making childbirth safer: promoting evidence-based care name of presenter prevention of postpartum...
TRANSCRIPT
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.