Konsep Dasar Pelayanan

Kebidanan Berbasis Bukti

(Evidence-Based Midwifery)
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How do we know that we are giving
the best care possible to a pregnant
woman or a woman in labour?

How do we know we
are doing ‘most good’
and ‘least harm’?

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The Old Paradigm

I have been doing

this for many years,
and in my experience
it works fine

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• Early EBM proponents showed that many
widely used therapies that had been adopted
based on “lower” forms of evidence proved to
be useless or harmful when subjected to
randomized trials
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Are these procedures essential in low
risk vaginal birth?

1. Shaving for labor

2. Enemas in labor
3. Fluids and food during labor
4. Continuous fetal monitoring
5. Routine episiotomy
6. Mobility during labor
7. Continuous support in labor
8. Birth positions
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 Shaving for Labour

Traditional belief: Best Evidence:

 Painful, embarrassing
 To reduce infection  Re-growth
uncomfortable
 To facilitate  Microabrasions cause
suturing/makes it infection
easier to stitch  Risk of HIV
transmission
 No benefits shown for
shaving
 Small cost benefit
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 Enemas in Labour
Traditional belief: Best Evidence:
 Encourages bowel movement  Painful, embarrassing
(peristalsis) and therefore
more prostaglandin is  Does not stimulate
released, which in turn contractions
stimulates contractions  Does not shorten labour
 Shortens labour  No difference with
neonatal infections
 Helps the baby’s head
descend  Does not decrease
soiling at birth,
 Necessary to avoid soiling at
the birth (keep it clean) and more messier bowel
therefore reduce the risk movements
of maternal and neonatal  Marginally increases
infection cost of health care 7
 Fluids and food during labour

Traditional belief Best evidence

 Risk of inhalation if  No difference in
general anaesthetic anaesthetic risk
needed  Dehydration leads to
acidosis, leads to fetal
 Keep everyone nil per distress
mouth  Dehydration can lead to
incoordinate contraction
 Nil per mouth only for
specific reason
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 Continuous fetal monitoring

• No significant difference in overall

perinatal death rate
• But was associated with a halving of
neonatal seizures
• No significant difference was detected
in cerebral palsy
• There was a significant increase in
caesarean sections
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 Routine Episiotomy

Traditional Belief:

 Clean incision
 Heals better
 Fewer 3 and 4 degree tears
 Less pain
 Use routinely

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Adapted from the WHO Better Birth Initiative http: /www.liv.ac.uk/lstm/bbimainpage.html
 Cochrane Systematic Review

Authors' conclusions

• Restrictive episiotomy policies appear to have a

number of benefits compared to routine episiotomy
policies.
• There is less posterior perineal trauma, less suturing
and fewer complications, no difference for most pain
measures and severe vaginal or perineal trauma.
• But there was an increased risk of anterior perineal
trauma with restrictive episiotomy.
.

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 Best Evidence: During Labour
Mobility during labour
Traditional belief Best evidence
 Bed rest is best for the  Improved progress
mother and baby of labour if mobile
(contractions are stronger)
 Augmentation less likely
 Less busy in the labour  Labour may be less painful
ward if labouring women  Assists with fetal descent
are confined to bed  No harms have been
associated

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 Continuous Support in Labour
Traditional belief:
 Companions discouraged
because of concerns about
cross infections
 Extra people who are not
health professionals always
get in the way
 There is no privacy for
other women in labour
 Staff are already
overworked and can not care
for labour support people as
well
Best Evidence:
 Better progress of
labour
 Fewer caesarean
sections
 Less pain
 More self-esteem
 Better relationship with
the baby
 More breastfeeding
 Less depression
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 Best Evidence: During Labour
Birth Positions
Traditional belief Best evidence

 Supine position and  Supine -progressive acidosis

lithotomy best access of baby, slower progress
for attendant (supine hypotension)
 Other positions (lateral tilt,
upright, squatting, forward,
 Supine safest position on all fours)
 Less pain
 Less vaginal trauma
 Improved fetal outcome 14
The New Paradigm
Deemphasizes intuition,
unsystematic clinical
experience, and mechanism
based rationale for clinical
decision making

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 Evidence-Based Medicine
(EBM)

• The 1992 announcement of evidence-based

medicine argued, ‘‘all medical action of
diagnosis, prognosis, and therapy should rely
on solid quantitative evidence based on the
best of clinical epidemiological research’’

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 Treatments should be given not because
they “ought” to work, but because
they “do” work

Treatments should be avoided not because

they “ought” to cause harm, but because
they “do” cause harm

Fletcher, Fletcher & Wagner (1996).

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 What is Evidence-Based
Medicine (EBM)?

Evidence-Based Medicine (EBM) requires the

integration of:
1. The best research evidence
with
2. Our clinical expertise
and
3. Our patient’s unique values and circumstances.

Straus SE, Richardson WS, Glasziou P, Haynes RB. Evidence-Based Medicine – How to
Practice and Teach EBM, 3rd ed. Edinburgh: Elsevier Churchill Livingstone, 2005.
Evidence-Based Medicine

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 Best Research Evidence
• Valid and clinically relevant research, often from
the basic sciences of medicine, but especially
from patient-centered clinical research into the
accuracy of diagnostic tests (including the clinical
examination), the power of prognostic markers,
and the efficacy and safety of therapeutic,
rehabilitative, and preventive regimens.
• New evidence from clinical research both
invalidates previously accepted diagnostic tests
and treatments and replaces them with new ones
that are more accurate, more efficacious, and
safer.

