#45 The Effects of the Arrive Trial and Critical Thinking in Research Interpretation with Lisa Miller

Justine:
Hi, I am Justine.

Sarah:
And I’m Sarah Lavonne.

Justine:
And we are so glad you’re here.

Sarah:
We believe that your life has the potential to make a deep, meaningful impact on the world around you. You, as a nurse, have the ability to add value to every single person and patient you touch.

Justine:
We want to inspire you with resources, education, and stories to support you to live your absolute best life, both in and outside of work.

Sarah:
But don’t expect perfection over here. We’re just here to have some conversations about anything birth, work, and life, trying to add some happy to your hour as we all grow together.

Justine:
By Nurses, for Nurses, this is Happy Hour with Bundle Birth Nurses.
Welcome back to another episode of Happy Hour with Bundle Birth Nurses. Today we have a repeat guest once again and her name is Lisa Miller, and if you are listening, I’m sure you’re excited to hear her again with us. We had so many wonderful emails and DMs about how great our last episode with you, Lisa, was. And I wanted to share, so I think I explained this in the last episode, but I fangirled a little bit when we had Lisa the first time and I got to talk to her on the phone and I was like, “Where am I? Who is this?” And we were talking about different topics that we could discuss with her, which I’m sure if you’re listening, you know that there’s many. But one of the things that was brought up was the ARRIVE trial. And Lisa had a very different opinion of the ARRIVE trial than I’ve heard from so many other nurses, and so I wanted to bring her on to discuss this opinion, dive into it because she makes such good points. And so Lisa, welcome back, and let’s just get on with it.

Lisa:
All right, thank you. Thank you for having me. Yeah, I’m excited to discuss this because I think it’s a case of there’s good science, but understanding the science, understanding the limitations, and then there’s a separate issue of abuse of science. The fact that somebody takes data that might be solid data and then uses it in a way that is inappropriate. So I think I’d like to talk about both of those things. And also, there’s a newer little bit at the end I’d like to talk about a little bit of a review that has actually looked… Now, it’s limited, but looked at the effect of the ARRIVE trial. So we have the science of the ARRIVE trial, use and misuse of the ARRIVE trial, and then the effect on the population, or at least part of the population, because the study I’m talking about is recent and only looked at hospitals in the Pacific Northwest. So whether you can extrapolate that to Georgia or Florida is probably unlikely.

Justine:
Yeah, that’s such a good point because the ARRIVE trial did take, what was it, in the forties of hospitals, 40 something different hospitals around the United States, so it was a pretty big lump sum.

Lisa:
It was.

Justine:
It was more representative of the United States.

