• difficulties in keeping up to date
with new information
• >50 trials and 2000 research
articles published /day!

• Product of our time

• Internet
• Electronic databases
 Need for, and importance of, evidence
based practice
Need
• Information overload (e.g. >50 trials and >2000 research articles
published every day!)
• Challenging ritual, habit, routine
• Responding to consumer demands
• Responding to cost pressures and demands on health systems
• Responding to patient safety agenda and developments in clinical
governance
• Meeting obligations of professional codes of conduct

Purpose
• To provide care that is:
safe and clinically effective
cost effective
Valued, respectful and important for patients and communities
 All healthcare professions need to
understand the principles of evidence-
based practice (EBP), recognise evidence-
based practice in action, implement
evidence-based policies, and have a
critical attitude to their own practice and
to evidence. Without these skills,
professionals and organisations will find it
difficult to provide best Practice
Dawes et al 2005
The emergence of EBP is one of the success stories of the 1990s

In the space of ten years the movement has

had a significant impact on health care and
Policy
Common challenges to EBP

Practitioners…………

• May not make efforts to keep up to date

• May be comfortable with traditional or ritual practices
• Professional ideology that emphasises practical rather than intellectual
knowledge
• May encounter obstacles within the organisation to change practice
• Work environment that does not encourage information seeking
• May lack the resources, especially time, to find the evidence
• Limited access to the literature
• Lack of training in information seeking & critical appraisal skills
• May lack confidence to change practice

Barker, Linsley & Kane (2016)

Challenges to EBP

Researchers…………….

• Evidence may be poorly disseminated or not at all – may not write up

their research findings
• Published material may not target practitioners in a manner
appropriate to their needs
• The time gap between finding the evidence and publishing the
findings is long
• The language used may be complex & not easily understood by the
reader
• The report does not address implications for practice

Educators??

Barker, Linsley & Kane (2016)

Where did you get the evidence
that you needed to make an
informed decision?
• On what evidence did you base your
decision?

• Were you aware of where to find any

relevant research studies?

• Were you aware of where to find any local

or national clinical guidelines?
 In what way did you take into account the
views, knowledge and wishes of
your patient or client?

• Was it the care they wanted?

• Did the women have the opportunity to
discuss their concerns and preferred
options for care?
• Did you have the opportunity to discuss and
reflect on your decision with colleagues and
share ideas about best practice?

Do you think that you were practising in the

way
that is most clinically effective for that
patient or women or client?
• 1972 – Archi Cochrane – monograph

• 1977 – Canadian survey – doctors failing to

keep up to date with current research

• 1980’s –Archi Cochrane’s ideas taken up by

Ian Chalmers who begins reviewing care
during pregnancy and childbirth

• 1987 – Archi Cochrane refers to Ian

Chalmers’ review as ‘a milestone in
the
history of randomised controlled
trials and in
the evaluation of care’
• 1988 - The Cochrane Collaboration formed

• 1992 - EBM in the literature, other disciplines follow

suit

• 1994 - NHS Centre for Reviews and Dissemination

(CRD) is established in the UK

• 1996 - The Joanna Briggs Institute (JBI ) in Australia

is founded

• 2000 - The Campbell Collaboration is established in

the USA
Evidence Based Health

1. Clinical scenario/Structured
question
2. Search for the relevant papers
3. Critically appraise the evidence
4. Use evidence to help decision-
making
 Integrate the evidence with clinical
expertise and patient preferences and
values
5. Reflection
 Evaluate the outcomes of the
practice decisions or changes based
on evidence
Where do you go to find evidence?

Five Minutes
 Primary and secondary
research
• Primary research: studies in which original
data are collected to answer a specific
research question. Randomised controlled
trials, cohort studies, case-control studies
and surveys are all examples of primary
research studies.
• Secondary research: uses information from
existing studies i.e. publications, or expert
opinion to answer a specific research
question. Systematic reviews, meta-
analysis (quantitative data), meta-synthesis
(qualitative or narrative data) and guidelines
are types of secondary research studies.
 Examples of where evidence
has changed practice

• Can you think of any

examples?

• Examples:
• Midwife‐led continuity models versus other models of
care for childbearing women
• https://www.cochranelibrary.com/cdsr/doi/10.1002/14
651858.CD004667.pub5/
full

• A systematic review to examine the evidence regarding

discussions by midwives, with women, around their
options for where to give birth
• https://bmcpregnancychildbirth.biomedcentral.com/articles/10.
1186/s12884-016-0832-
0

• Physiotherapy management guidelines for the non-

ventilated patient
• http://www.brit-thoracic.org.uk/Guidelines/Physiotherapy-
Guideline.asp
 Changing Practice
Systematic Review Practice

Sustained uterine massages not Increased positive birth experience

recommended as an Reduced abdominal discomfort
intervention to prevent PPH

Episiotomy for vaginal birth Reduced international episiotomy rates

Position for women during second stage Increased the use of upright positions
of labour for birth

