Delivery Room Leadership

Over the past monts, we have spent a considerable amount of time with doctors and midwives. Somewhere between conversations about induction, epidurals, C-sections, waiting and intervening, I began to notice something.

The outcomes of these conversations were often surprisingly similar, yet the conversations themselves felt fundamentally different. Our experience with doctors was that they tended to enter relatively quickly with an assessment and recommendation: this is what I think is happening, and this is what I believe we should do. The midwives we met often started somewhere else. Before offering their opinion, they asked how we saw the situation. How did we feel about induction? What were our thoughts about an epidural? What mattered to us if the birth did not go according to plan?

Interestingly, there is a well-established approach in healthcare that closely resembles what we experienced: Shared Decision-Making. The idea is that expertise exists on both sides of a medical conversation. The healthcare professional brings scientific knowledge, technical competence and experience. The patient brings knowledge the professional cannot possess: their own values, fears, priorities and preferences. A good decision draws on both.

Looking back, this was what many of the midwives seemed to be doing. They did not avoid giving advice or surrender their professional authority. They simply sought to understand our perspective before adding theirs. And somewhat paradoxically, this made us more receptive to their recommendations, not less.

This is, of course, a personal observation rather than a scientific comparison of two professions. Doctors in Austria receive training in medical communication, just as communication forms part of midwifery education. There are wonderfully curious doctors and highly directive midwives. Still, our experience made me wonder whether the difference we noticed had less to do with communication techniques themselves and more with professional identity.

My hypothesis is that midwives may enter their profession more strongly as companions of a process. Pregnancy and birth are not, by definition, problems. They are processes already unfolding. The role is to observe, support, create favourable conditions, recognise deviations and intervene when necessary. Doctors, by contrast, are trained primarily as problem-solvers: diagnose, assess risk, identify pathology and act.

And thank goodness they are. When something goes seriously wrong, I do not want someone merely accompanying the process. I want an expert who recognises the danger, makes a decision and acts.

But every professional strength has a shadow. If you spend years becoming exceptionally good at solving problems, not solving something can become surprisingly difficult. Waiting can feel like passivity, uncertainty can feel uncomfortable, and asking another question can seem less useful than giving the answer you already believe to be correct.

I recognise this tendency because mountain guides suffer from exactly the same temptation. We have knowledge and experience, recognise patterns before our guests do and often see dangers they cannot yet see. Expertise gives us authority and responsibility, but it also creates the temptation to constantly demonstrate both. We decide, instruct and intervene. There is something almost godlike about professions in which other people turn to you because you are expected to know what to do.

Sometimes that is exactly what is needed. If an avalanche is coming down the mountain, I am not going to facilitate a group discussion about everyone’s preferred course of action. Likewise, in a medical emergency, I want the doctor to take charge. When danger is immediate or time is scarce, directive leadership is not a failure of participation; it is part of responsible leadership.

The problem begins when the leadership style that works brilliantly in an emergency becomes our default everywhere else.

Leadership theory has developed considerably since Kurt Lewin’s classic distinction between autocratic, democratic and laissez-faire leadership. Among the approaches that have emerged since, my personal favourite is participatory leadership. I do not see it simply as another name for democratic leadership. Participation does not necessarily mean handing the decision over to the group. It means involving people in understanding the situation, contributing information, exploring possibilities and shaping the way forward, while the leader can still retain responsibility for the final decision.

That distinction matters. Participatory leadership does not force us to choose between authority and inclusion. A leader can listen without surrendering leadership, invite participation without giving away responsibility, and change their mind without losing credibility.

This is where the connection with Shared Decision-Making becomes particularly useful. A doctor may understand the medical evidence better than the patient, but the patient understands their own priorities better than the doctor. A mountain guide may understand the objective dangers better than the guest, but the guest knows their own fears, ambitions and physical condition. A leader may have the broader overview and final responsibility, but the people closest to the work often see constraints, opportunities and problems that remain invisible from above.

Asking for another person’s perspective is therefore not just a nice way to make people feel included. It is a means of obtaining information we do not have. It can improve the quality of the decision itself. At the same time, participation creates something that instruction alone struggles to produce: ownership. Research on motivation and autonomy consistently points to the value of agency. People tend to invest more strongly in decisions they have helped shape and to trust leadership more when their perspective has genuinely been heard.

That brings me back to the delivery room. We often found ourselves more willing to follow the advice of the people who had not started by telling us what to do.

There is a subtle but important difference between opening a conversation with “I think you should have an induction” and beginning with “How do you feel about induction?” The first immediately establishes the expert’s position, and everything that follows is inevitably expressed in relation to it. The second leaves room for fears, preferences, misunderstandings and values before the professional adds their expertise. The eventual recommendation may be exactly the same. The professional has not lost authority and the patient has not taken over responsibility. But the person affected by the decision has become a participant rather than merely a recipient.

A similar principle appears in Motivational Interviewing: rather than immediately imposing arguments for change, we first seek to understand and evoke the other person’s own motivations, doubts and reasons. The common thread is not a reluctance to use expertise. It is a different sequence for using it: understand before you advise.

Perhaps that is the broader leadership lesson the delivery room brought back into focus for me. The more expertise we acquire, the greater the temptation to skip directly to the answer. We recognise the pattern and know what we would do. But understanding the problem is not the same as understanding the people experiencing it. And advice offered before understanding can feel like control, while exactly the same advice offered afterwards can feel like support.

There is an old saying that speech is silver and silence is golden. For leadership, I might adapt it slightly:

Asking is silver. Listening is gold.

Even that comes with a condition. Asking questions is easy. We can learn techniques and ask, “What do you think?” while already preparing to explain why the other person is wrong. Real listening requires accepting the possibility that what we hear might actually change our mind.

That does not weaken leadership. It is part of good leadership.

There will always be moments when a leader needs to step forward, take responsibility and say, “Follow me.” But sustainable motivation, belief and trust require another ability as well: knowing when to step back just enough to let others into the decision.

Perhaps the highest expression of expertise is not having the answer fastest. It is having an answer, retaining the authority to act on it, and still being curious enough to ask:

“How do you see it?”

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