Lament, in Stereo
Tuesday, May 10, 2011 at 12:49PM
By Lauren A. Plante, MD, MPH
I was startled to read Dr Annette Fineberg’s essay “An Obstetrician’s Lament” in the May issue of Obstetrics & Gynecology, not because I disagree with anything she had to say in it, but because it appeared in our premier journal and therefore reached about 50,000 other OBGYNs. A couple of years ago, at the start of the “patient-choice cesarean” controversy, I coauthored a piece entitled “Patient-choice vaginal birth?” and didn’t even try submitting it to Obstetrics & Gynecology: we just assumed the editors wouldn’t consider it and submitted it to a family practice journal instead. But either Dr Fineberg’s eloquence or the simple passage of time has brought this once-taboo subject out in the open for the rest of us to think about.
On the one hand, obstetricians always claim we want the best for mothers and babies; on the other hand, we assume we always know what that is. Our practice style is typically high-intervention and low-interpersonal, and after a while the other styles become both less visible and less acceptable to us. We are the keepers of the sacred steel, and if your baby doesn’t just fall out we can carve her out of you. Smile and be grateful, okay?
Most of us have limited and ever-lessening experience with natural birth. Sometimes I hear my residents telling one another about a precipitous labor and delivery, by which they seem to mean nothing happened that required their participation. They don’t actually recognize normal labor and birth, though I can’t realistically blame them, because what they see in our hospital doesn’t bear much resemblance to normal. They’re quick off the trigger, because that’s what’s rewarded: when you’re managing a board full of women in labor, it’s more like traffic control than anything else. Room 4 hasn’t delivered yet? Well, did you start pit? Or, is the OR free yet? Because we’ve got the next three C-sections lined up, so let’s move it along. I used to assign medical students just to labor-sit—-just plan to spend their shift with the same laboring woman, learn the process, learn some patience, be there for her. But usually a senior-level resident will countermand that order, pull the medical student to do something rather than just be somewhere.
Dr. Fineberg points out that OBGYNs are often considered the bad guys. We didn’t mean to be. We didn’t choose this specialty to wreak havoc or ride right over women’s wishes. But we weren’t that patient to start with, or we wouldn’t have chosen a largely surgical specialty, and our training often rubbed the idealism right off us. And by this time the discourse is so colored by suspicion on everyone’s part that it’s hard to know how to fix it. We ought to support VBAC, and breech vaginal delivery, and out-of-hospital birth, but our experience is so largely focused on the things that go wrong that we assume catastrophe. And the less welcoming we are to women who want those options, the wider the gulf, and the less safe those options become…because we drive them underground. My residents have certainly never seen a home birth that went well: how could they? They only see the ones that didn’t go smoothly and so were transported to hospital. Sometimes they see the ones that should have been transported much earlier, only the woman and the midwife pushed the envelope that much further just to avoid the inevitably unpleasant interaction with the physician. Sometimes they see a catastrophe, but don’t recognize that it could have been avoided if there was a safe and welcoming backup place. Without the denominator, they’re convinced that the out-of-hospital world is a dangerous place. I recently spent a few days with a midwife who’d been attending births at a birth center for decades. When she was starting out, she said, with an unsupportive and rather grudging backup, she was convinced that she never delayed a hospital transport for fear of that interaction. But when she landed in a supportive and welcoming backup arrangement, she was surprised to find that her transfer rate went up. Not her cesarean rate, just her transfer rate… because she could bring a woman in sooner if either of them had concerns about how labor was proceeding.
There’s always a lot of pushback from OBGYNs when anyone starts talking about women’s choices. Generally, women’s choices are better supported by the establishment when those choices further concentrate power within that establishment. The final argument always brings up safety: the dead-baby specter trumps all other considerations. So let’s just stipulate: everyone is interested in safety. The OBGYN who may attend a thousand births in his career is no more interested in safety than the woman who will have two of those births and raise those children. Safety requires skills, respect, transparency, and enough time. If physicians can’t provide those things, we shouldn’t balk when women seek them elsewhere.
This post is featured as one of a series of posts by OB-GYNs in response to the May 2011 article, An Obstetrician’s Lament, by Dr. Annette Fineberg.
Reader Comments (14)
I found myself nodding, nodding, nodding as I read through this post. "She's got it!" "It" being the deep understanding of the multi-faceted reasons behind women's choices to step outside the technical standard of care offered in hospitals. Refreshing to not hear the tired refrain that women choosing homebirth are more interested in "the experience" than the safety of their child. While the ridiculousness of the comment seems apparent, it's not always easy to explain the why's while in the middle of an emergency transport from home to hospital. Dr. Plante did a lot of the explaining here and for that, I am so grateful! Now I need to memorize what she said.
