Less is more…

I once wrote about a study that gave me a lot of food for thought and led me to write about how less is more. It was called the STORK study (Styles et al 2011), and it looked at midwives’ intrapartum decision making.

The approach was simple. Researchers gave midwives a series of scenarios and asked them whether they would refer the woman to obstetric care or ‘keep’ them. They then attempted to see if the midwives’ answers correlated with factors such as the number of years’ experience they had, whether they worked in a midwifery led unit or hospital setting and what their attitude towards risk was.

Somewhat surprisingly, although the midwives exhibited a wide variety of responses in the circumstances under which they would ‘refer’ or ‘keep’ women, there was no correlation between their responses and any of these factors. The only significant correlation was that the midwives who worked in a health board area which had recently had a series of high-profile adverse events were more likely to refer sooner than their counterparts in other areas.


A very modern problem

Soon after the publication of the study, I was on a speaking tour which gave me the opportunity to discuss this study (and many others) with midwives, obstetricians and other people involved in the care of birthing women, and one of the discussion points that arose over and over again is the way in which what we do sometimes tends to be more hands on (in the broadest sense of the term) after something goes wrong.

When horrid things happen, we tend to focus on what we should do about it.

With the emphasis on the word do.

In fact, so often, our immediate response to anything that happened that didn’t happen in the way that we thought it ought to happen is to focus on what we can do to prevent a similar situation in the future.


A growing problem

I see this in many scenarios and this has become even more of a problem in the years since I first wrote about it. Nowadays, reports are written and action points set; entire professional groups and ideas are vilified. This is usually a kneejerk response to one tiny facet of the problem. It happens without reason and without reference to nuance, complexity or the wider context.

I had a conversation with a colleague about action points recently. A person who has a senior position in maternity care. “One problem with action points,” she said, “is that we spend so much time ticking off the action points that we have less time for face-to-face care. And there never seem to be reports or initiatives that decrease the action points, or processes through which we decide that they can be de-escalated.”

This is a problem in many other bureaucracies too.

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I’m not saying that the urge to ‘do differently’ is inappropriate or unnatural. In fact, quite the reverse. It seems a completely natural, human response to adversity. “Oh no”, we think, “this shouldn’t have happened. It would be good if it didn’t happen again, so let’s try to figure out how and why it happened and do something which will prevent it happening again in the future.”

And, as I discussed in What’s Right For Me, humans have a bias towards taking action rather than standing by.

Even when evidence shows that waiting or standing by actually leads to better outcomes.


The creation of action lists

just be

Often, research and reports lead to long lists of recommendations about what we should do differently. These lists often include more monitoring, screening and/or intervention than before, either universally or for women who fall into specific categories. However, even on a very simplistic level, I can immediately think of three reasons why this approach may be problematic.


The complexity of ‘why’

First, it is generally very difficult to determine exactly why something happened. Untoward events that happen during pregnancy and childbirth are often very complex, as the literature which analyses adverse events highlights over and over again. There are often many varied and unrelated factors which have fed into a situation, and it is the rare situation where one simple error, omission or event directly led to the problem at hand.


Prevention isn’t always easy, or a given

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The second issue is that, even if we can tease out one straightforward reason which explains why something happened, we can’t necessarily be sure that doing something differently will prevent it happening again. We might postulate that taking a particular action might prevent problems occurring in the future, but even after very careful analysis such a postulation is more like a research hypothesis which we need to test rather than a finding upon which we all need to act. At least in theoretical terms.

This is often true with induction of labour. It is recommended because there might be a slightly higher chance of a problem in one situation than another, and yet there is no evidence that it will lead to better outcomes. Worse, there is evidence that it has downsides and leads to some women having poor experiences.


Action can do more harm than good

In fact, the possibility that we may be doing more harm than good occurs in many situations, and is the third problem.

The something different that we do may have other knock-on effects and actually create more problems in the long run.

This is why researchers calculate statistics such as the number needed to treat. If someone suggests (for instance) that giving all factory workers a particular drug before they begin work will reduce the rate of work-related accidents, we not only need to see if this is true but also look at whether the routine administration of such a drug might have any unwanted effects as well as those that we are seeking to create. Would there be value in the drug if it reduced the rate of occurrence of some kinds of accidents while increasing the likelihood of others? Even screening tests can have unwanted consequences, not least of which are the false positive and false negative rates that are an inevitable consequence of any test that we use.


The tip of the iceberg

This list is only the tip of the iceberg; I haven’t even begun to mention issues such as individual choice and consent, mainly because I want to keep the focus on the emphasis that we place on action, on the concept of doing something; often more than we did before.

Report after guideline after study after consensus paper say we must do more. More monitoring, more checking, more screening, more form filling, more, more, more…

Sometimes we need to do more. But sometimes we need to do less. Or do nothing. Sometimes it would be better to think, or even just be, rather than do. Yet the culture that has grown around modern birthing emphasises, promotes and supervalues doing. Doing has become what is expected of us, and it is very difficult to say that doing more isn’t always the answer.


The less we do, the more we give…

Nicky Leap wrote about her understanding of this:

‘In life there is the potential to stumble across a phrase that pulls us up short, often a simple truth that will resonate through our core beliefs and values, heralding a profound impact on how we approach life thereafter. So it was for me when I was a newly qualified midwife and Independent midwife Hazel Smith said, in an almost throwaway aside, “You know, in midwifery, it’s often true that, the less we do, the more we give.’’’ (Leap 2010:17-18)


While Nicky was writing about the midwife-mother relationship on this occasion, I think this phrase may have sister phrases that might be true in other aspects of maternity care. Midwives have long known that, the less we do, the more likely we are to enable women to work with their body’s natural ability to grow, birth and feed their babies.

The less we do, the more likely we are to see women who don’t experience side effects of drugs and interventions which can then create adverse events in themselves.

If more is truly useful, then let’s do more.

But so often it feels like more is a kneejerk reaction which isn’t going to solve the problem, and maybe in some situations doing less might have prevented the problem in the first place.

Sometimes more is vital. Sometimes more is absolutely the answer. But maybe, at other times, less may be more, and when that is the case, it ought to be okay to say so.



Leap N (2010). The less we do, the more we give. In: Kirkham M ed. The midwife-mother relationship. 2nd ed. Basingstoke: Palgrave Macmillan.

Styles M, Cheyne H, O’Carroll R et al (2011). The Scottish Trial of Refer or Keep (the STORK study): midwives’ intrapartum decision making. Midwifery 27(1):104-111.


A version of this article was originally published as Wickham S (2011).  When less may be more…  EM 2(7): 51.


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