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 Hierarchy of evidence
Quality Type of evidence
1a (best) Systematic review of randomized controlled trials
1b Individual randomized controlled trials with narrow confidence interval

1c All or none case series (when all patients died before a new therapy was introduced,
but patients receiving the new therapy now survive)

2a Systematic review of cohort studies

2b Individual cohort study or randomized controlled trials with <80% follow up

2c Outcome research; ecological studies

3a Systematic review of case-control studies
3b Individual case-control study
4 Case series
5 (worst) Expert opinion

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Strength of Recommendation

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 Strength of Recommendation
A Strong evidence of efficacy and substantial
clinical benefit support a recommendation for use
B Moderate evidence of efficacy or strong evidence of
efficacy but limited clinical benefit support a
recommendation for use
C Insufficient evidence to support a recommendation for or
against use, or evidence of efficacy might not outweigh
adverse consequences or alternative approaches
D Moderate evidence of lack of efficacy or of adverse
outcome support a recommendation against use
E Good evidence of lack of efficacy or of adverse outcome
supports a recommendation against use
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 Clinical Expertise

• The ability to use our clinical skills and past

experience to rapidly identify each patient’s
unique health state and diagnosis, their
individual risks and benefits of potential
interventions, and their personal
circumstances and expectations.

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 Patient Values
• The unique preferences, concerns and
expectations each patient brings to a
clinical encounter and which must be
integrated into clinical decisions if they are
to serve the patient.

Patient Circumstances
• Their individual clinical state and the
clinical setting.
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 How Do We Actually Practice EBM?
• Step 1: converting the need for
information (about prevention,
diagnosis, prognosis, therapy,
causation, etc.) into an answerable
question.

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 How Do We Actually Practice EBM?
• Step 2: tracking down the best evidence with
which to answer that question.

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 How Do We Actually Practice EBM?
• Step 3: critically appraising that evidence for
its validity (closeness to the truth), impact
(size of the effect), and applicability
(usefulness in our clinical practice).

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 How Do We Actually Practice EBM?
• Step 4: integrating the critical appraisal with
our clinical expertise and with our patient’s
unique biology, values, and circumstances.

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 How Do We Actually Practice EBM?
• Step 5: evaluating our effectiveness and
efficiency in executing steps 1–4 and seeking
ways to improve them both for next time.

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 What Are the Limitations of EBM?
• Misunderstandings and misperceptions of EBM, such
as the concerns that it ignores patient values and
preferences and promotes a cookbook approach.
• Expressed worry that EBM will be hijacked by
managers to promote cost-cutting.
• The contention that EBM is an ivory tower concept.
• The concern that EBM leads to therapeutic nihilism
in the absence of randomized trial evidence.

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 What Are the Limitations of EBM?
• Limitations unique to the practice of EBM that
must be considered:
– The need to develop new skills in seeking and
appraising evidence cannot be underestimated.
– The need to develop and apply these skills within
the time constraints of our clinical practice must
be addressed.

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Evidence-Based Global Maternal
Health Practice

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 Evidence-Based Interventions for
Major Causes of Maternal Mortality
Magnesium
Sulfate

Active Management
Family Planning Eclampsia
of the Third Stage of
and Postabortion 12%
Severe Bleeding Labor
Care Unsafe 24%
Abortion
13%
Antibiotics
Infection Indirect Causes
15% 20%*
Tetanus Toxoid
Immunization Obs. Other
Labor Direct
Iron supplements,
Clean delivery 8% Causes Malaria Intermittent
8%* Treatment and
Partogram Antiretrovirals for HIV
*Other direct causes include: ectopic pregnancy, embolism, anesthesia-related
*Indirect causes include: anemia, malaria, heart disease 35
Source: Adapted from “Maternal Health Around the World” World Health Organization, Geneva, 1997
Key Intervention: Partograph

•Decreases incidence of:

•obstructed and
prolonged labor
and fistula
•infection
•newborn asphyxia

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 Key Intervention: Active
Management of Third Stage of Labor
(AMTSL)
• Can reduce postpartum hemorrhage by up to
60%
• Consists of:
– Oxytocin 10 IU IM
– Controlled cord traction
– Uterine massage

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 Key Intervention: Emergency
Obstetric and Newborn Care (EmONC)
Basic EmONC
IV uterotonics
IV antibiotics
IV anticonvulsants
Manual vacuum aspiration
Assisted delivery
Manual removal of placenta
Newborn resuscitation

Comprehensive EmONC
BEmONC + surgical
capability and blood
transfusion

Photo: ACCESS/Afghanistan 38
 Interventions to Reduce
Maternal Mortality
Historical Review
• Traditional birth attendants
• Antenatal care
• Risk screening

Current Approach
• Skilled attendant at delivery

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 The higher the proportion of deliveries attended by skilled
attendant in a country, the lower the country’s maternal mortality
ratio
2000
Maternal deaths per 100,000 live births

1800
R2 = 0.74
1600 Y Log. (Y)

1400

1200

1000

800

600

400

200

0
0 10 20 30 40 50 60 70 80 90 100

% skilled attendant at delivery

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The pipeline from knowledge to practice 41
 Closing Remarks

• Medicine is not just a science—it is a human

activity. It entails ritual, custom, and the
expectations of doctors, patients, and society.
• To safeguard against ineffective or harmful health
care we need doctors who:
• want to do the best they can for their patients,
• are willing to continually question their own
managements, and
• have readily available sources of information about
what does work.
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