People don't like to think, if one thinks, one must reach conclusions. Conclusions are not always pleasant. - [forms light horizontal]Helen Keller

The world isn't just the way it is. It is how we understand it, no? And in understanding something, we bring something to it, no? Doesn't that make life a story? - [forms light horizontal]Yann Martel, Life of Pi

Until recently, I never really thought about the downside, or potential cons, of breast-feeding. But with Dr Verklan's Parting Thoughts column in the last issue, "Breastfeeding Can Be Lethal,"1 I learned that not every aspect of breast-feeding is positive. And that brought me new knowledge and a different perspective on something that I thought was safe, natural, and the best thing for every baby. Now I do not mean to suggest that Dr Verklan's column has turned me against breast-feeding, it is just that now I am thinking with a very fresh viewpoint about how patients and families should be educated and supported for safe and successful breast-feeding. This experience led me to my favorite topic, metacognition, or thinking about thinking, and the importance of understanding as many pros and cons to a situation or topic before drawing a conclusion. I also started thinking about what Yann Martel, (the author of one of my favorite books-Life of Pi) meant by his quote-that the nature of what something "is" comes to each of us via our own understanding of it and includes our personal and professional biases, as well as our actual experiences (or lack thereof) with the particular issue or item.

Helen Keller noted that thinking can lead to conclusions that are not always pleasant, and I concur. It was extremely unpleasant to read about the newborn deaths related to breast-feeding, but ultimately such awareness can help us save lives and create new ways of supporting breast-feeding for families. Being able to address pros and cons of any situation before crafting responses (and in perinatal care, before creating protocols or rules) is extremely important. So why is it that clinicians can so easily become angry or defensive when discussing topics such as induction of labor, vaginal birth after cesarean, water birth, or homebirth? I think both Helen Keller and Yann Martel have the answers-discomfort and worldview.

Clinicians tend to have fairly strong opinions and often divided opinions on induction of labor, vaginal birth after cesarean, water birth, and homebirth. This is to be expected on the basis of the differences of approaches and opinions one will find in even a cursory perusal of the literature on any of these topics. But I am writing today not to draw conclusions or provide my own opinions on any of these topics (and I certainly have my own opinions!). Rather, today's column is about thinking and challenging all of us to be very thorough not only in the assessment and reviews of the literature on any of these topics but also to explore our individual worldviews, experiences, and biases when thinking about these topics. And to share a story about how perspective can be a real issue in discussions.

Many years ago I was having lunch in Chicago with a friend who is a prominent medical malpractice defense attorney. We had already worked together on a large number of cases and over the years had developed a professional friendship. An article had just been published noting that the improved safety of cesarean section being comparable with vaginal delivery (note that this was in the lay literature and not a peer-reviewed journal; do not mistake it for fact). Over lunch the attorney asked me the following questions: "If cesarean section is now so very safe, why do we even let women go into labor? Why don't you just do a cesarean on all patients?" After reclaiming my chicken salad from across the table and apologizing profusely for spitting it out in the first place, I actually struggled to give him an answer. Besides falling back on the "but that would be ridiculous, labor is normal and natural" or using a cost-benefit analysis, I stopped for a moment and thought about his perspective on the subject. Here sat a defense attorney. He only saw bad outcomes. He found many cases difficult to defend. He had not trained as a midwife like I had, and he was greatly saddened by the outcomes he was seeing in the obstetric cases he handled. Add to that his role as a father of 2 young girls and of course it would be natural for him to conclude that elective cesarean at term was a great idea. Today I could show him the literature on the role of labor in human birth, the consequences of multiple cesareans such a placenta accrete or percreta, and the growing body of literature questioning the current cesarean rates nationwide. But for the life of me, at that lunch table years ago, I was hard-pressed to provide a great argument against his premise of cesarean for everyone, and I doubt there would have been much I could muster to change his worldview at that point in time.

Currently, the literature abounds with differing viewpoints and conflicting or at least varying evidence on a variety of hot topics in perinatal medicine and nursing. We would all do well to remember the opening quotes from this column (and when I say we, I am including myself) and to think critically about how our experience and worldview colors our opinions and even our reading of the literature. More importantly, we should be open to understanding the worldview and biases of others when opening dialogues about these topics. We must learn to have respectful conversations, to acknowledge different opinions as valid, and to never resort to name-calling or accusatory language in our discussions, whether in person or in print. Finally, we must be willing to change our viewpoints and adapt our rules when faced with overwhelming evidence of any safety issues. We must also remember that regardless of how vigilant we are as professionals, our patients my choose options we do not or cannot support and yet present at our institution for help. It is imperative that we be able to at least understand the perspective that may have led to their choice and offer whatever help and support we can provide in a nonthreatening, nonjudgmental, and nonpunitive manner. Life really is a story, and each of us tells it a bit differently.

-Lisa A. Miller, CNM, JD

Founder

Perinatal Risk Management and Education Services

Portland, Oregon

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