Medical Knowledge and Clinical Skills as Mediators Between Evidence-Based Medicine and Clinical Competence in Postpartum Hemorrhage Management: A Cross-Sectional Study

Vollständiger Abstract

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Background: Postpartum hemorrhage (PPH) is the leading cause of maternal mortality, accounting for approximately 28% of maternal deaths in Indonesia. Although evidence-based medicine (EBM) is widely advocated as the foundation for clinical quality improvement, the specific pathways through which EBM enhances clinical competence in PPH management remain insufficiently characterized. Objectives: To assess Indonesian midwifery students’ knowledge and clinical skills as mediators of the relationship between evidence-based medicine (EBM) and clinical competence in postpartum hemorrhage (PPH) management. Methods: A cross-sectional explanatory study was conducted among 150 eligible midwifery students enrolled in an advanced bridging program at a health sciences college in East Java, Indonesia, from October to November 2025. Data were collected using a validated 30-item self-report questionnaire (5-point Likert scale) that assessed EBM practice, medical knowledge, professional behavior, clinical skills, and clinical competence in PPH management. Structural Equation Modeling based on Partial Least Squares (SEM-PLS) was performed using SmartPLS 4.0 with 5,000-resample bootstrapping. Results: EBM was significantly associated with medical knowledge (β = 0.406, P < 0.001) and clinical skills (β = 0.376, P < 0.001) but not with professional behavior (β = 0.132, P = 0.124). Both medical knowledge (β = 0.098, P = 0.001) and clinical skills (β = 0.159, P < 0.001) significantly mediated the relationship between EBM and clinical competence. The clinical skills construct was the strongest direct predictor of clinical competence (β = 0.429, P < 0.001). The model explained 79.5% of the variance in clinical competence (R2 = 0.795). Conclusions: Medical knowledge and clinical skills are significant dual mediators of the EBM–clinical competence pathway in PPH management, with the clinical skills pathway being dominant. These findings support the integration of EBM curricula with simulation-based skills training to enhance clinical competence among midwifery students. Curricula could target both knowledge acquisition and psychomotor skill development through evidence-based practice frameworks, pending confirmation in multisite studies.