Lisa:
Yeah, it utilized the MFMU centers, so all of the hospitals involved in the were part of the maternal fetal medicine units for NIH studies, so this was a large, large study. So where would you guys like to start? You want to just talk a little bit about long-held beliefs? I grew up thinking that induction of labor increased your chance of cesarean and still, for many people, that’s a firmly held belief, that induction of labor itself carries an increased risk of cesarean. And part of that may have come, and I will send you guys the references for this, part of that may have come by the fact that if you are comparing C-section rates in induction of labor versus C-section rates for somebody in spontaneous labor, there’s a huge difference. Is that a fair comparison when you want to look at C-section rates? No. It is not a fear comparison, and therein lies the problem.
So just to give you some stats, if you looked at induction of labor versus spontaneous labor at, say, 38 weeks gestation, IOL, 11.9%, spontaneous labor, 7%. Big difference. How about 39 weeks? 14.3% versus 9.1%. And the area where I think this myth of the doubling of the section rate comes from was from data, and this is from 2006 COI, and I will send you guys the citation so you can have it, but at 40 weeks, induction of labor had a C-section rate of 20.4% versus spontaneous labor, 10.9%. But here’s the rub. Spontaneous labor is not guaranteed. You are not guaranteed to go into spontaneous labor at any gestational age. So if you want to compare C-section rates, you have to compare induction of labor with expectant management, with waiting for spontaneous labor. And there were other trials prior to the ARRIVE trial that did this and showed that when you did that, you weren’t seeing these same disparities.
Okay, so what did the ARRIVE trial do? The ARRIVE trial looked, and this is really important because a lot of people get this wrong and some of the misuse is coming from this lack of knowledge. The ARRIVE trial looked only at nulliparous, singleton, vertex, so the NTSV population, but low-risk. No risk factors were allowed, so we’re talking about a very limited group of patients. Nulliparous, term, singleton, vertex, no risk factors. And they recruited a huge number of people for review, 50,000 people. However, 27,600 people were not eligible. So that left you with about 23,000 women who were eligible for the study, and they went through the process of informed consent. 73% declined to participate in the study.
So the idea that women are all over induction or all over not induction, I don’t think we can extrapolate that. Now, some of the women may have declined to participate in this study because you were randomized into either the induction group, which was around 39 weeks, or expectant management. And with expectant management, you had to agree not to be induced prior to 40 and five seventh days of gestation, and you had to agree to be delivered by 42 and I think two sevens. So that gray area of 40 and five to 42, you could extend. There’s been some misinformation that people had to be induced at 40 and five. That is not true. They had to wait and could not be induced prior to that. All right? So those are our two groups.
Now, what did the groups look like? Well, age has been a big factor and age. The average age was mid-twenties. I think it was 23 in the induction group and 24 in the expectant management group, but the age range was from 20 to 28 in both groups. So these are mostly young, nulliparous women who have no risk factors, and I don’t think a lot of people understood that. So to extrapolate this data and use it on, say, somebody who’s 38 years old who has a pregnancy resulting from assisted reproduction and maybe is a gestational diabetic would be completely inappropriate, so that’s number one.
Number two is how they did it, and I think that’s very important as well. Let me cut to the chase real quick. What did the study really show? What’s the big bugaboo? Is that it was not the manner of how labor started. There was not a difference. And in fact, the inductions at 39 weeks had a statistically significant lower cesarean section rate. Albeit the section rate for both groups was low overall, it was statistically significantly reduced in the induction group. However, let’s talk a little bit about management at these 40 hospitals. Cervical ripening was left up to the physician. However, labor was not called as a failed induction until 12 hours or more following rupture of membranes and use of uterine stimuli. Now, this is important because I personally believe part of our area of, say, high section rate can be due to people not managing latent phase failure correctly, so that’s an important point.
The other point that I think is very, very important was looking at patient satisfaction, and patient satisfaction, they use something called the Labor Agency Scale, which is a midwifery derived tool, and they actually found that the scores were higher after delivery and that there was a difference in labor pain overall based on what these patients reported in the induction group. So these are some of the findings. Now, why did people get all in an uproar? Well, one, this was myth busting. Here we have a situation where something that has been long-held by midwives and labor and delivery nurses. Induction increases the rate of C-section is supposedly disproven. So let me have a caveat there. It’s definitely disproven for this particular subgroup of patients, which may not match everybody’s patient population.
One of the discussions I had with Liz Howard after this, who at the time was running the academic midwifery service at Brown and is a good friend of mine, is, “What are we going to do? Does this mean we have to or we should be offering low-risk patients induction at 39 weeks?” And she and I talked about it and the result is this. Her section rate at that time for their group I think was well below 15%, so why would you do it? If your section rate is already low in the low risk population you’re taking care of, I don’t think there’s a reason to necessarily offer this. Now, there were some other findings as far as hypertension and sepsis in the groups, and that we can get into if we need to, but I think the broader concepts are more important. The idea is this. Two things that you should take away from the ARRIVE trial, in my opinion.
One, the manner how labor starts, the way in which labor starts, is not a significant factor in affecting C-section rate for your low-risk NTSV population. That’s number one. Number two is that if you already have a low cesarean section rate in a population that prefers non-interventive birth, while I think you can certainly talk about the study and talk about induction at 39 weeks, it is not something that your population is going to be interested in, and there is no mandate, if your complication rates are low and your section rate is below 18% in that subpopulation, there’s absolutely no mandate for you to offer it. Why would you? You already are doing better than what the studies show. So that’s the ARRIVE trial in a nutshell. Do you have any comments or questions based on what I’ve just said or stuff that you have heard that maybe we should talk about?

