Making Informed Decisions
“If you don’t know your options, you don’t have any.”
Diana Korte & Roberta Scaer // A Good Birth, A Safe Birth
“I can’t emphasize enough how important it is that I EDUCATED myself. …what I saw in movies/TV shows …is not accurate…. Women … should LEARN everything they can … and find a practice/hospital that will respect their choices.”
Respondent to Listening to Mothers III // Declercq E, Sakala C, Corry MP, et al. Listening to Mothers III. Pregnancy and Birth. New York: Childbirth Connection; 2013.
“Concepts of ‘choice’ are center-stream in maternity care. …Yet the way in which these choices are presented defines and limits them. She may believe she has more choice than she does.”
Sheila Kitzinger // Sheila Kitzinger’s Letter from Europe: birth speak. Birth 1996;23(1):46-7.
“It is still usually expected that good communication is bound to result in ‘informed consent.’ …Compliance tends to be perceived as a consequence of effective patient management…. While ‘informed consent’ echoes through the language of birth, ‘informed refusal’ is rarely tolerated.”
Sheila Kitzinger // Sheila Kitzinger’s Letter from Europe: birth speak. Birth 1996;23(1):46-7.
“The most obvious limitation in the notion of alternatives is that it implies that there exists a comprehensive set of options to choose from and that the chooser is in a position freely to exercise choice in an informed way. I would suggest that neither of these conditions is fulfilled in present day maternity services.”
M. P. M. Richards // The trouble with choice in childbirth. Birth. 1982;9(4):253-60.
“Arguing for choice can be too much like getting a shop to stock two kinds of frozen fish fingers when the real issue may be to find somewhere that sells fresh fish.”
M. P. M. Richards // The trouble with “choice” in childbirth. Birth. 1982;9(4):253-60.
“You have learnt something. That always feels at first like you have lost something.”
George Bernard Shaw // Major Barbara
Best Practice
“All women deserve access to high-quality, comprehensive, coordinated, and cost-effective care in the communities where they live, with informed choice among appropriate caregivers, care practices, and birth settings.”
Maureen Corry // Transforming maternity care. Action steps toward a high-quality, high-value maternity care system. Women’s Health Issues 2010;20(1 Suppl):S2-S3.
“[B]irth [that is powered by the innate human capacity of the woman and fetus] is more likely to be safe and healthy because there is no unnecessary intervention that disrupts normal physiologic processes. Some women and/or fetuses will develop complications that warrant medical attention to assure safe and healthy outcome. However supporting the normal physiologic processes of labor and birth, even in the presence of such complications, has the potential to enhance best outcomes for the mother and infant.”
American College of Nurse-Midwives, Midwives Alliance of North America, National Association of Certified Professional Midwives // Supporting Healthy and Normal Physiologic Childbirth: A Consensus Statement by ACNM, MANA, and NACPM
“A corollary to the medical dictum ‘First do no harm’ might be ‘second, do some good.’ …It is difficult to justify high rates of obstetrical interventions (especially elective) in a low-risk population of pregnant women in the absence of demonstrable neonatal benefits, given that these interventions have finite maternal risks.”
J Christopher Glantz // Rates of labor induction and primary cesarean delivery do not correlate with rates of adverse neonatal outcome in level I hospitals. J Matern Fetal Neonatal Med 2011;24(4):636-42.
“Every effort should be made to ensure that women’s birth environments are empowering, not stressful, afford privacy, communicate respect, and are not characterized by routine interventions that add risk without clear benefit.”
Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. // Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD003766. DOI: 10.1002/14651858.CD003766.pub5.
“The tentative first small steps taken by innovative clinicians and researchers can soon become giant leaps in terms of the breadth of indication and tolerances of safety, once in the clinical domain.”
Muchatuta & Kinsella // Remifentanil for labour analgesia: time to draw breath? Anaesthesia 2013;68(3):231-5.
“Health-care providers and health systems need to ensure that all women receive high-quality, evidence-based, equitable and respectful care. The right amount of care needs to be offered at the right time, and delivered in a manner that respects, protects, and promotes human rights.”
Miller S, Abalos E, Chamillard M, et al. // Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide. Lancet 2016;388(10056):2176-92.
Childbirth
“There is no other organ quite like the uterus. If men had such an organ, they would brag about it. So should we.”
Ina May Gaskin // Ina May’s Guide to Childbirth
“The power and intensity of your contractions cannot be stronger than you because it is you.”
Anonymous
“If you can’t fight and you can’t flee, flow.”
