In the September 2009 issue of Evidence Based Midwifery, Dr Denis Walsh in his paper Pain and epidural use in normal childbirth
(Walsh, 2009) presents a series of arguments in support of his view
that epidural analgesia interferes with the physiology of normal labour
and that maternity services are failing ‘to provide forms of care that
are known to lower epidural rates’. The paper stops short of saying
that epidurals should be withheld in some women.
Unfortunately Dr. Walsh’s arguments do not support his conclusions.
First, he makes the error of mistaking correlation
for causation. According to a recent Cochrane review (Anim-Somuah et
al, 2005) epidural analgesia is correlated with an increase in
instrumental delivery and a prolonged second stage of labour (but not
unplanned caesarean section). However, this correlation has not been
shown to be causative, that is, it has not been demonstrated that
epidural analgesia causes instrumental delivery.
Since the correlation between epidural analgesia
and instrumental delivery has not been shown to be causative, it cannot
be stated that a reduction in provision of epidural analgesia would
result in an improvement in rates of instrumental delivery or a shorter
second stage of labour.
Similarly, Dr. Walsh states that epidurals are
associated with a need for more syntocinon when in fact epidural
analgesia is often requested after syntocinon augmentation, as the
latter results in more painful labour. Fetal malposition, for example,
the occipito-posterior position, is associated with a more painful
labour and this again often results in a request for an epidural, but
the epidural is not the reason for the malposition of the baby.
Dr. Walsh bases much of the rest of his argument on
anecdote, conjecture and unproven assertions. The language in his paper
uses frequent ‘weasel words’, words and phrases which seem to be
powerful but which are actually empty of meaning. Examples include:
‘These are the countless numbers of personal testimonies that women
share…’; ‘In fact there is considerable anecdotal evidence that…’;
‘However, the vast majority of women…’
and ‘… it appears that women have never been more frightened of the process.’
Dr. Walsh’s paper boils down to what is,
effectively, his opinion. Expert opinion ranks as category IV evidence,
which is the weakest level of evidence (Scottish Intercollegiate
Guidelines Network, 2008). Debate on this topic is welcome, but
stronger evidence will be needed before a widespread change in current
practice can be advocated.
The General Medical Council publication on the duties of a doctor (GMC, 2009) explicitly states that doctors have a duty to ‘take steps to alleviate pain and distress’
Pain during labour does not have to be tolerated. Many women, aware of
the potential of epidural analgesia to provide pain-free labour, choose
this option despite being aware of the potential drawbacks. We support
our patients’ right to make that choice for themselves.
Aidan O’Donnell, BSc MBChB FRCA.
Consultant obstetric anaesthetist, St. John’s Hospital, Livingston, EH54 6PP, UK.
Vicki Clark, MBChB FRCA.
Consultant obstetric anaesthetist, Simpson Centre for Reproductive Health, The Royal Infirmary of Edinburgh, EH16 4SA UK.
Dr Walsh responds
Thank you for your comments. The intent of my paper
was to encourage debate and discussion on this very important topic. It
was an ‘opinion piece’, putting forward arguments based on a range of
sources that included some clinical evidence, evidence from qualitative
research, experiences of midwives and my own involvement with midwifery
over a number of years.
When making choices about forms of care,
individuals use a range of sources, not just clinical evidence. It was
with this in mind that I wrote this discursive article. You dismiss the
use of weasel words and phrases, but in debating a topic, this
linguistic technique is commonplace. People make up their own minds
based on their particular lens of how they understand the issue.
While I am disappointed that you chose not to
comment on attitudes to pain outlined elsewhere in the article, I do
accept your critique regarding causation and correlation. It was
misleading to list side-effects that imply causation, rather than to
simply say there is an association between epidurals, which is the
Cochrane review wording (Anim-Somuah et al, 2005).
I think we would agree that research on epidurals
use in an otherwise normal labour has been neglected, especially in
relation to how women understand and interpret pain.
Thank you once again for your letter.
PhD, MA, RM, RGN.
Associate professor of midwifery, University of Nottingham, Nottingham City Hospital, Nottingham NG5 1PB
Anim-Somuah M, Smyth RMD, Howell CJ. Epidural versus non-epidural or no analgesia in labour. (2005) Cochrane Database of Systematic Reviews 4
: CD000331. Doi: 10.1002/14651858.CD000331.pub2
Scottish Intercollegiate Guidelines Network (2008). Sign 50 a guideline developer’s handwork. http://www.sign.ac.uk/pdf/sign50.pdf
(accessed 15 February 2010).