Routine cardiotocography is not Auscultation using a Doppler ultrasound device

recommended for the or Pinard fetal stethoscope
assessment of fetal
wellbeing
Midwifery led continuity of care Reduction in medical or shared or other
models of care
Hierarchy of
Evidence
JBI Levels of Evidence -
Effectiveness
Level of Effectiveness
Evidence E (1-4)

1 SR (with homogeneity) of experimental studies (e.g. RCT with

concealed allocation)
OR 1 or more large experimental studies with narrow confidence
intervals
2 One or more smaller RCTs with wider confidence intervals
OR Quasi-experimental studies (e.g. without randomisation)
3 3a. Cohort studies (with control
group) 3b. Case-controlled
3c. Observational studies (without
control groups)
4 Expert opinion, or based on physiology, bench research or
consensus
Five steps of
EBHC
Asking the
question

Evaluation and Finding the

reflection evidence

Acting on the Appraising and

evidence interpreting the
evidence
 Process of EBP: Stages and Skills
Stages Skills
Asking a relevant question How to create a well structured
question
Finding the evidence How to search for literature
Appraising the quality of the Being able to use tools and
evidence and assessing its principles of critical appraisal
applicability to your own context
and patients
Acting on the evidence Using methods of change
management, guideline
development and quality
improvement
Evaluation of change Undertaking service evaluation
and clinical audit
Evidenc
e
• Where do I go to find the
evidence?
Understand your question

• What type of question is it?

• Is it qualitative or quantitative?

• What type of studies ?

Where to start?

• Search for guidelines

• CARE!- when where they last updated?

• Search for previous Systematic Reviews

• CARE!- what was the last search date?
Quick
search

• TRIP
www.tripdatabase.com

• The Cochrane Library

www.thecochranelibrary.
com

• The Joanna Briggs

Institute
http://joannabriggslibrar
y.org/
Evidence
• Guidelines
• National Institute for Health and Care Excellence
(NICE). www.nice.org.uk

• Scottish Intercollegiate Guidelines Network (SIGN) –

develops evidence based clinical practice guidelines
for the National Health Service (NHS) in Scotland.
www.sign.ac.uk

• Other Guidelines. Indonesia?

How good are the Guidelines?
• Date?
• Quality
– Treat them like any other source of evidence
– Appraise guidelines
– The Appraisal of Guidelines for Research and
Evaluation (AGREE) Instrument evaluates the
process of practice guideline development and the
quality of reporting
– AGREE II is the new international tool for the
assessment of practice guidelines.
– www.agreetrust.org
How good is the
Review

Preferred Reporting Items for

Systematic Reviews
(PRISMA)
www.prisma-
statement.org/statement.htm
Search
Strategy
• Features of search strategy
• Sensitivity – ability to identify all the relevant
studies
• Specificity – ability to exclude irrelevant studies,
also known as precision
• Inverse relationship between
sensitivity and specificity – means that
a large number of articles retrieved
may not be relevant to the review
question
• High sensitivity will tend to have low specificity
Database
s
• MEDLINE – 1966 onwards
• EMBASE – 1974 onwards
• Science Citation Index
• PsycInfo – 1987 onwards
• CENTRAL – The Cochrane Central
Register of Controlled Trials
• CINAHL – Nursing and allied health
literature
• LILACS – Latin American and
Caribbean Health Science
Identifying relevant
literature
• Bibliographic databases
• Follow-up from reference lists
• Personal contact with experts
• Unpublished studies
• Non-English language studies
• Register of clinical trials
Search strategy to locate
RCTs MEDLINE (OVID)
1. randomised controlled trial.pt.
2. controlled clinical trial.pt.
3. randomised.ab.
4. placebo.ab.
5. clinical trials as topic.sh.
6. randomly.ab.
7. trial.ti.
8. 1 or 2 or 3 or 4 or 5 or 6 or 7
9. humans.sh.
10.8 and 9
Boolean
Operators
Combine terms
with
OR
Basal Cell Carcinoma OR – either term can
be present

Basal Cell
Carcinom
a
smokin
g
Combine terms
with
AND
Basal Cell Carcinoma AND
smoking

Basal Cell Smokin

Carcinoma g
Quick
tips
• Take a common word stem and look
• for spelling variations e.g.

◦ smok* - will retrieve papers smoking, smoker,

smokers… but also smoked salmon
• Phrase searching

◦Use double quote marks if you want

words to appear next to each other e.g.

“smoking cessation”
Hel
p
• Finding the Evidence tutorials:
• EBM web-site – EBM tools – Finding the Evidence
http://www.cebm.net

• PubMed
• Short online tutorials
• Quick guides to PubMed – basics, MeSH search and
MyNCBI
http://www.nlm.nih.gov/bsd/disted/pubmed.html
Ranking the “Quality” of Evidence of
Effectiveness

• To what extent does the study design minimize bias/demonstrate

validity
• Generally linked to actual study design in ranking evidence of
effectiveness
• Thus, a “hierarchy” of evidence is most often used, with levels of
quality equated with specific study designs
Where to find me
• [email protected]
• Whatsapp: +6281232330990
• ig: @dizzabudiono
• Line: dizzabudiono_
• Twitter: @dwiizzadizza