Robert Elias
“Rain, after all is only rain;
It is not bad weather;
So also pain is only pain;
Unless we resist it,
When it becomes torment.”
I Ching
Midwives
“All women need a midwife. Some need a doctor.”
Sheila Kitzinger // Human rights and midwifery. Birth 2011;38(1):86-7.
Medical-Model Management
“I am constantly amazed at the list of things women are told they have ‘failed’ at: they can ‘fail’ to dilate, to progress, to home birth, to breastfeed-and their babies can ‘fail’ to thrive. Bits and pieces of them can ‘fail’ as well: contractions can be ‘inadequate’ as can their pelvis. Their cervix can be ‘incompetent’ (or merely ‘unfavorable’)…. [A]n examination of [the] somewhat aggressive language may reveal ways of thinking about care which are inappropriate in themselves. ‘Allowing’ a woman a ‘trial’ of labour, for example…. Why is it necessary to tell one particular group of women that they are ‘on trial’ and regard them in this way? Indeed, it is hard to imagine any circumstance in which it is appropriate to put a woman or her uterus ‘on trial’ (after a second stage ‘arrest’ perhaps!).”
Hilda Bastion // Confined, managed and delivered: the language of obstetrics. Br J Obstet Gynaecol 1992;99:92-93.
“When nature does work, it cannot be improved. Technology does not enhance a natural process that is working. It can only mar or destroy it.”
David Stewart // The 5 Standards of Safe Childbearing
“[I]nnovation in obstetrics could be characterized as a series of massive and poorly controlled experiments.”
Iain Chalmers // Evaluating the quality of new procedures. Arch Gynecol Obstet. 1987;241 Suppl:S101-6.
“All mothers should have access to safest vaginal birth practices. We should not ask mothers to choose between vaginal birth with avoidable harms and cesarean section.”
Childbirth Connection // NIH Cesarean Conference: Interpreting Meeting and Media Reports https://www.childbirthconnection.org/article.asp?ck=10375
“We are too apt as a profession, to be influenced by prejudice, especially when it is backed by great authority.”
Samuel Gross // Founder and 1st president of the American Surgical Association, speaking to the American Medical Association in 1884 against episiotomies, quoted in Episiotomy by I. Graham
“The most invasive and potentially dangerous technology-because from it proceeds all others-is the clock.”
Sheila Kitzinger
“For every complex problem, there is a solution that is simple, neat, and wrong.”
H. L. Mencken
“Arbitrary practice variation creates a free-for-all mentality in which any reason for an intervention can be put forth without accountability. To make progress, obstetric patients and practitioners must agree about what constitutes evidence-based best practices (as such exist), adhere to them, and work toward optimizing outcomes while avoiding unnecessary intervention. This approach can minimize variation, achieve excellent results, and avoid the continual medicalization of the birthing process.”
J. Christopher Glantz // Obstetric variation, intervention, and outcomes: doing more but accomplishing less. Birth 39(4), 2012.
“To allow is to exercise as much, if not more power, than to forbid.”
Ronald D. Laing quoted by O’Mara P, Ponte W, & Facciolo J. in Having a Baby Naturally.
“Medicalized prenatal care has been no more able to surmount the social ills which contribute to America’s poor pregnancy outcomes than emergency rooms have been able to solve our nation’s violent crime problem.”
Thomas Strong, Jr. // Expecting Trouble: The Myth of Prenatal Care in America
“Am I saying that midwives are better than obstetricians? Emphatically, no. But for uncomplicated pregnancies (i.e. 70 to 90 percent of all pregnant women), obstetricians can’t do any better than midwives do. Indeed, obstetricians are to routine prenatal care what neurosurgeons are to simple headaches: overkill.”
Thomas Strong, Jr. // Expecting Trouble: The Myth of Prenatal Care in America
Practicing Defensive Medicine
“The woman about to become a mother, or with her infant upon her bosom should be the object of trembling care and sympathy wherever she bears her tender burden or stretches her aching limbs…. God forbid that any member of the profession to which she trusts her life …should hazard it negligently, unadvisedly, or selfishly.”
Oliver Wendell Holmes // Medical Essays 1842-1882
“If you play God, you will be blamed for natural disasters.”
Marsden Wagner // Born in the USA
“If you’re going to get sued anyway, you might as well do the right thing.”
