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What’s Behind the Cochrane? (or…, “The Good News About Midwives Gets Better!”)

Note: If this post looks familiar, then thank you for being one of my dedicated readers who has followed me from the very beginning. Yes, this is a repost of my very first blog post and this week marks the first anniversary of Science & Sensibility! Happy blog-aversary to us!  Later this week, I’ll share a few of my favorite posts and other milestones over the past year. And if you missed this one a year ago, here’s an “understanding research” lesson all wrapped up in a package of very good news (ok, not-so-new news) about midwives!

Often, the closer I look at a study, the less confident I become about the results. I’ve learned that you can’t always trust a paper’s title or abstract, and media coverage of new studies can be woefully misleading, even when it is not carefully orchestrated by those with a vested interest (which it often is). Being advocates for “evidence-based care” means not just knowing that a study has been published, but knowing whether that study is any good, and in what circumstances (if any) the results are relevant and reliable. It also means having our guard up against deeply flawed studies that shape policy and practice despite their limitations. (Henci Goer has done a fantastic job deconstructing some of these influential studies in her series, When Research is Flawed.)

A systematic review synthesizes all of the literature on a given topic, using rigorous criteria for which studies will be included. For instance, Cochrane systematic reviews are typically confined to randomized, controlled trials in which there is no evidence that the randomization process has been intentionally subverted. For this reason, Cochrane reviews are considered the “gold standard” of evidence.

But what happens when the trials that make up a systematic review themselves have flaws or limitations? We end up with Cochrane reviews that can mask problems in the literature, and we can inadvertently put the evidence-based “stamp of approval” on a practice that still needs to be studied further. This is referred to as the “garbage in, garbage out” phenomenon, and we see plenty of it in the obstetric literature.

One kind of garbage that Cochrane reviews rarely address is crossover. This is when some of the participants randomized to the “control group” (e.g., no intervention) end up getting the intervention that is being tested. This problem is rampant in trials of induction, pain relief, and episiotomy, among others. Some women randomized to “expectant management” end up getting induced; some women randomized to “non-epidural pain management” end up getting epidurals; some women randomized to “conservative use of episiotomy” end up getting episiotomies, and so on.  This makes it much more difficult to use our statistical toolbox to discover differences between the two groups, and as a result we see smaller differences, or even no difference. The “evidence-based” conclusion then becomes “there’s no difference is unwanted outcomes, so the intervention is harmless.” But “no difference” can also mean “this study wasn’t big enough to find a difference” or, in this case, “there was too much crossover to detect a true difference.”

The crossover problem usually drives me crazy because it often serves to perpetuate medical-model bias and medical-model practices. But I had an “ah ha” moment when I discovered a crossover-of-sorts problem in the 2008 Cochrane systematic review of midwife-led care. This review was released to fanfare within the birth community. Finally, the enormous body of literature on midwifery had been synthesized by Cochrane reviewers and the conclusions were firmly in favor of midwife-led care! The results were, indeed, unusually impressive. While the conclusions of many Cochrane reviews are couched in tentative language and call for more research, the reviewers here concluded decisively, “Midwife-led care confers benefits and shows no adverse outcomes. It should be the norm for women classified at low and high risk of complications” (p. 17). Still, when I looked a little closer, I was perplexed that some of the differences the Cochrane reviewers found were small or even non-existent. What? No difference in c-sections? Only a small difference in episiotomy? What’s going on here?

A kind of crossover is the culprit, and this time it means that the good news just gets better! It turns out, of the 11 trials comprising over 12,000 women, in all but 1 of these trials (with only 318 participants), some or all of the women in the control groups were actually cared for by midwives. The difference was that that these midwives were supervised by physicians, or they shared their client caseload with physicians. The Cochrane reviewers were not interested in comparing midwives versus doctors. They took it for granted that midwifery care itself is safe, effective, and satisfying. This is, after all, a global consensus, to which the United States remains in stubborn and lonely opposition. Working from the assumption that midwives are an important part of the maternity care system, the question becomes how should we organize that system? Who should coordinate the care of childbearing women – midwives or doctors? Midwife-led care means that women receive their primary maternity care with the midwife, and the midwife engages an obstetrician or other consultant when some aspect of the woman’s or baby’s care falls outside of the scope of independent midwifery practice. This stands in stark contrast to the typical arrangement in the United States, when midwives are supervised by obstetricians or employed by hospitals, and obstetric protocols and productivity standards drive midwifery practice.

Women often believe that going to an obstetrician practice that employs midwives is getting “the best of both worlds.” The Cochrane review of midwife-led care in fact tells us that such arrangements are ineffective, inefficient, and may be hazardous to the health of women and babies.

Citation: Hatem M, Sandall J, Devane D, Soltani H, Gates S. Midwife-led versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD004667. DOI: 10.1002/14651858.CD004667.pub2.

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  1. avatar
    Heather
    April 19th, 2010 at 12:31 | #1

    That “best of both worlds” view is EXACTLY how I used to feel. My first child was born with an OB-only practice. I switched to a practice with both OBs and CNMs for the second child. I had a CNM attend my birth at the hospital. And now, trying to conceive #3, I am planning a homebirth because I have seen how much the current system forces midwives to over-medicalize perfectly normal births when they occur in the hospital setting. It’s just too bad the political and health-insurance system won’t see it that way and PAY for my homebirth (at what would likely be a much lower cost).

  2. April 19th, 2010 at 14:34 | #2

    Congratulations on a year of excellent blogging! :)

  3. April 19th, 2010 at 17:53 | #3

    Congrats on your anniversary!

  4. avatar
    Laura
    April 19th, 2010 at 21:24 | #4

    I’m confused how the review actually shows that independent midwives are better then. Considering the cross-over and that results were similar, doesn’t it imply that an care of an independent midwife and a midwife until control of the hospital or OB is similar?

  5. April 19th, 2010 at 21:33 | #5

    The reason the review shows that independent midwifery is more effective than supervised midwifery is that that is exactly what they were studying. The trials included in the study randomized women to receive midwife-led care or some other model of care (shared care between midwives and doctors, or midwives supervised by doctors or MD-only.) There wasn’t “crossover” in the strict sense of the term – the control group (supervised midwives, shared care, or MD-only care) did not receive the actual “intervention” (independent midwife-led care). But most of them did receive midwifery care – that is, care actually provided by a midwife. That’s the source of the “crossover”, and that’s why the differences in things that you think of when you think “midwifery model” (cesarean, episiotomy, etc.) may be small or nonexistent. But there were many significant differences between the groups, and they all favored midwife-led care.

    I wrote this post because most of the people I talked to about this Cochrane review either didn’t know it existed or, if they did, assumed it was a Cochrane comparing midwives with doctors. I myself was surprised when several weeks after hearing about the Cochrane Review, I actually sat down and read it and had my “ah ha” moment. Does that make any more sense now?

  6. January 2nd, 2013 at 12:41 | #6

    Do you know where I can find an online source for the following article by Henci Goer?

    “When Research is Flawed: Critiques of Influential Research Studies”, by Henci Goer

    It appears that Lamaze has deleted it from their website.

    Thanks,
    Joy

  1. April 22nd, 2010 at 18:08 | #1