General Medical Council. (2009) Good medical practice: duties of a doctor
(accessed 15 February 2010).
Walsh D. (2009) Pain and epidural use in normal childbirth. Evidence Based Midwifery 7(3):
By Ann Marie Begley
Lecturer at the School of Nursing and Midwifery, the Queen’s University Belfast
Evidence-based midwifery, patterns of knowing
Porter’s paper (2009) represents an excellent example of how the arts can facilitate insight and inspire reflection on practice, particularly evidence-based practice (EBP). He also presents a challenge to Carper’s (1978) thesis that there are four ‘fundamental patterns of knowing’ in practice. Carper’s work is an example of the development of philosophical and scholarly maturity in the late 1970s and 1980s, and at that time it represented a watershed in epistemology. It has been cited and analysed extensively since publication, and more than 30 years on I believe that the most significant and enduring contribution of this paper is the assertion that we cannot rely on empirical knowledge alone. This does not in itself undermine the importance of empirical knowledge or EBP.
Porter asks: ‘So how might we be persuaded that midwifery knowledge includes personal, aesthetic, and ethical ‘knowing’?
The problem, I think, with Carper’s thesis is the use of the word ‘knowledge’ in relation to non-empirical ‘patterns’ of ‘knowing’, and I share Porter’s discontent to that extent. Can Carper’s non-empirical ‘patterns’ be called knowledge, or do they represent some other faculty? Yet, even if they cannot be classified as knowledge, this does not necessarily sound the death knell for Carper’s thesis. Porter seems to be:
Objecting to these ‘patterns’ being referred to as knowledge; and Challenging the claim that they form an essential part of the intellectual capacity of practitioners.
The response to the first point is fairly simple. It is futile to get embroiled in heavy discussions about whether these patterns or faculties can be referred to as knowledge, or if they fall into some other category. The issue of exactly what constitutes knowledge has been the subject of philosophical debate since the time of Plato Guthrie (1956) and we have really moved no further on today. The problem can be resolved by employing what might be called a semantic manoeuvre – call these ‘patterns of knowing’ something else! We might refer to these ‘patterns’ as excellences of character and intelligence (Thompson, 1976; Urmson, 1998), mental qualities (Beauchamp, 1998) and qualities of temperament (Ellington, 1993). They could also be called attributes, dispositions, virtues or faculties of the mind. Whatever words we use to describe the personal, aesthetic or moral dimensions of practice, the suggestion that a midwife can practice well without them is counterintuitive: a diet of scientific knowledge alone is not sufficient.
So, in relation to the second bullet point these faculties are, alongside empirical knowledge, essential in practice. Midwifery practice is much more than a series of complex clinical interventions and it requires attributes such as excellence in intellectual pursuits, good judgement, discernment, executive skills and excellence of character (moral excellence). The competent practitioner requires a balance of these.
Then there is the difference between knowledge and wisdom. Wisdom is the appropriate use of knowledge, and the practitioner who lacks the wisdom to use evidence appropriately will not practice well. So, EBP is only as good as the midwife who uses it. A midwife who engages in EBP but who lacks good social skills, sensitivity, compassion and wisdom (both practical and theoretical), will not be a good midwife. She will not become an expert practitioner, or an exemplar (Begley, 2005; 2006). Any challenge to this position should make us wonder how midwives can possibly engage with women in various complex, sensitive, and intimate contexts without these other faculties coming into play.
Porter then asks: ‘Can we really expect clients today to take it on faith alone that midwives are animated by authenticity, empathy and ethics?’
Nobody needs to ‘take it on faith’ that these attributes are present or that they are used effectively – we simply need to observe, or have experience of a good midwife in practice. These qualities or attributes are experienced by clients and their partners and I do not think that we need to produce further evidence to support the claim that they are an integral part of midwifery practice. The shoe is, rather, on the other foot. If we are to be convinced that aesthetics, ethics and other attributes do not form part of the interlocking web of qualities which go to make up the good midwife, then the sceptic needs to present us with evidence in support of this claim.
Expert practice requires a synthesis of science (including evidence) and sensitivity – and sometimes we all need to be reminded to get in touch with our sensitive sides!
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Carper B (1978) Fundamental Patterns on Knowing in Nursing. Advances in Nursing Science 1:
Ellington JW. (1993) Kant I. (1785) Grounding for the metaphysics of morals.
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Guthrie WKC. (1956) Plato, Protagoras and Meno. (Translation) Penguin Classics: Reading.