Justine:
Well, I loved how you just broke it down into those two categories, because I’m thinking about my population and my facility. So we do about 350 to 400 births a month and we are usually about two to three days behind on inductions every day, so we schedule four inductions a day and we’re usually behind. Our list is always backed up. And so when we’re behind, we skip all the electives because there’s this attitude of, “Well, we’re bringing in a medical. Elective, they should wait until labor starts. Why are they even doing it?” And then we hopefully, in the mind, it’s like, “They’ll just deliver. They’ll come in and deliver, and sometimes they do, but now I’m like, “Yes, bring in the medical inductions,” but I would love to even share this episode with my coworkers to be like, “We maybe stop thinking so negatively of these 39 week inductions, because if we can get them in at 39 weeks, there is maybe more of a chance that they will deliver vaginally because our C-section rate is higher versus waiting until they’re 40, 40 and two, 40 and three.”
And again, we can go into this, but the study did show that it can be protective against hypertensive disorders, correct? And we have a huge population of that where I live. And so I love that this episode is going to help not villainize this study so much, because people are so mad about the study of elective inductions. And I think it just comes down, and we’ve chatted a little bit offline about this, of staffing and how we’re running our units. And you mentioned yesterday, and maybe you can mention that here, of what did you say about the goal of, if your goal is to get them in and out off the board, what was the wording you said that was helpful?

Lisa:
I said, if your goal of how you’re managing your labor unit is to clear the board like, “We’ve got a lot of patients, we got to get them delivered, we got to clear the board,” and you are doing inductions where you are not following the guidelines, which by the way didn’t get a lot of press. The guidelines on failed induction that applied to all risk NTSV was published also in 2018, I want to say January or February, but it predated the ARRIVE trial. But people went nuts over the ARRIVE trial, and so that study didn’t get as much play. And that’s one of the things when I teach my classes on uterine activity in management of labor, I pull that study out and say, “If you want to slow your section rate, this is more important than the ARRIVE trial, because that study looked at NTSV all risk population and set very clear guidelines for defining failed induction of labor.”
That was also an MFMU trial, but the ARRIVE trial came. And look, I don’t blame people for being angry about not having bed capacity, not having staffing. That is absolutely correct. And if people are misapplying ARRIVE, they’re not using shared decision-making, they’re not really doing informed choice where they’re talking to patients or they’re offering an ARRIVE-style approach to induction to somebody who is [inaudible 00:16:38], not low-risk, maybe somebody who is not in the category. And I think age is an issue. How many 37-year-old nullips do you know that are truly low-risk, right? AMA alone is an increased risk for stillbirth. So what I’m saying is we have to look at the data, and when you’re looking at science, you should have a neutral response. Is it good study? Is it not a good study?
The ARRIVE trial is a very well-done study. That doesn’t mean it applies to every woman you’re going to see in your office or you’re going to see in labor and delivery, and the fact that people are misusing it. Now, I’d like to give you just a little history here. I’m just going to go in the way back machine for a while. And in the eighties, when neither of you were probably born, I was working, and what came out? Something called active management of labor, AMOL, and this was from what was called the Dublin trial. So this was Dublin, Dublin, Ireland, where care was provided by midwives. Nobody was admitted until the midwife had told them they were in labor. And this study looked at, again, who were in labor and use of oxytocin, so active management of labor, so it was really more augmentation than induction, and they found better outcomes.
However, they had a very low epidural rate. Nobody was admitted until they were in labor diagnosed by a midwife, which was not one centimeter in long. But people in the US started to say, “Oh, well, I’m going to aim all everybody.” So it was the same type of abuse that I saw. Here, a study comes out, it applies to a limited group of people with a specific model of care that is not the normal model of care here in the US at that time or now, unfortunately, in my opinion, because I think midwifery care should be the primary model of care. And that study was abused. So I’m seeing history repeat itself, and I’m seeing it be repeated with the ARRIVE trial and people taking good science and vilifying the science because they don’t like how people are misusing it, what it’s doing to their volume.
Now, do I think you should be honest with patients? Yeah. If you don’t have the bed space or staffing to be offering this, then you should tell women and their families that, because that is an issue. But I think we need to change our concept of what elective induction is, because if you’re a low-risk woman in between the ages of 21 to 28 and you have a NTSV pregnancy, nulliparous, term, vertex, then me talking with you about induction to get labor started at 39 weeks is not elective, it’s science-based. Based on the ARRIVE trial, you would meet the criteria. But given what happened during the study conclusion, many women who are educating themselves about birth may decline that, and that’s the concept of shared decision-making. You present options, alternatives. And one of the things I want to give kudos to is AWHONN. As you know, I’ve spoken at AWHONN, been a member, been on the board and currently a member.
I loved their response following the ARRIVE trial because right away they came out and very rapidly, this passed by the board of directors on January 18th, 2019, they redid their position statement on elective induction of labor. And I just want to read to you just a couple of sentences, because I think it really brings it home. Association of Women’s Health Obstetric and Neonatal Nurses, AWHONN, advocates against elective induction of labor before 39 weeks gestation. That’s a given. We don’t want to be inducing people prior to 39 weeks. Induction at or after 39 weeks gestation is an option that should be carefully weighed against expectant management. Nurses support a woman’s choices and provide quality care during the entire perinatal period. To me, they couldn’t have said it better. This is not a decision to be made lightly, but this is and should be between the provider and the patient, and what’s the nursing role?
As long as if you have somebody coming in and you don’t think they understand the risks, benefits, alternatives, that they really haven’t had informed choice, then I think you as a nurse, even though it’s last-minute, even though you’re probably not going to change anything in labor and delivery, I do think you have an ethical and professional duty to speak up and try to engage another provider-patient discussion, even if it’s in labor and delivery before you start the cervical ripening or oxytocin. So I do feel very strongly about nurses being advocates, but where do we really need help? I’ll tell you. Prenatal education. Nurses can have such a great role in prenatal education and getting the word out and having these discussions. I don’t see as many people, maybe you guys do where you’re at, but there seems to have been a drop-off in prenatal classes that have any real depth, that are beyond a hospital tour, but something that really talks about birth and options and provides data..

