Evidence-based practice: new opportunities, new responsibilities

The contextual influence of professional culture: Certified nurse-midwives’ knowledge of and reliance on evidence-based practice

This paper reports research undertaken to assess US certified nurse-midwives' (CNMs) knowledge of, access to, and use of evidence-based medicine (EBM). Findings are presented in the context of interprofessional, institutional, and popular culture. The descriptive study follows concepts of diffusion of innovation, evidence-based patient choice, and authoritative knowledge to analyse incentives and barriers to the implementation of evidence-based midwifery care. Structured interviews were conducted with practicing CNMs in an urban practice site and a regional teaching centre. The analysis of responses explored congruence between practitioner knowledge, professed practice, and published professional as well as hospital-based internal practice guidelines, for two specific interventions for which there is ample systematic review, epidural and episiotomy. The CNMs demonstrated enthusiasm for their own individual understanding of EBM, but responses to specific questions about EBM-supported practice indicate that many had an incomplete understanding of the concept. Furthermore, in those cases where CNMs demonstrated accurate knowledge of EBM, practice protocols followed subspecialty dictates, thereby preventing their knowledge from translating into adherence to EBM-guided clinical practice guidelines. Finally, patient expectations for technological intervention appeared to influence CNMs' care decisions, even when those expectations lacked sound supporting evidence. If, as conceived by its originators and champions, EBM is to be widely adopted, then practitioners such as CNMs need to accurately understand its concepts and also to be afforded the opportunity to exercise professional control over its implementation. Central to an epistemically balanced EBM is the need to ensure that midwifery knowledge contributes in a robust and ongoing fashion to EBM's scientific research base. Lastly, EBM advocates must identify balanced strategies to both rationally and fairly address consumerist pressures for aggressive health care consumption.

The use of water immersion for treatment of massive labial edema during pregnancy

The purpose of this article is to present a case of a pregnant woman with nephrotic syndrome who had unusually painful edema, and to share an intervention used to relieve her discomfort. The labial edema experienced by this patient was particularly problematic and interfered with normal activity; the hydrotherapy used in this case for treatment was successful in reducing the edema and the pain associated with it. When addressing atypical clinical problems such as this one, nurses can use evidence-based, inexpensive interventions to help their patients.

Where is the "E" in MCH? The need for an evidence-based approach in safe motherhood

Measuring the impact of obstetric interventions on maternal mortality and/or morbidity is especially difficult in developing countries, where most maternal deaths occur. Therefore, program planning has been based on theory rather than proved effectiveness. After reviewing both the strategies that have been promoted to reduce maternal mortality and the adequacy of existing evidence used to justify their selection, the investigators highlight reasons why rigorous criteria for the selection and evaluation of interventions should be adopted. Adequate evaluation of intervention effectiveness under real-life conditions in developing countries is an efficient way to identify interventions for large-scale program replication and could speed progress in reducing maternal deaths.