I just wish we had the answers as to what it would take for Doctors such as this to be the norm. And then what would it take to get women to TRUST those Doctors again. I know of two, maybe three in my metro area who I would "trust" to be understanding. Except, darn it, those doctors are not even OB/GYN's, they are in fact Family Practice physicians who also do OB... Sorry, don't know a single OB/GYN personally who is as open-minded as the one above. *sigh*
This is a great piece. I can't say much more... I wish there were more systems and backups like this in place.
so insightful; what a rarity
This is all very well put. However, while the diagnosis is on-target, where are the true solutions? Not just the goals, but the manners in which to reach them?
I couldn't read the original article, I guess I'd have to pay to do so.
I will say, I agree with this doc 100%. "Safety requires skills, respect, transparency, and enough time. If physicians can’t provide those things, we shouldn’t balk when women seek them elsewhere." Precisely. I know a ton of women, myself included, who thought they were signing up for something reallly different from what they received, and not just because of nature. Far from it. I had NO reason to suspect what would unfold. And, usually it had both physical and emotional tolls.
I also agree and think it's ALL ultimately a woman's choice. Many doctors don't view it that way. You do, that's awesome. What to do about the ones who view womens' choices as making some sort of move AGAINST her fetus or the doctor when really she's thinking about both of them (the mom and baby)??? And, she's obviously NOT thinking much about the doctor - but she's also less biased in that respect. (For instance, an obese acquaintance who nearly died during her first c/s and had a horrific recovery, wanted to VBAC.. Was in great health for her size, probably better health than my skinny butt, U/S showed a strong scar.. was told NO NO NO you are TOO FAT, DEAD BABY THIS THAT.. so fearing for HER life in a surgery, she waited at home with a montrice and went in advanced labor fingers crossed and pen ready.. Successful VBAC, perfectly healthy baby, but not without being dehumanized, insulted, and achieving different sorts of battle scars... Even when women do "the right thing" (not VBACing at home) they are mistreated!! What are they supposed to do!?) I guess.. have doctors with more sense.. talk sense.. into them?
I think you are very right on another point. Using terror tactics besides in the utmost of horrible situations is, however usually effective, at the time, but it's usually unnecessarily brutal (probably the time thing again.. why waste time explaining your rationale for 30 minutes to an "illogical pregnant woman" when you can just mention c-section or dead baby or deadly infection or whatever?).. and if women discover it was made up/fudged... or they were manipulated/taken advantage of in a sensitive or even a truly decompensated (like a very high fever... like me...) state.. particularly if it causes them a great deal of mental anguish AND/OR harms them physically.. HOW are they supposed to trust the medical establishment? Why should they? Because they were alive at the end? What if next time things really are very dire, but now it is the boy who cried wolf??? (Maybe she's thinking of her and her babies safety in that regard .. She trusts a midwife at home or a birth center or a montrice in the hospital with her to tell her when shit really IS hitting the fan.. IMO that IS safer than a person that refuses to believe a word out of the nurses/doctors mouths and has no one to confirm anything for her.)
And, the stonewalling with medical records (editing them to the point of .. no point sending them on, like mine) and requesting no cameras has got to stop, too. I know, I know, only a lot of reform would take away the silver bullet known as the career-ending-lawsuit but come on.. I need to know what really happened. Not the severely abridged version. And, I'm personally not putting myself in a situation where the med pros are so terrified of me having evidence of malpractice a camera.. and knowing what was written down at the time.. is forbidden... not again. Not unless I can't help it.
Yeah.. I think women in first world countries do take how safe birth has become for granted a bit.. which is a point a lot of docs like to make.. but we (in the first world) tend to take everything for granted, and "everything", food, water, appropriate shelter, appropriate sterilizations, medical knowledge and safer surgery and anesthesia, as it were, is a huge part of why it's so much safer, SURE... It's not about all that, though. Since, it could be safer.
Docs seem to take for granted how what we think we know can change very quickly.
Safe is relative, safe is not so black and white. Safe is also -down to the individual-, not a statistic on a sheet. Hospital might statistically appear to be safer (at least in regards to neonatal mortality, which the stats for are murky and possibly incorrect in the first place) based on some studies which docs seem to buy, but assuming they were 100% right.. how much responsibility do they (the medical establishment) have in that, too... by severely alienating homebirth midwives/OOHB and the women who choose them? They just make it worse for themselves, women, and babies by being judgmental and receiving them with misplaced and innappropriate anger. They could also do better, anyway. You hit the nail on the head with that assessment..
And, I think that major healthcare and malpractice reform, along side with that midwifery reform (how is it not biased to have homebirth midwives that are friends decide the fate of each other after an error/bad judgment/malpractice? And, they should be more integrated, and by integrated I mean respected and well-taught perhaps in strict apprenticeships and with their own more strict licensing, not necessarily under ACOG's thumb.), then also more checks and balances in medicine without fear of said career-ending-lawsuit (more... career-ending penalizations for true negligence, brought to the surface without fear of retribution by "I didn't see anything, did you?" peers... and I'm not talking about the necessary tolls of training new doctors and midwives, I'm talking about things like doctors who are addicts or quacks continuining to practice because they're protected by "I didn't see anything odd" and do NOT tell me that hasn't happened or I'll tell you a long story!) .. would play into a perfect-world scenario. But, alas I doubt that is going to happen with Congress in the pockets of insurance companies and Americans being a bit too easy to stir up with trigger words like "socialist".