Sarah:
Which is a perfect plug for the Bundle Birth side of Bundle Birth Nurses, where we have all sorts of classes that do have depth that are taught by myself for the patient side. We don’t have to get on this train, but I also hear providers discouraging families from getting that prenatal education. “Oh, you don’t need it. Oh, you’ll learn everything in the way. Oh, this and that. It’s not important. Oh, it’ll tell you to be afraid. Oh, blah, blah, blah.” And I’ve heard it all, when literally I’ll have clients that will be like, “Well, my doctor told me not to take a class. It’s unnecessary.”

Lisa:
And that speaks to, again, the model of care in this country. And maybe that. Let’s just think about that for a minute. One of the richest countries in the world, we have more tech than anybody else, but we can’t seem to get it together with maternal morbidity and mortality. Maybe it’s the model of care. Maybe it’s engagement with women and the concept of real shared decision-making. Look, I had a non-interventive practice for many, many years as a midwife. We had a low C-section rate. I think our C-section rate was, again, even in a mixed risk population that we serve, about 15%. But one of the things we did was we had a special visit. We didn’t force people to make birth plans. A lot of our patients wanted to make them, but we actually had a visit that we did not get paid for.
We had two visits in my practices that everyone that we really didn’t get paid for because we couldn’t bill accordingly. One was a 45-minute visit around 35, 36 weeks to discuss all the birth issues, and that was the only goal of the visit. And the second one was we did a two-week postpartum visit that, again, wasn’t going to be reimbursed. It was part of our [inaudible 00:24:56], because we found that seeing somebody at two weeks was when we would pick up postpartum depression issues, breastfeeding issues at this early visit instead of waiting for six weeks, and we decided to do that as a practice. And I think that model of care made a huge difference.

