Presentation1 Promotingevidence basedcare

							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


                     U ns a f e
                    a bor t i on
                       13%            H e mor r ha ge
                                             25%

            I ndi r e c t
               20%
                                          Se ps i s
        Ot he r di r e c t
                                            15%
               8%
                                       HDP
              Obs t r uc t e d
                                   E c l a mps i a
                  l a bor
                                        13%
                     7%
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

 Evidence-based medicine is the systematic,
    scientific and explicit use of current best
evidence in making decisions about the care of
                individual patients.
 Levels of Evidence and Grades of
 Recommendations

    Grade of     Level of
                            Interventions
recommendation   evidence
                            Systematic review of randomized
                   1a
      A                     controlled trials
                   1b       Individual randomized controlled trial
                   2a       Systematic review of cohort studies
                   2b       Individual cohort study
      B
                   3a       Systematic review of case-control studies
                   3b       Individual case-control study
      C             4       Case series
                            Expert opinion without explicit critical
      D             5       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
         Reduced Risk                    Increased Risk
       Confidence Interval




                                                     Results consistent
                                                        with chance




0.01   0.1                   1                10              100
                  Odds           Ratio

                         No Difference
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.