Bravo.
I published the entire article on my site. You can find it here:
http://navelgazingmidwife.squarespace.com/navelgazing-midwife-blog/2011/5/10/an-obstetricians-lament.html
Thanks, Navelgazing Midwife.
I will be printing out the article and sending it to a particular (former) OBGYN in my community who has been giving midwives a hard time (OP editorials and all, reporting to sheriff, etc). I am so tired of most OBs thinking that they know everything when they haven't even taken the time to read the studies, or really think about WHY a woman would seek care elsewhere. Thank you for this very well written, thoughtful post. Too bad more OB's can't see the big picture. I esp. like "The OBGYN who may attend a thousand births in his career is no more interested in safety than the woman who will have two of those births and raise those children." I get really pissed when Dr. think negatively of my choice to HB, like I am not interested in safety!!!
Thanks Dr. Plante. It's been about 10 years, but articles like this that remind me why you were such a legend among us Drexel OB residents :-)
I think there are many OBs who agree in principle with these concepts. Moving beyond fear of a lawsuit to the point where we are willing and able to accomodate a woman's choices is the problem. If we could revamp the legal system in this country, I believe we would see more OBs who are supportive of a woman's autonomy and right to choose, "coming out" and supporting vaginal breech births, VBACs, and collaboration with home-birth midwives. The problem is, by the time that happens, who will remember how to do those things?
I applaud Dr. Fineberg's public acknowledgement that fear of liability and lack of experience among obstetricians has left many birthing women with virtually no options other than surgical birth in the hospital setting. As a way to begin moving beyond the current paradigm she offers:
“Collaborative practice with midwives is a good start, but in order for obstetricians to be more than providers of cesarean deliveries (a thankless and, in most cases, technically simple procedure) we need to have conversations with our patients that are not one sided and allow for true informed consent. Many of the obstetric disasters we have all seen.....are at least in some part iatrogenic if examined deeply enough.
That failed induction for convenience with early artificial rupture of membranes and chorioamnionitis. The first cesarean delivery done at age 15 after 2 hours of pushing with an epidural that then leads to the fifth cesarean years later, and then accreta and life-threatening hemorrhage, are both typical examples.”
We have obstetrics and midwifery, two somewhat divergent professions, vying for authority to care for low-risk pregnant women. The above quote demonstrates to me precisely why obstetricians should not attempt to concentrate their expertise among the masses of low-risk childbearing women. Birth is by nature, unpredictable. Obstetricians appreciate predictable outcomes, and in fact seem to be most comfortable with them. Isn't that partially why they introduce so many interventions in the average, normal birth? To attempt to create a predictable and manageable outcome?
If obstetricians want to get out of the OR, yes, they must begin to examine not only the concept and application of informed choice in their practice as Fineberg proposes, but they must also recognize the existence of other factors in the patient-provider dynamic that congeal their role as infallible authority figures who can guarantee outcomes in birth. As both a midwife and mother who benefited from obstetrical care in hospital birth I am grateful for the evolving knowledge-base the profession has to offer. I think though that the domain of obstetrics should reside, by and large, in the care of high-risk women and babies who benefit most from the interventions and skill set offered by surgical specialists with advanced training.
Dr. Plante touches on the idea as well that obstetricians may not be the most appropriate providers for low-risk women seeking a minimally interventive birth:
"Dr. Fineberg points out that OBGYNs are often considered the bad guys. We didn’t mean to be. We didn’t choose this specialty to wreak havoc or ride right over women’s wishes. But we weren’t that patient to start with, or we wouldn’t have chosen a largely surgical specialty."
This is why it may be impossible for profession of obstetrics to redefine its values and commitment to women's autonomy as it is currently structured. How many medical students are attracted to obstetrics because they want to safeguard normal, physiological birth, or help a woman through the course of her labor, unmedicated? Women need surgical specialists in the OR far more than they need them in the birth room. While discussions about "change" and "choice" for women are a start, I believe that rather than trying to force a change that is antithetical to the underpinnings of the profession, childbearing women will be best served by a decisive re-focusing of obstetrical expertise to the high-risk arenas in which it naturally excels.
I began reading this article with trepidation, sure that the response to the original article would point out the superior approach of obstetrics, etc. But I was so pleasantly surprised. Where are the Lauren A. Plantes of the world when the media is looking for an obstetric opinion on cesareans/home birth/women's birth choices? The fact I was so ready to assume another OBGYN had the same disregard for a woman's right to birth naturally, without interference unless it is medically necessary, troubles me. Thank goodness there really are OBGYN out there like Lauren. If only the obstetric culture in general reflected these attitudes more widely.