Sarah:
So I see two areas of opportunity here for us as nurses. One is what you’ve already said, and it is no surprise to any of us because it literally comes up in every single episode when we talk to anybody across the world of birth, and that is that we have to be completing the shared decision-making process. And that’s where I think about mentorship and that class in our mentorship program is the one that people skip. It’s maybe not quite as thrilling as a physiologic birth or a breastfeeding course, but to me that shared decision-making class is the foundation of our practice. We have to know what our role is. We have to know how to advocate we have to know legally what we’re required to do and legally what’s the doctor or midwives’ requirement. And that is a very awkward dynamic at the bedside when the way that we practice is different than a shared decision-making model being the standard of care. We are not practicing in that way.
And once again, I think you’re absolutely spot on. Imagine a world where the shared decision making process was completely completed. Think about the trauma rates that would go down when patients feel like they have control over their care. It has such a trickle down into absolutely everything that we do. The other side is that I think what I’m hearing from the two of you in the discussion that’s already even had is we know that there is very strong opinion about the ARRIVE trial and about induction of labor and about the impact on care and about all these things. And we have these conversations, and I think this is, to me, a great alert to our audience, one, to actually read the research yourself. We take so much information from the masses because we’re told. And mind you, a place like this would be a more reliable resource to go to. If you want things summarized from the resource you’re going to have to pay for a class or come to a podcast like this.
That’s why you go and you do your education, otherwise you’re going and you’re finding the research yourself. And we have to be critical thinkers about what we’re seeing rather than just take in everything that we’re being told. The other piece and side of this is that if the shared decision-making process is completed, if we know what the research is, I think that there is also a potential area of opportunity and just a slight challenge I want to bring to us, that we can have our own opinions about it. We can have what we would do or not, but the amount of emotional residue that’s left when we bring those opinions to the bedside and we disagree with what’s going on, we have to be able to look at the scenario and go, “Well, the patient is choosing this, knowing the risks.” Even elective C-section. Let’s use an extreme example. That the patient, you’ve seen the consent.
I know Lisa’s face was like, “Ah, I agree,” but even then, and they shouldn’t be done, by the way, let me just say. But to use that extreme example, the patient has been talked to about the risks, benefits, alternatives. It’s been discouraged because of X, Y, Z. They’ve had the opportunity to share their values and preferences, where it all comes from, and they still proceed with an elective. I can walk onto that case and be completely distraught about it, or I can walk onto that case and say, “All right, I’m going to give my best to this patient. This is not my life. I have full confidence that it is not my responsibility to prevent them from harm when they know what potentially they’re walking into.” And I pose that as a question to going back to the shared decision-making challenge of that cultural shift and that becoming the norm.
How much better would we feel about our jobs if we could feel that way about every case that we maybe disagreed with or wouldn’t choose ourselves, but we feel confident that the patient is making the choice for themselves because all of the information has been given, nothing’s been withheld. I saw a DM come into Bundle Birth Nurses this morning where she’s there at the bedside. The doctor told the patient that she had an infection that put her at risk for a vaginal birth and recommended a C-section. That infection was GBS. She came onto this case and the patient was all like, “Oh my God, I need a C-section,” and she’s trying to advocate for correct information being told, but now the patient is stuck between a rock and a hard place because she’s being told something else by both the nurse and somehow the anesthesiologist got involved, and now what does the patient do?
They’re like, “Well, my doctor’s telling me this and my nurse is telling me this, and now I’m in the middle and now I’m all confused,” and the patient elected for a C-section. And again, we could tell story upon story upon story, but again, going back to that shared decision-making place, posing the question, what a difference that would make on every layer of our care and our own professional satisfaction.

