Beyond evidence-based medicine: complexity and stories of maternity care Soo Downe BA (Hons) RM MSc PhD Professor of Midwifery Studies, Research in Childbirth and Health (ReaCH) group, School of Public Health and Clinical Sciences, Faculty of Health and Social Care, University of Central Lancashire, Preston, Lancashire, UK Correspondence Soo Downe School of Public Health and Clinical Sciences Faculty of Health and Social Care University of Central Lancashire Preston, Lancashire, PR1 2HE UK E-mail: sdowne@uclan.ac.uk Accepted for publication: 11 November 2009 doi:10.1111/j.1365-2753.2009.01357.x Introduction In 1979, Ian Chalmers gave obstetrics the wooden spoon award, as the worst health care discipline in terms of evidence and practice [1]. This observation led directly to the publication of Effective Care in Pregnancy and Childbirth [2], and then, eventually, to the creation of the Cochrane Collaboration [3]. The intention was honourable: to summarize and disseminate all the existing evi- dence in a particular field, so that important information was not missed, so that health care staff could maximize their certainty about the best possible treatments and so that those using the health services could have the best possible treatment. Govern- ments and managers saw the potential for this approach to protect public funds against litigation risk. If widespread agreement could be reached about best practice, this could be translated into pro- tocols and guidelines. If health care staff were then mandated to follow these rules, litigation cases could be defended. An addi- tional bonus was the opportunity for cost-effective health care, based on authoritative rulings from organizations, such as the National Institute of Clinical Effectiveness (NICE) in the UK. All of this is logical and worthy, at least in principle. However, the translation of formally condoned ‘evidence’ into practice has been highly problematic. The main issue of contention has been what kind of evidence is accepted as authoritative. From a Khunian perspective of ‘normal science’ as a social construct [4], current authoritative science thinking in medicine and health care has, until very recently, been strongly rooted in positivism. This has translated into a hierarchy that strongly favours the randomized controlled trial, based on the concept that bias in any experiment will corrupt the result [5]. The gold standard in this paradigm is large (enough) trials with simple protocols [6]. This approach has been very successful in locating improved treatments in many areas of health care. In maternity care, for example, the use of magnesium sulphate for pre-eclampsia has made a dramatic contribution to improving the outcomes of preg- nant women with pre-eclampsia and eclampsia [7]. However, there is an increasing recognition that this approach to knowledge, based on simple linear thinking at a population level (what is best for the majority), may not provide the solutions for a range of more complex issues at the level of the individual, where most service users interact with most health care staff. Indeed, writing recently on complexity in maternity care, Murray Enkin, one of the authors of Effective Care in Pregnancy and Childbirth, has stated: This paper . . . was conceived during an era of medical authoritarianism, born in a time of nascent childbirth educa- tion and family-centered maternity care, matured in a period of enthusiastic (but not unquestioning) homage to evidence- based obstetrics, and culminated in a reluctant but comforting acceptance of uncertainty . . . It is, to use an ancient word I only recently learned, a clinamen, a swerve, a point of intel- lectual revision [8] In fact, a move towards complexity thinking is not so much of a clinamen as it might appear to be. In a paper published in 1997, David Sackett and colleagues make it quite clear that evidence- based medicine, then in its infancy, was ‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients . . . integrating individual clinical expertise with the best available external clinical evidence from systematic research . . .’ [9]. Importantly, they go on to state that: By individual clinical expertise we mean the proficiency and judgment that we individual clinicians acquire through clini- cal experience and clinical practice . . . reflected in . . . more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients’ predicaments, rights, and preferences in making clinical Journal of Evaluation in Clinical Practice ISSN 1356-1294 © 2010 The Author. Journal compilation © 2010 Blackwell Publishing Ltd, Journal of Evaluation in Clinical Practice 16 (2010) 232–237 232