The work of the National Perinatal Epidemiology Unit. One example of technology assessment in perinatal care

Academic contributions to the development of evidence and policy systems: an EPPI Centre collective autoethnography

BACKGROUND

Evidence for policy systems emerging around the world combine the fields of research synthesis, evidence-informed policy and public engagement with research. We conducted this retrospective collective autoethnography to understand the role of academics in developing such systems.

METHODS

We constructed a timeline of EPPI Centre work and associated events since 1990. We employed: Transition Theory to reveal emerging and influential innovations; and Transformative Social Innovation theory to track their increasing depth, reach and embeddedness in research and policy organisations.

FINDINGS

The EPPI Centre, alongside other small research units, collaborated with national and international organisations at the research-policy interface to incubate, spread and embed new ways of working with evidence and policy. Sustainable change arising from research-policy interactions was less about uptake and embedding of innovations, but more about co-developing and tailoring innovations with organisations to suit their missions and structures for creating new knowledge or using knowledge for decisions. Both spreading and embedding innovation relied on mutual learning that both accommodated and challenged established assumptions and values of collaborating organisations as they adapted to closer ways of working. The incubation, spread and embedding of innovations have been iterative, with new ways of working inspiring further innovation as they spread and embedded. Institutionalising evidence for policy required change in both institutions generating evidence and institutions developing policy.

CONCLUSIONS

Key mechanisms for academic contributions to advancing evidence for policy were: contract research focusing attention at the research-policy interface; a willingness to work in unfamiliar fields; inclusive ways of working to move from conflict to consensus; and incentives and opportunities for reflection and consolidating learning.

Seventy-five trials and eleven systematic reviews a day: how will we ever keep up?

When Archie Cochrane reproached the medical profession for not having critical summaries of all randomised controlled trials, about 14 reports of trials were being published per day. There are now 75 trials, and 11 systematic reviews of trials, per day and a plateau in growth has not yet been reached. Although trials, reviews, and health technology assessments have undoubtedly had major impacts, the staple of medical literature synthesis remains the non-systematic narrative review. Only a small minority of trial reports are being analysed in up-to-date systematic reviews. Given the constraints, Archie Cochrane's vision will not be achieved without some serious changes in course. To meet the needs of patients, clinicians, and policymakers, unnecessary trials need to be reduced, and systematic reviews need to be prioritised. Streamlining and innovation in methods of systematic reviewing are necessary to enable valid answers to be found for most patient questions. Finally, clinicians and patients require open access to these important resources.

The origins, evolution, and future of The Cochrane Database of Systematic Reviews

The Cochrane Database of Systematic Reviews (CDSR) evolved in response to Archie Cochrane's challenge to the medical profession to assemble "a critical summary, adapted periodically, of all ... relevant randomized controlled trials". CDSR has been an electronic publication from its inception and this has meant that Cochrane reviews (i) need not be constrained by lack of space; (ii) can be updated as new information becomes available and when mistakes or other ways of improving them are identified; and (iii) can be cross-linked to other, related sources of relevant information. Although CDSR has become widely cited, it must continue to evolve in the light of technological and methodological developments, and in response to the needs of people making decisions about health care.

The Cochrane pregnancy and childbirth database. Implications for perinatal care policy and practice in the United States

The Cochrane Pregnancy and Childbirth Database (CCPC) is the most sophisticated realization of the meta-analytic potential within the health fields. At the core of this ongoing collaborative international project are about 600 systematic reviews of the effectiveness of specific forms of perinatal care, which have been created from a registry of clinical trials. The scale and quality of information available through CCPC are unprecedented. An examination of implications of CCPC suggests that many far-reaching changes in perinatal policy and practice are indicated. CCPC has become a model for similar work that is being organized in many other clinical areas under the umbrella of the pan-clinical Cochrane Collaboration, and the experience and implications of CCPC will be of interest to many working in other areas. The implications of these ambitious meta-analytic projects are profound; the degree to which they will be realized is less certain.

Trends in perinatal death rates in Denmark and Sweden, 1915-1990

Perinatal mortality rate (PMR) is often taken as an indicator of the quality of obstetric care. Its decline started in the early 1940s in Denmark and Sweden, at the same time as in several other European countries, and its development has been strikingly parallel in the two Scandinavian countries. The changes in the mothers' ages and birth order do not coincide with the changes in the PMR. The percentage of children born weighing less than 2500 g has been very stable over time, albeit higher in Denmark. The move towards hospital confinements in obstetric care took place mainly in the 1930s in Sweden, i.e. before the decline started, and in the 1950s and 1960s in Denmark. The factors investigated have contributed very little to explain why the PMR started to decline in the early 1940s. Factors associated with the distribution of perinatal deaths in a population do not seem to be able to explain the changes taking place over time. In the current study it is postulated that factors behind the change in the PMR are improvements in the mothers' health together with the decline in the total period fertility rate from the beginning of this century. With a smaller number of children the risk of infection was reduced and the amount of food available to each child and pregnant woman increased. This better health in early life may be associated with improved reproductive health in the adult years.

The diffusion of obstetric technology into rural U.S. hospitals

We determined the distribution and sophistication of obstetric technologies in all 80 maternity hospitals in the state of Washington and examined the effect of rural or urban location, birth volume, and physician staffing on technological intensity. Although smaller and more rural hospitals refer most premature and low-birth-weight infants to regional referral centers, sophisticated prenatal and intrapartum technologies are available in the majority of even the smallest and most remote rural units. Rural hospitals have slightly lower obstetrical intervention rates than do their urban counterparts, but the differences are not great.