Michael Klein
Augmentation of Labor
“There is probably no organ that is so uncontrolled and so erratically inefficient as the human uterus…. [I]f a pregnant uterus wanders into France, it becomes so hyperactive that there is more than a 40-percent chance that it will need subduing by a range of tocolytic drugs in order to prevent untimely expulsion of the baby. On the other hand, if it wanders into Ireland, it becomes so sluggish that no tocolytic agents are marketed in the country and the odds are two to three that it will need to be driven on by oxytocin to expel a baby that would have fallen out a long time ago, if only it had stayed in France. If it crosses the Atlantic, the chances are that neither of these attempts to curb erratic uterine behavior will be effective and that one uterus in five [one in three as of 2013] will need a scalpel to bring it to its senses and release its contents.”
Marc J. N. C. Keirse // A final comment …managing the uterus, the woman, or whom? Birth 1993;20(3):159-61.
“An accelerated labor is as safe as a streamlined parachute.”
J. G. Thornton & R. J. Lilford // Active management of labour: current knowledge and research issues. BMJ 1994;309(6951):366-9.
Electronic Fetal Monitoring (Cardiotocography)
“The concept of the nursing station, with obstetric nurses sitting in front of banks of monitors while women labor alone, harpooned to electronic equipment, was an invention of the late 20th century. It was an uncontrolled experiment in the United States, which spread around the world and is only recently being evaluated. Compared with social childbirth, it is associated with artificial stimulation of the uterus, medication for pain relief, assisted vaginal deliveries, a virtual epidemic of cesarean sections, babies sent to intensive care, and many women suffering from posttraumatic stress disorder.”
Sheila Kitzinger // Rediscovering the social model of childbirth. Birth 39(4), 2012.
Epidurals
“[N]othing we do in anesthesia is benign; risk is a constant companion to our practice, and must always be considered alongside any perceived benefits.”
Muchatuta & Kinsella // Remifentanil for labour analgesia: time to draw breath? Anaesthesia 2013;68(3):231-5.
“[They’re] not exactly lying, but [they’re] careless with the truth.”
Henci’s tweak of a line from a song in Calamity Jane
“As one mother, …unable to feel the birth because of an epidural block said, ‘It’s like seeing a rabbit pulled out of a hat.’ Being the hat is a far cry from being the magician”.
Barbara Katz Rothman // “The Social Construction of Birth” in The American Way of Birth, Pamela Eakins ed.
“If we put women in hospitals with restrictive policies—they’re hooked up to everything, they’re expected to be in bed—of course they’re going to go for the epidural…. They come to your hospital, and they have no choice…. They can’t manage their pain because you won’t let them.”
Judith Lothian quoted by Jennifer Block in Pushed: The Painful Truth About Childbirth and Modern Maternity Care.
Limitations of Evidence
“The need for unbiased research struggles with the inherently biased sources of that information—human beings.”
Kenneth Schulz // Randomized controlled trials, Clin Obstet Gynecol 1998; 41(2): 245-56.
“From time to time, common sense needs to be invoked in intrapartum care to argue against unnecessary prior evaluation of something that has obvious benefits. Do we need an [randomized controlled trial] of maintaining privacy, of relating respectfully and of the need to listen to women during labour? These aspects come under treating an individual with dignity and caring for women with compassion and sensitivity.”
Denis Walsh // Evidence-Based Care for Normal Labour and Birth
“Others adopted the view ‘if it ain’t randomized, it ain’t true.’ It created opportunities to worship randomized controlled trials not for the valuable information that they can provide, but as holy cows that need adulation irrespective of whether they produce any milk. A perfectly constructed and conducted randomized controlled trial does not automatically protect it from producing clinical nonsense…. Does anyone need a randomized controlled trial to determine whether the abdomen should be left open or sutured after a cesarean section? …There is also no top-level evidence on what is safest or what is quickest when leaving the top floor of a building: leaping through a window or taking the stairs. Yet, does anyone need a trial to settle this issue?”
Marc J. N. C. Keirse // Evidence-based medicine and perinatal care: from dawn to dusk. Birth 39(4), 2012.
“Our evidence suggests that mainstream obstetric science follows mainstream obstetric practice. A patient and expectant approach to birth…where all is considered normal until proved otherwise, produces a science that proves intervention to be unnecessary. Alternatively, an aggressive approach to birth…, where birth is regarded as normal only in retrospect, generates a science that demonstrates the need for monitoring and intervention.”
R. De Vries & T. Lemmens // The social and cultural shaping of medical evidence: case studies from pharmaceutical research and obstetric science. Soc Sci Med 2006;62(11):2694-706.
“…decision-based evidence making.”
Phil Hall
Studying a Study
“Four apples and five oranges makes four apples and five oranges, not nine appleoranges.”
