Evidence-Based Practice (EBP) is considered the gold standard for childbirth care. But are we truly practicing its principles? Most often, references to EBP center on scientific literature, with randomized controlled trials occupying the highest echelon of reliability. Yet, in doing so, we risk overlooking two equally vital pillars of EBP: clinical experience and patient values. Without these, EBP becomes like a stool with one leg—unstable and incomplete.
Perhaps you, like me, have suggested something supportive of physiologic birth, only to be met with, “Well, the evidence says…” as if that phrase alone ends the discussion. Instead of fostering curiosity, the heart of scientific inquiry, “the evidence” is often used to shut doors, funneling knowledge into rigid protocols that reduce the profound complexity and mystery of birth into something that can be “proven” and standardized.
Evidence Based Practice, when honored fully, stands on three legs: scientific studies, clinical experience, and patient values. Acknowledging this balance, what happens when the scientific literature suggests one path, yet clinical experience or patient values tell us otherwise?
Take laboring down as an example. Cahill et al.'s 2019 study suggested laboring down increased risks like hemorrhage and chorioamnionitis, leading many providers to abandon the practice. Yet nurses, relying on their lived experience, often find laboring down invaluable. Many resort to subtle resistance—documenting a cervix as "still 9" to buy patients more time. This quiet rebellion is a testament to their belief in a practice they see benefiting mothers and babies, despite conflicting evidence.
Elder midwife Whapio Diane Bartlett reminds us, “Biology without mysticism is flat.” When we seek an objective view of birth, we miss so many important aspects that live in the realm of the subjective…the experience of giving birth, the experience of being born, the experience of witnessing and midwifing birth. Birth cannot be divorced from its context—the environment, the caregivers, the mother’s state of mind. Scientific studies aiming to isolate variables often ignore the environmental and systemic factors that profoundly shape outcomes.
What if the problem isn’t just how we use evidence, but also how obstetric culture shapes what evidence is produced in the first place? How can we adequately study physiologic birth when it’s rarely witnessed, let alone understood, within the intervention-driven model that dominates hospital care? To truly honor Evidence Based Practice, we must reclaim the wisdom of physiologic birth—through experience, observation, and listening to the birthing people we serve–and our own lived experience as clinicians and caregivers.
Where Do We Go From Here?
If we are to move beyond this fractured application of Evidence Based Practice, we must embrace change with a systems lens. Here’s how:
Restore the Three-Legged Stool True EBP integrates evidence, clinical expertise, and patient values. Policies should reflect this triad, not just the latest study. We must resist the urge to standardize care at the expense of individualization.
Reclaim Physiologic Birth Supporting physiologic birth is an art form, requiring presence and humility. Training and mentorship programs should prioritize exposure to physiologic birth, allowing providers to witness and trust its process.
Center Patient Values Listening to birthing families is a sacred responsibility. Care plans must honor their preferences, informed by their unique cultural and personal contexts.
Create Environments that Support Physiology Environments shape outcomes. Simple changes—dimming lights, limiting interruptions, fostering trust—can reduce intervention rates and improve outcomes.
Reframe Evidence Evidence should inform practice, not dictate it. Even the most rigorous studies are filtered through subjective interpretation. By critically evaluating evidence and acknowledging its limitations, we create space for holistic care.
Toward a New Paradigm
What comes after Evidence Based Practice as we know it? Perhaps it is a return to wisdom based practice: a model that integrates science, intuition, and ancestral knowledge. A model that honors the complexity of birth and the humanity of those involved.
As Whapio often says, “Birth belongs to the people.” It is not the property of hospitals, protocols, or even practitioners. To truly support physiologic birth, we must loosen our grip, embrace the unknown, and trust in the profound capacity of birthing people to guide their own process. Only then can we build a stool that stands firm—balanced, strong, and rooted in truth.
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