Porter S. (2009) On the antiquity of evidence-based midwifery and its discontents. Evidence Based Midwifery 7(1):
Thompson JAK. (1976) Aristotle, The Ethics of Aristotle
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Professor Sam Porter PhD, BSSc, DipN
Chair in nursing research at the School of Nursing and Midwifery at Queen’s University Belfast.
: Patterns of knowing, evidence-based midwifery
It is gratifying that a reader feels sufficiently moved by what one writes to spend time in considering and responding to it. However, there are a number of assertions about my paper (Porter, 2009) that I wish to discusss.
The writer observes that I seem to have two major problems with Carper’s (1978) patterns of knowing. The first is that I object to them ‘being referred to as knowledge’. I make no such objection. Indeed, I explicitly and repeatedly describe them as ‘patterns of knowing’ and ‘forms of knowledge’. My argument was not with Carper’s thesis that such patterns of knowing exist, but with those who have used her model to attack evidence-based practice (EBP) (Fawcett et al, 2001).
The writer believes that I am challenging the claim that Carper’s patterns of knowing ‘form an essential part of the intellectual capacity of practitioners’. Once again, I am not making any such challenge. My discussion was not about the contribution they make to the intellectual capacity of practitioners per se, it was about how that contribution is demonstrated.
To return to my engagement with Fawcett et al (2001) and the authors’ contention that EBP constitutes a form of empirics that smothers other patterns of knowing, my problem with this idea was the authors’ exclusive attribution of blame for this state of affairs on the negative effects of EBP. I suggested that part of the reason for its dominance lay in its amenability to public verification or refutation. I noted that, in contrast, Carper sets up aesthetics, personal knowledge and ethics as patterns of knowing that, to greater or lesser degrees, elude testing or description. My point was that this is where the problem lay, not in the patterns themselves.
Why is it a problem? Well, to use the quotation from my paper that the writer singled out, it revolves around the question: ‘Can we really expect clients in this day and age to take it on faith alone that midwives are animated by authenticity, empathy and ethics?’
While all of these patterns are essential to good practice, it is not good enough for practitioners just to claim that they possess them. What clients need to see is how they are worked out in practice, or as the writer puts it in fine empirical fashion, ‘we simply need to observe’!
There is much in her discussion concerning the indispensability to good midwifery care of attributes such as wisdom, compassion and sensitivity that is commendable. The problem is that, once again, she seems to be assuming that I was adopting a contrary position. To reiterate, this is a categorical misrepresentation of my argument. Of course midwives should be wise, compassionate and sensitive in their interactions with clients. Where I part company with the writer is in her failure to distinguish between the attributes midwives should have, and the attributes that they actually display in their interactions with clients. While we would all hope that these would be one and the same, it is naive to assume that they will be in all circumstances.
This conflation of the aspirational and the actual is most clearly articulated in the assertion that: ‘These qualities or attributes are experienced by clients and their partners and I do not think that we need to produce further evidence to support the claim that they are an integral part of midwifery practice’
(my emphasis). While these qualities should indeed be an integral part of midwifery practice, those of us, including myself and the editor of this journal (Porter et al, 2007), who have produced evidence concerning midwives’ interactions with their clients, have established that this is not always the case. For example, we discovered occasions where, rather than being the outcome of authentic negotiation with mothers, midwives’ actions were determined by the bureaucratic requirements to which they felt they needed to adhere.
While the aesthetic, personal and ethical knowledge of midwives is certainly evidenced in the experiences of some clients some of the time, to assume that these forms of knowledge are always used and that we have no responsibility to examine whether or how much they animate everyday midwifery practice is to bring down the shutters on any form of critical reflection. That way leads to professional arrogance and poor practice.
So what is the alternative? My central argument was that for other patterns of knowing to challenge the dominance of empirics, they need to become more amenable to the scrutiny of those whom they are designed to help. This means that those who recognise the significance of alternative patterns of knowing have a responsibility to get down to the hard work of clearly showing how aesthetics, personal knowing and ethics contribute to the quality of practical midwifery care. Indeed, it is only through uncovering the factors that promote or impede that contribution that we can hope to continue improving care. I have to say that I do not regard such a position as either insensitive or lacking in insight, but I will leave that to readers to judge.
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Porter S. (2009) On the antiquity of evidence-based midwifery and its discontents. Evidence Based Midwifery 7(1)
Porter S, Crozier K, Sinclair M, Kernohan WG. (2007) New midwifery? A qualitative analysis of midwives’ decision-making strategies. Journal of Advanced Nursing 60(6):