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« Is The Big Push for Midwives an Oppressive Campaign? | Article Round-up: Early Inductions, Practice Variation and Baby-Snatching »

J.D. Kleinke on Defensive Medicine, Obstetrics and Women's Health

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By Jill Arnold


J.D. Kleinke, author, medical economist and health care information technology pioneer wrote an article titled, A Normal Pregnancy is a Retrospective Diagnosis, which was featured today on The Health Care Blog. At the risk of deterring readers from clicking over to read the entire piece by zealously pulling excerpts of interest, I am pasting the passages here while imploring that you read his work.

Having the honor of currently reading an advance copy of his new book, Catching Babies, makes me want to refrain from intermingling my words with his, as his apt description of the cultural norming of defensive medicine and how women’s reproductive health bears the disproportionate burden of practice variation and angst needs no prefacing or commentary from me.


In obstetrics, “defensive medicine” is not just assumed, but actively evoked as part of a normative explanation for medical decisions. I have heard the phrase “we have to do this to cover ourselves legally” uttered to patients with such frequency, it has gone from appallingly crass, to admirably candid, to nearly superfluous.



Whether or not this does explain every dysfunction in obstetrical care, as many would have us believe, medicine does not get any more defensive that this: the inexorable increase in birth interventions has driven a growing number of women away from the medical establishment, off the grid, to home births attended by “lay” or unlicensed midwives. It has spawned a cottage industry of “alternative birthing” activists. And it has inspired language no less ugly than terms like “birth rape” (seriously - Google it) to describe what many view as a mangling of womens’ bodies against their will by OB/GYNs held hostage by lawyers who do not ambulance-chase malpractice so much as hearse-chase mal-outcomes - many of which are the fault not of any doctor, but of nature, God, or bad luck, depending on your beliefs.



Our medical malpractice system, like much of the post-modern American health care system itself, is a house of broken mirrors for our own worst neuroses as a society; and a big part of these neuroses includes our pathologizing of childbirth, along with our pathologizing of shyness, baldness, the normal effects of aging, dry eyes, twitchy legs, and whatever other little misery we can figure out how to medicate next.



As Americans, we seem hellbent on controlling the uncontrollable; this is why we create so many breathtaking medical technologies and give the world almost all of its breakthroughs in the treatment of cancer, heart disease and other real diseases. 



In my earlier work about the economic and political conflicts that define the delivery of health care in the US, I kept noticing that the greatest variations in care - and deepest cultural angst and antagonisms - seemed always to be associated with women’s health: our grossly disproportionate misdiagnosis and undertreatment of heart disease in women; our obsession with breast cancer when lung cancer is far deadlier and far more preventable; the almost criminal variations in hysterectomy rates around the country; the uninformed, blanket imposition of one group’s religious values on all women’s reproductive decisions. 



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Reader Comments (4)

Thanks for the post - fabulous full article and comments following...good discussion. It's a little on the long side, but I suggest everyone try to read it. His book is now on my *to read* list.

Thanks Jill!

February 2, 2011 | Unregistered CommenterAnne

I think that in the future we will look back at induction and augmentation and c-section the way we look the historical practices of exorcism and burning people at the stake. We rush to end pregnancies when a baby might be too small or too large, or not active enough, or "due". This is done just-in-case some disease has occurred. Witch hunts were conducted just-in-case evil spirits were present. The woman in Kleinke's article was threatened and subjected to painful treatment. If the induction hadn't worked quickly enough, she would have been cut open. While Kleinke thinks it is a shame that his treatment is overly cautious, he doesn't acknowledge that it is barbaric torture.

February 2, 2011 | Unregistered CommenterPriss


This version is edited--I hit the button too early above so the web master can delete--also I though this would be a new post--so didn't mean to change topic.

So--I just had a lovely delivery. A couple with their second pregnancy. First baby born in Japan, and here because of work, and speaking very little English--the poor mother virtually NO English. She was unable to bring her interpreter every time so we made good use of IGoogle translate.

She came in today at 37 1/2 weeks smiling, but wincing a little so I checked her cervix--which I don't normally do until 39 weeks. She was 8 cm and I didn't feel a head! She was a complete breech---darn it! She had been vertex the week before! Everybody starts to run around the office and call the labor floor--but they know me well. The nurse supervisor just says, "I assume we will be having a vaginal breech?" "Why YES! We will be"

I had to rearrange my office and drove over to meet them at the hospital. She wanted an epidural so we honored her request. We went ahead and had one done that gave her good motor control. We did have an IV for that, but then the lights go dim, and we waited. When she felt an urge to push we encouraged her to relax and wait until the urge became stronger--she was laughing and smiling and very happy. Next thing we see two little feet starting to wiggle at the perineum, and got her to push. Now guys--I DID put her in stirrups--not my usual-- but for a vaginal breech you want to have all the bases covered just in case. She pushed three times and baby out to the chest---unfortunately she had bilateral nuchal arms, so had to do some rotating to free them up and then the head a little tight. I don't typically put on Pipers but after two pushes the head would not deliver, so I quickly slipped them on and out came the head. She had a little first degree laceration fo perineum--no episiotomy. Baby girl--5 lbs 6 oz and Apgar 8 and 8. Got to nurse about 10 minutes after delivery and older sister thought the whole thing was nice. All was very calm.

Some of us still try to give the birth experience that you all look for on this site--but I can tell you that if there was a bad outcome here---the ACOG guidelines woudl be used to hang me out to dry.

February 2, 2011 | Unregistered CommenterHelen Sandland

"...our grossly disproportionate misdiagnosis and undertreatment of heart disease in women; our obsession with breast cancer when lung cancer is far deadlier and far more preventable..."

First of all, heard disease in women is by definition undertreated because it is, largely, difficult to diagnose in the first place.

Second, let's not underestimate the deadliness of breast cancer - it is the second most common malignancy in women in the US, and the second most deadly. Skin cancer actually ranks first in commonality, while lung is, in fact, the most deadly. By this data, shouldn't breast cancer BE an obsession of ours?! I can't imagine friends or family affected by this horrible disease telling me, "I wish we were a little less obsessed with breast cancer."

February 3, 2011 | Unregistered Commenteranon
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