Lisa:
Yeah, I have to agree. I couldn’t have said it better and I’m so glad you guys are doing what you’re doing. I am thrilled with all the work you’re doing in this area, but I agree. We have to be respectful. One of the things I used to say, and I still say it, midwife means with woman. That’s what I am. I’m a midwife first. Okay? I was a nurse first, but midwifery has been my career. And midwife means with woman. It doesn’t mean with woman, as long as you do what I think is best for you. We need to support women’s choices, whether that’s… And again, I am definitely against elective cesarean birth. I think setting yourself-

Sarah:
Agreed.

Lisa:
The only way I might be able to get behind it is if you said, “I only want one child.” And then the risk, again, is very limited because you’re not creating a scarred uterus, so then I’m a little less anxious about it. But if I’m really talking about women having autonomy over their body and their decision, then I need to be able to provide respectful care even when I disagree with that decision. Now, the different area, though, as you said, much easier for me to do that if I know and have evidence that a shared decision-making approach was taken. This GBS story that you talk about doesn’t sound like there was a true exchange of risk benefit information, although it’s hard for us to know. Somebody sends a DM, we don’t know what was said. Maybe she had some other history, maybe there was a history in her family of a GBS death. If you talk to a family that’s experienced that, they are not going to want a vaginal delivery, and GBS, you can be positive one day and negative four days later.
So it’s a murky area, but I agree. If there’s shared decision-making in play, we need to be able to respect that. Now, I think the next area I wanted to talk to you guys about is something that just came out on the effects of the ARRIVE trial, and this was just recently published in the Green Journal, and this was Effects of the ARRIVE Trial, Induction Versus Expectant Management in Term Nulliparous Patients. This is by Nethery and colleagues, and again, I’ll send you the site, but what they did is they did a time series analysis and they looked at 13 hospitals in the Pacific Northwest. We’re talking probably Washington and Oregon. And they analyzed almost 30,000 births, about 15,000 pre-ARRIVE and 13,000 post-ARRIVE. And what they found was that the induction rate increased, and it increased significantly, and at some of the hospitals more or less, but it definitely increased in the year following the ARRIVE trial.
So what they looked at for post-ARRIVE was a little bit more than a year, August 2018 through December 2020. And they had a very large difference in the incidence of inductions, but they looked at nullips. They didn’t only look at low-risk. So they did stratify it later and compare the two, and there was definitely an increase. But what they found was there was no statistically significant change in cesarean birth or hypertensive disorders with this increase. So the question then is, well, if there was no statistically significant increase in section rate, that’s good. There was also no statistically significant decrease, which is what the ARRIVE trial showed. Why this study to me only shows that, yes, there’s been an uptick in induction across the board and doesn’t give us any other great valuable information that we can really apply to the population, is the fact that these are 13 hospitals in the Pacific Northwest.
I don’t know if you guys know practice areas, but if you look at where there’s more midwifery care, promulgation of birth centers, the type of care that you get in this area versus some other states and some other areas or areas where there are maternity deserts, I’m not sure that we’re going to see a change in outcomes even with an uptick in induction rates, because we have a management style that maybe, A, has low cesareans to begin with or relatively low, and doesn’t have the same amount of hypertension. And they point that out themselves. Some of the things that they talked about in their study, which I do think you should read, is that the population had a higher median maternal age, 29 years versus 23 years in the ARRIVE trial, a much higher rate, significantly higher rate of commercial health insurance, 64.8% versus 43.9%, and a different racial and ethnic distribution.
And that’s one of the problems to me with all of these studies. We know about the disparities in healthcare and we know about the differences in outcomes. So it may be very difficult to do a large enough study that specifically looks at what the ARRIVE trial looked at in a way that becomes helpful to certain populations that we might want to help the most. So these are all things I think we should think about. I think it’s good to read some of these studies. I do think the ARRIVE trial has increased the rate of inductions, and not always appropriately so, but what can we do about it? Well, one, we need to work more as you said on shared mental models and making sure that providers and clinicians, and we’ve got to educate the public, because an educated public is going to do much better. My joke years ago when I was running my practice at Northwestern is that many of the women I saw in a midwifery practice, these are people who are coming to midwives, spent more time deciding on how to buy a new car than preparing for childbirth.
So childbirth preparation has to come back into play at a community level. And until we get that going and have a well-educated public, I do not think we’re going to make a dent in induction rates, section rates, maternal mortality, morbidity rates, those types of things. And the other thing I think is we need a well-educated clinical and nursing staff. When I am teaching and find physicians, nurses, and midwives even don’t know what relaxation time is, don’t understand the effect of uterine activity on fetal acid base or uterine acid base, are not familiar with the study that I talked about, looking at how to define failed induction of labor and yet they’re doing all these inductions. Well, we’re not going to do well. We are setting ourselves up for failure by not being clinically educated. We’ve got to get the physiology down and we’ve all got to learn how to read a study, how to parse a study, and how to understand the limitations of a study, and who the data might apply to and who it won’t apply to.

