Republic of Moldova: evidence-based medicine – a new approach to childbirth

The concept of evidence-based medicine is revolutionizing obstetric and prenatal care in many countries – the Republic of Moldova is one of them. Among the lists of telephone numbers, family photos and yellow notes on the wall at the Municipal Perinatal Centre of Chisinau, capital of the Republic of Moldova, hangs a quotation in bold print: “Patient satisfaction is one of the main indicators of health care quality”.

To a visitor from the west, the message may not sound unduly remarkable, but to obstetrician/gynaecologist Stelian Hodorogea, Assistant Professor at the Medical University of Chisinau, it is one of the keys to a concept that has changed his view of what it means to be a physician. Stelian Hodorogea is a tall, lean man whose lively, boyish gestures suggest that he is having difficulties curbing his enthusiasm. Sitting at his desk, he eagerly explains what the new doctrine signifies for him.

“If I ask five colleagues about their opinion on a case, I get five different answers” he says. “But with evidence-based medicine I know I can find the best current practice. My favourite definition of evidence-based medicine is that it is the integration of the best available data with the clinical experience of the doctors and the preferences of the patients,” he says, “although we who work in obstetrics shouldn’t use the word ‘patients’. We ought to say ‘clients’, since most of the women we work with are healthy.”

The term evidence-based medicine (EBM) goes back to the 1980s when a medical school in Canada coined the phrase to designate a clinical strategy it had been developing, the essence of which was that every measure taken in medical care should be based on the best available scientific evidence. Accomplishing this involves a process of systematically searching for and evaluating contemporary research findings, and incorporating them into medical practice. EBM therefore requires new skills of physicians, including efficient information seeking and the ability to assess results.

The concept of practising medicine based on sound evidence is, of course, not new. However, the information explosion of the past two decades has given the concept new and previously unimagined possibilities. Today, EBM is increasingly seen as a new benchmark in medicine, replacing the traditional authority-based norm.

For Stelian Hodorogea, the paradigm shift began when he attended a course in reproductive health in Sweden five years ago. One lecture, called “Are we doing the Right Thing?” dealt with the concept in detail. “I was shocked,” he remembers. “The idea that we could critically question our own practice was entirely new to me. During Soviet times we were cut off from the rest of the world, without access to western research. It was startling to find out that so many of the medical practices used in other parts of the world were different to ours, without our knowing why.”

His new insights were confirmed when WHO organized the Republic of Moldova’s first evidence-based medicine training programme in 2003. “I would almost say that it changed my life, at least professionally,” he continues. “I’m no longer limited to only having access to my colleagues’ thinking. I can observe practices used in other countries which have much better results than ours.”

Another component of EBM valued by Stelian Hodorogea is the practice of asking the patient’s opinion and involving her in decision-making. “It’s doubtless the best way to obtain satisfied patients and avoid complaints,” he says. “It is a method that was never practiced in this country earlier, and one which many of my colleagues still find it difficult to embrace.”

For Valentina Baltag, a former colleague of Stelian Hodorogea now working at WHO/Europe, the encounter with EBM was a similar revelation. “After I had attended my first course I thought: ‘This is so obvious! Perhaps everyone else has figured it out ages ago, and I’m the only one still in the dark’” she says. “But then I realized it takes a sort of shift in the mind to begin to practice it.”

This shift in the mind was particularly needed in scientific research, Valentina Baltag discovered. “When I studied medicine, all our textbooks were written by Soviet authors and based on Soviet knowledge,” she continues. “We didn’t know English and were totally unaware of the fact that research criteria in the west were quite different to what we were being taught.”

Much of the research carried out in the former USSR, she says, was carried out with methods that would not be scientifically acceptable in the west. “We were simply not trained to design a reliable scientific study, and never came into contact with methods like randomized controlled trials or blind tests for example. Looking back on some of the research we carried out I often think, ‘Mama mia, if only we had only known then what we know now!’”

Discarding old and familiar methods of working and adopting radically different ideas is not easy. When Valentina Baltag introduced the first WHO training in EBM in the Republic of Moldova, she routinely encountered resistance from some participants.

“There are always people who question EBM when they first hear about it, especially decision-makers with a long history of clinical practice,” she explains. “For them, accepting evidence-based medicine involves a loss of prestige, since it often means accepting that what they have been practicing for many years have not been correct. Another obstacle is the fact that our medical system is so paternalistic” she adds, “the doctor is seen as an authority that should never be questioned, and evidence-based medicine does just that – it questions whether the doctor knows what he is doing.”

Back in Stelian Hodorogeas’s office at the Municipal Perinatal Centre, the discussion turns to the subject of concrete changes instigated by the introduction of EBM in the country. Asked to give some examples, Stelian Hodorogea gives a long list: from practical alterations such as introducing partnership-deliveries for mothers and babies to the implementation of new clinical guidelines and adapting more effective treatments of complicated conditions like pre-eclampsia and hypertension during pregnancy. In addition, more than 6000 care providers have, with the support of the United Nations Children’s Fund (UNICEF), been trained in evidence-based ante- and intranatal care.

Moreover, the concept of evidence-based medicine is also beginning to spill over onto other areas of health care. At the local postgraduate school of public health, for example, EBM is now part of the curriculum. However, as Stelian Hodorogea points out, the revolution is far from complete. “Many doctors still use methods which are not supported by evidence, out of habit” she says. “Pregnant women are often seen as sick patients, and far too many of them are admitted to pathological sections. And once a woman is in hospital, doctors feel she must be treated, often resulting in the overuse of drugs. Not only is this practice expensive, it rarely has the desired effect.”

Valentina Baltag is nevertheless optimistic about current developments. “Of course a lot of the old system still prevails” she agrees. “This will be a long process.”