What Does Evidence-Based Mean?
Part of the mission of Breastfeeding USA is to provide evidence-based information. What does that statement mean? What is evidence? In the strictest sense, it is information that is backed by solid, peer-reviewed research based on established scientific principles. For a very long time, there was little strong empirical evidence related to breastfeeding, and most of the existing research was concerned with the components of breastmilk. Thankfully, there is now a growing body of research on many aspects of breastfeeding. Sometimes, the results affirm what we already suspected to be true, and sometimes they are surprising. The strongest information is provided by systematic review of randomized, blinded, controlled trials. The problem with waiting for this type of affirmation is that these types of trials are either very involved and expensive or impossible to conduct. Who will pay for this kind of investigation into best breastfeeding practices? And even with the best research, there can be questions about whether the results can be generalized to a large population.
So, what if there is no research on a particular topic? There are many common breastfeeding (and medical) practices that have no formal research to support them. From an editorial in the British Medical Journal in 1996, "The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research." This article stresses the need to customize the application of new information based on the client's circumstances and preferences. What are the implications for Breastfeeding Counselors? We should use the results of the latest and best research, our own observations, and the experiences of others working with breastfeeding dyads to make decisions when working with mothers and babies.
We have seen the problems inherent in using anecdotal information and poorly-designed research. For example, we no longer advise mothers to toughen up their nipples or to nurse their babies in only a few, very specific positions. Indeed, recent ultrasound studies seem to negate the very existence of the long-recognized milk sinuses that (we thought and taught) babies needed to compress in order to receive milk. Those individuals working with breastfeeding dyads need to more systematically document and share what they are seeing and how mothers and babies respond to various interventions so that we can advance our knowledge of what truly works and what doesn't. Counselors and health professionals should not routinely offer suggestions that many others have found are rarely successful. If we have access to the combined observations of many skilled counselors and health professionals, we can feel more confident in using information that is not backed by formal research. Also, we must be careful to differentiate between observation and interpretation. It is not unusual for two people to witness the same event and have different ideas about what they have seen: does a swaddled baby stop crying because he is calmed and happy or because he is overwhelmed and has shut down?
An evidence-based practice is balanced. We must consider the circumstances, values, and preferences of the mothers we serve as we share our evidence-based information. Without the best current and classic external research, practice and information become outdated and may be ineffective or even harmful. Without clinical and/or personal experience, practice and information risk becoming solely research-dominated and may not take an individual mother's needs into account. Without taking into consideration the mother's values, preferences, and realities of life, practice and information become irrelevant and may become unethical.
Maintaining current knowledge of the latest, peer-reviewed research is very important for anyone who is helping mothers and babies succeed with breastfeeding. In the absence of such research, we can include, thoughtfully, the body of experience that many counselors and professionals have developed in breastfeeding their own children and through helping other dyads. An evidence-based practice not only presents the best information available but also respects the mother's right to evaluate that information and use it to make informed decisions for her family. We must not forget that much of our role as counselors has nothing to do with facts and figures but is instead focused on making a connection with another mother and empowering her to make the best decisions for herself and her baby.
The Cochrane Collaboration is a great resource for finding out more about evidence-based research and practice.
Sackett, D., Rosenberg, W., Muir Gray, J.A., Haynes, R.B., & Richardson, S. (1996). Editorial Evidence Based Medicine: What it is and What it isn't. British Medical Journal 312:71.