Sarah:
Well, and the other thing that I’m hearing here is that based on the ARRIVE trial, we can’t just decide to throw an induction at people at 39 weeks and that be how we lower our C-section rates.

Lisa:
Agreed. Agreed. Offering induction at 39 weeks in the low-risk NTSV patient is an option, looking at your population and individualizing care. So I have no problem with that as long as the woman in her family understands how we’re going to do it, why we’re going to do it, what the alternatives are, and what the actual risks are based on gestational…. We don’t need to villainize data. Data is data. Come on.

Sarah:
Yeah. And I think people just don’t don’t know how to interpret it themselves. And it’s like, oh, you hear it and then you bring your opinion in versus actually reading it yourself and understanding it and forming an opinion about what the actual data says versus about how you feel about the data. And then that informing your practice, it’s too muddy. It’s too much emotions.

Lisa:
It’s too emotional. It is. People get very emotional about these topics and it’s like, “Look, you should not be getting emotional about science.” Now, should you get emotional about the abuse of science? Absolutely. I’m all about that. I am very angry when I see the abuse of science, but emotion for emotion’s sake and not being able to separate myth from fact is really problematic. We hold a lot of beliefs that are proven not to be true, and yet we hang on those. We don’t like to give them up. And there is a psychological basis for that. Studies have shown that people, even once presented with evidence, if it’s a long-held and deeply held belief, they won’t give it up even when evidence is presented to the contrary. So even all the things that I’ve said may fall upon deaf ears if people have already made up their minds, but it won’t stop me from talking and trying.

Sarah:
Well, and one contraction, one person, one data point at a time. That’s how change happens. It doesn’t happen overnight. You can’t snap your finger and force people to change or even adjust their viewpoints. But it’s the same with, say, a closed knee pushing. How has that turned into a more common thing? By one patient at a time and actually seeing the outcome, and then going, “Huh, interesting. I don’t want to do that. No, that’s not how you open the outlet.” And then you slowly but surely then you get stuck, you try it, you see it work. “Oh, maybe we’ll try that every so often,” versus it becoming the standard of care.
So we are in the process of this movement forward. We have seen it. In the last two years since we’ve been on the game, we’ve seen so much forward movement, and I am sure, Lisa, you can speak to your career, my career over 10 years. There has been so much that has shifted in those 10 years. And when you’re in the weeds and when you’re feeling like you’re seeing the patient in front of you that’s being counseled on a C-section for GBS, that’s really frustrating. And yet, it’s everything that we’ve said for so long. Pause at the door, don’t write their story, show up and offer your best to that one individual patient, that those little nuggets of investment on your part actually contribute and they build towards us actually changing outcomes.

Lisa:
I love that. I love that.

Justine:
Thanks for spending your time with us during this episode of Happy Hour with Bundle Birth Nurses. If you like what you heard, it helps us both if you subscribe, rate, leave a raving review, and share this episode with a friend. If you want more from us, head to bundlebirthnurses.com or follow us on Instagram.

Sarah:
Now it’s your turn to go and get your hands on some research and think for yourselves, and help advocate for the shared decision-making process with every single patient. It’s one patient at a time, completing by the end of your shift, being able to look back and know that your patient got the truthful information that they needed to hear to make informed decisions for themself, empowering them for their birth experience. We’ll see you next time.