Tracy Greenhalgh // How to Read a Paper: The Basics of Evidence-Based Medicine
“The plural of anecdote is not data.”
Frank Kotsonis
“If you have an opinion about any matter it should be based on ascertained facts,
not upon hope, or fear, or prejudice.”
Bertrand Russell
“One of the most influential biases in the acquisition of evidence is choice of the question, and the best evidence in answer to the wrong question is useless.”
S. M. Menticoglou & P. F. Hall // Routine induction of labour at 41 weeks gestation: nonsensus consensus. BJOG. 2002;109(5):485-91.
“He uses statistics the way a drunken man uses lampposts—more for support than illumination.”
Andrew Zang
“Science is the belief in the ignorance of experts.”
Richard Feynman
“Researchers have already cast much darkness on the subject, and if they continue their investigation, we shall soon know nothing at all.”
Mark Twain
“It is better to have absolutely no idea where one is than to believe confidently that one is where one is not.”
Cesar Francois Cassini de Thury, 18th Century French surveyor
“The essence of knowledge is having it, to apply it; not having it, to confess your ignorance.”
Confucius
“The trouble with conventional wisdom of medical practice is that it tends to be more conventional than wise.”
David Grimes // Grimes DA. How can we translate good science into good perinatal care? Birth. 1986;13(2):83-90.
Clinical experience: “making the same mistakes with increasing confidence over an impressive number of years.”
D. Isaacs & D. Fitzgerald // Seven alternatives to evidence based medicine. BMJ. 1999;319(7225):1618.
“To suppress a fact is to publish a falsehood.”
Dorothy Sayers // Gaudy Night
Instituting Reforms
“Every system is perfectly designed to get the results it gets.”
Paul Batalden, Medical Director, Senior Fellow, Institute for Healthcare Improvement (IHI) https://www.youtube.com/watch?v=doQOKmrptDU
“Facts can be disproved, and theories based on them will yield in time to rational arguments and proof that they don’t work. But myth has its own, furious, inherent reason-to-be because it is tied to desire. Prove it false a hundred times, and it will still endure because it is true as an expression of feeling….It is illogical-or at least, pre-logical; but from this very fact it gains a certain strength: logic may disprove it, but it will not kill it.”
Elizabeth Janeway // Man’s World, Woman’s Place
“Emotions and beliefs are masters; reason their servant …At the least, reason excuses; at the most, it restrains its master.”
Henry Boettinger // Moving Mountains
“Culture, in compelling but unspoken ways, dictates the proven, acceptable methods by which members of the group address recurrent problems. And culture defines the priority given to different types of problems. It can be a powerful management tool.”
Clayton Christensen // Harvard Business Review July-August 2010 http://hbr.org/2010/07/how-will-you-measure-your-life/ar/1
“If we fail to speak truth to power, …we will end up speaking lies to the powerless.”
Arthur Waskow // God Wrestling
“Don’t wait for the light at the end of the tunnel…stride down there and light the bloody thing yourself.”
Sarah Henderson
“The trouble with people is not that they don’t know but that they know so much that ain’t so.”
Josh Billings
“When you discover that you are riding a dead horse, the best strategy is to dismount.”
ascribed to the Dakota Indians
“If fifty million people say a foolish thing, it is still a foolish thing.”
Andrew Gide
“Nothing hurts a new truth more than an old error.”
Johann Wolfgang von Goethe
“If you haven’t made at least a dozen enemies, you haven’t done the show, baby.”
Bette Davis quoted by Mr. Blackwell in “More News”
“It is dangerous to be right in matters on which the established authorities are wrong.”
Voltaire
“If you have never been called a defiant, incorrigible, impossible woman… have faith… there is yet time.”
Clarissa Pinkola Estés
Women Who Run with Wolves
“Power concedes nothing without a demand. It never did and it never will.”
Frederick Douglass
“It is not power that corrupts but fear. Fear of losing power corrupts those who wield it, and fear of the scourge of power corrupts those who are subject to it.”
Aung San Suu Kyi
“Attempts fail, but not as certainly as tasks never attempted.”
Lois McMaster Bujold // Paladin of Souls
“You are not required to complete the work, nor are you free to cease from it.”
Pirke Avot 2:21
“It is difficult to get a man to understand something when his salary depends upon his not understanding it.”
Upton Sinclair
“Speak your mind even if your voice is shaking.”
Maggie Kuhn
“We’ve got to fight. And we gotta look like we’re havin’ a good time doing it.”
Bill Clinton quoted by Ellen Goodman in the Washington Post http://www.workingforchange.com/printitem.cfm?itemid=16014