“Evidence-based practice” has entered the vocabulary of midwives over the past decade; indeed, it may be “one of the most fashionable” terms in health care.1 The shift in the way we perceive our work now centers decisions about patient care on the best possible evidence about what works, rather than relying on the opinions of experts or mentors.2,3 However, as this paradigm takes hold, there has been little debate about “what constitutes evidence.” The underlying assumption seems to be that “evidence” is equated with research evidence, specifically quantitative research, and ideally, randomized clinical trials. The rationale for randomized trial evidence has been discussed in this column before,2,3 and readers surely know that unbiased observation, the hallmark of properly conducted clinical trials, is the “sine qua non” of evidence-based care.
The reality of providing care for our patients, however, is that much of what we do, and need to do, is not grounded in that kind of evidence. Randomized trials are difficult and expensive to conduct, and there is increasing discussion about the generalizability of findings from a select group of research subjects to the general population of people seeking care.4,5 As clinicians encounter new problems or wonder about different approaches to care, the first steps toward building an evidence base are necessarily derived from thoughtful observation and extrapolation from known constructs in physiology and behavioral science. Decisions about patient care often must be made by clinicians far in advance of any hard evidence from clinical trials. As Fullerton and Thompson have noted,6 “Much of midwifery practice is considered an art based on common sense, tradition, and woman-centered approaches to caring … that may not easily lend itself to examination by scientists or clinicians.” Although we need to recognize the inherent value of unbiased research evidence, we cannot reject other sources of knowledge.
This issue of the Journal offers a variety of “evidence” about issues in patient care. We include here a methodologically rigorous clinical trial, a comprehensive literature review with clinical practice recommendations, and some brief explorations of clinical topics in obstetrics and family planning. We stress the importance of placing each type of evidence in its proper context and recognizing its inherent limitations. Nonetheless, the variety of types of data presented here represent the reality of searching for answers about how best to provide clinical care.
The Journal is pleased to publish the long anticipated findings from Leah Albers' randomized trial of perineal management in labor. Dr. Albers has conducted a rigorous assessment of varied techniques for avoiding genital tract trauma. In addition, the report itself should be read by aspiring researchers and consumers of research as a primer on how to conduct a trial and how to present its strengths and limitations for thoughtful consumption.
In the absence of clinical trial research data on the outcomes of various management approaches, how does a midwife decide what is appropriate practice? Rather than reverting to an uncritical reliance on expert opinion or “eminence-based practice,” common practices (or their uncommon alternatives) should be evaluated as critically as evidence from research is evaluated. Rycroft-Malone argues that knowledge derived from clinical experience must be “made explicit in order for it to be disseminated, critiqued, and developed.”1 Hence, there is the need for publication of observations from clinical practice, for theoretical dissection of the why's and how's based on related science, and for thoughtful synthesis of what is known. Reasoned approaches to patient care evolve from such articles. Readers can follow the thought process of the author and decide to agree or disagree with the conclusions. Presumably, a reader's own dissection of the evidence will be similarly externalized and offered up for critique, if not as a published article, at least as a discussion with fellow clinicians or a letter to the editor.
In this vein, we highlight several articles on clinical management problems that deserve exposition even if they are not derived from rigorous clinical trial findings. Mercer's literature review and recommendations about nuchal cord management offer thorough assessment and rational perspective in an area in which there are no trials of competing management practices. Penney discusses the hypothesized relationship between severe nausea and vomiting of pregnancy and infection with H. pylori and describes case management in a faculty practice. Although no clear treatment recommendations can be derived from this brief case series, open discussion may prompt more intensive observation of the possible link. Smith's analysis of data from a study of contraceptive habits offers a perspective about the types of counseling that might better serve women who use oral contraceptives. Although none of these articles provides the “gold standard” evidence of randomized trials, each approach provides another piece in the jigsaw puzzle of clinical care.
The Journal editors encourage other practitioners to use the publication forum to “make explicit” the thought processes and knowledge base that underscore clinical care decisions. We advance knowledge by sharing what we know and what we think and by offering up those thoughts for dissection and critique.