Journal of Midwifery & Women’s Health www.jmwh.org Original Research Is It the Evidence? The Evolution of Individual Maternity Care Providers to Delayed Cord Clamping Mayri Sagady Leslie, CNM, EdD, Debra Erickson-Owens, CNM, PhD, Maria Cseh, PhD Introduction: Studies of organizational strategies to incorporate evidence into practice and change provider behavior have shown limited success. The majority of existing research centers on influencing participants to change practice versus understanding what occurs when providers have successfully shifted to an evidence-based practice on their own. This study sought to explore the dynamics involved when individual midwives and physicians transitioned from a practice less based on the evidence to one with more scientific support. Delayed cord clamping was selected as the exemplar practice for the study. Methods: A qualitative grounded theory approach was used. Seventeen providers were interviewed throughout the United States. This included 5 physicians and 12 midwives from a variety of practice configurations and birth settings including the home, birth center, and hospital. Results: Five themes arose from the stories of the participants: 1) trusting colleagues, 2) believing the evidence, 3) honoring mothers and families, 4) knowing personal certainty, and 5) protecting the integrity of the mother and the baby. The themes served as drivers of change for the providers in what emerged as an evolution toward change rather than a decision to change. From the themes, the model for individual evolution to evidence- based practice was developed. Discussion: Important findings included the significant role that colleagues play in an individual’s journey toward a new practice, the fact that the evidence alone was never a sole driver of change, and the emergence of a discourse: Who owns the baby? The model developed as a result of this study provides a new framework for both future research and potential strategies to support the incorporation of evidence into practice. J Midwifery Womens Health 2015;00:1–9 c  2015 by the American College of Nurse-Midwives. Keywords: Evidence-based practice, medical decision making, behavior, practice pattern, delayed cord clamping INTRODUCTION Multiple factors impact obstetric outcomes in the United States. Key among these is the fact that a number of mater- nity practices are not well supported by current evidence. 1 In a 2008 systematic review, 41 forms of maternity care utilized for low-risk women during labor and birth were evaluated with the US Preventative Services Task Force system for quality of evidence. 2,3 When this evaluation is compared with frequen- cies of use for the same practices in a national study of US birthing mothers (Listening to Mothers III), 4 the evidence- practice gap is apparent (Table 1). Some practices with an A rating were used in less than one-quarter of the births, whereas practices rated D were commonly employed. In another ex- ample, a 2010 Cochrane review found no evidence to restrict fluids or food to women in labor. 5 However, women in the Lis- tening to Mothers III survey reported that 60% had no access to fluids and 79% were not allowed to eat. 4 A critical step in closing this evidence-practice gap is to better understand how to effectively support maternity providers in aligning their practices with the best available ev- idence. To date, the majority of efforts dedicated to this objec- tive have focused on strategies designed to change provider behavior at the institutional or group level. The purpose of this study was to explore the ways that in- dividual maternity care clinicians (midwives and physicians) described their process of changing from a clinical practice Address correspondence to Mayri Sagady Leslie, CNM, EdD, George Washington University, School of Nursing, 2030 M Street NW, Washington, DC 20036. E-mail: mayri@gwu.edu that was less evidence-based to one that was supported by cur- rent evidence. Due to the limited success of such change ini- tiatives at the organizational level, the study’s objective was to learn from individuals who had already changed practice on their own and to learn about the factors that facilitated their decision to move toward the evidence. 6 Management of the umbilical cord at birth was selected as the exemplar clinical practice for this inquiry. Specifically, the participants had made the choice to shift from early cord clamping to delayed cord clamping. This change in practice was selected because delayed clamping is well supported in the medical literature as providing numerous benefits, with little or no harm to mother and newborn. 7–12 BACKGROUND Research on changing provider behavior to incorporate evi- dence into practice has primarily evaluated interventions fo- cused on the behavior change of multiple providers at one time. For instance, a new practice policy is introduced along with provider education to support the change. Subsequently, the providers’ behavior change and clinical outcomes are mea- sured. However, studies show that organizational change ini- tiatives fail in the range of 60% to 70%. 6 The Cochrane Effective Practice and Organization of Care Group has identified more than 300 systematic reviews on strategies to change practice patterns of professional health care providers in organizational settings in order to improve care. 12 A summary of the reviews included data on interventions such as audit and feedback; computerized reminders; local opinion leaders; and educational materials, 1526-9523/09/$36.00 doi:10.1111/jmwh.12333 c  2015 by the American College of Nurse-Midwives 1