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Another Obstetrician's Lament

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By Gustavo San Roman, MD

This obstetrician’s lament is that somehow in the debate of home birth versus hospital based birth both sides have forgotten that labor is a physical process.  At the beginning of time, the physical nature of labor was very evident, because if labor did not result in a vaginal birth then the lives of both the mother and her baby would be lost.  The inherent risk that this physical process would not result in a vaginal birth was determined solely by the physical characteristics of the mother and her baby.  The concept of having other humans assist a woman during labor arose from an effort to decrease each woman’s inherent risk.  These assistants needed to be part experienced coach and part skilled extractor of babies that get stuck in the birth canal.  Unfortunately, even with these helpful assistants, some women and their babies could not be saved.  This gave rise to the concept of a cesarean delivery.

About 100 years ago a paper was published comparing women who had a cesarean delivery versus a woman who was run over by a wagon and another who was gored by a bull.  The women who delivered their babies via abdominal trauma had better outcomes than the women who had a cesarean delivery.  However, with the discovery of aseptic technique, antibiotics and advanced surgical training a cesarean delivery has become a reasonable alternative when labor does not result in a vaginal birth or when it is safer for the mother or baby. 

However, safer is a relative term.  Perhaps in the hands of an assistant (now called an obstetrical care provider) who has never performed a vaginal breech birth it is safer for a woman to have a cesarean delivery.  If your hospital does not have an anesthesiologist who is in house, perhaps it is safer to perform a scheduled cesarean delivery rather than inducing labor for an attempted VBAC.  These are questions that should be answered long before labor begins.  If a woman does not like the answers provided by her obstetrical care provider then the woman can seek out another provider with better answers if she wants to avoid a cesarean delivery.  However, at no time should we forget that labor is a physical process and that the physical characteristics of the mother and her baby will determine each woman’s inherent risk for cesarean delivery.

Asking an obstetrical care provider about their experience and skill with breech presentation and VBAC are easy questions to ask.  The more important and more difficult question is; “Will the obstetrical care provider’s experience and skill increase or decrease a woman’s inherent risk for cesarean delivery?”  Unfortunately, obstetrical care providers cannot answer this question unless they are using a method to measure their results that accounts for the inherent risk of the women that they deliver.  Therefore, it is important to understand that an obstetrical care provider’s high or low cesarean delivery rate may not reflect the experience or skill of the obstetrical care provider.  This is because a high or low cesarean delivery rate may be more a reflection of the inherent risk of the obstetrical care provider’s patient population than the experience or skill of the provider.

In an ideal world we would have obstetrical care providers (obstetricians, family practitioners or midwives) that analyze their own results with a method that can determine the best way to decrease the inherent risk of laboring women without compromising safety.  Those providers (home or hospital based) that find the labor management strategies that are best at decreasing a woman’s inherent risk would then promote these strategies to all of the other obstetrical care providers.  If these strategies are applied in or near a hospital setting then this should end the debate because the best of both home and hospital based births could be combined and the worst of each would be eliminated. However, for this ideal world to become a reality we would need to see to it that women or babies who suffered unavoidable injuries at birth receive help from all of the members of our society and not just from the pockets of obstetrical care providers.  In this ideal world everybody would know that labor is a physical process and women would obtain their best physical condition before considering taking on such a physical process.  I will work tirelessly to make this ideal world the new reality so that my lament may be no more.


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.


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Reader Comments (21)

Yes, birth is a physical process, but it is much, much more than that. And the physical process of labor can be affected by emotional, spiritual, and other influences. Women labor best in surroundings that do not cause anxiety. For myself and many other women, hospitals cause anxiety, which can interfere with labor and bring on complications.

May 12, 2011 | Unregistered CommenterD. Lane

Are you suggesting everyone with an unplanned pregnancy.. that isn't in optimal health.. get an abortion.. or am I just reading what you wrote incorrectly?

I hate the "obstetrical care provider" thing that is used over and over and over. It made me roll my eyes after about the 10th time. You lost me mid-way through your very redundant ramble which only has a few really important points, so I had to re-read it a few times in order to actually force myself to read the entire article. Your points appear to be, as it were.. 1. Birth is a physical event, which cannot always have its risk eliminated (I agree with a previous poster that birth is NOT just a physical event, but I agree birth has its own inherent risks which can not always be avoided, and that modern safer c/s has helped to avoid some of them) 2. Only really healthy people who plan pregnancy should get pregnant and it appears to me you believe.. remain pregnant.. since, after all unplanned pregnancy - particularly to someone not in perfect health, is inherently riskier.. Problem being, 50% of pregnancies are unplanned.. and the people in our society who are statistically more apt to truly be in perfect health might not be suitable parents OR responsible pregnant folk (re: teenagers and very young adults). You also discount birth control failure and a general societal lack of proper explanation about what makes babies. As a more than 15 year old fellow teen, I had to explain to more than one friend, how ovulation and such works.. and took more than one friend to the local clinic for free pregnancy tests. Some of which, were positive. 3. In a perfect world, suing wouldn't be necessary in order to provide care for humans inevitably damaged during the birth process (I very much agree with this point!)

The assumption that women can just "get a different opinion" is kind of ignorant, though. Many women -trust- their OB's. Then, the OB gives them half the story when it comes to ERCS, the half that says ERCS is best. They give them only part the story when it comes to breech, twins, going over 40 or 41 weeks, nursing whilst pregnant, taking a drug whilst nursing, whatever.. and you seem to think that most providers have good intentions. Well, classically, the road to hell was paved with good intentions. Child molestors often have "good intentions". Good intentions or not, some of them believe women are too stupid or too selfish or too immature or WHATEVER to take in the full story (that they are aware of, which is often enough woefully inadequate in and of itself, since one human can only do and know so much at one time and a doctor should be smart enough to know that) and digest it and make their own choices that would lead to a healthy outcome. They also seem to develop beliefs about things based on singular experiences or poorly done studies. That is NOT good medicine, though it is typical of fallible humanity. But, it is definitely not honesty.

Your lament wasn't a lament. I read it as propaganda that is telling women "If you don't like what one provider says, ladies, just find a different one". Basically, vote with your feet. But, that's easier said than done, and most women don't dislike what the doctor says.. most women gobble it up like it's mmm delicious. They just, believe it. LIES and ignorance and not enough time and "I'm a superhero!" mentality are the problem, here. Don't you see that? Don't you have more passion than what you displayed here?

May 12, 2011 | Unregistered CommenterFogedaboudid

Hi Fogedaboudid – Thank you for bringing up some very important points. The mission of my work is clearly stated on my home page “Our mission is to decrease Birthrisk by providing these tools along with information about pregnancy, labor and delivery including the answer to the very important question: What is my risk of having a cesarean delivery?” In no way, shape or form does abortion enter into the discussion of how to decrease the risk of birth. Or in other words, there MUST be a birth to decrease Birthrisk. Please accept my apology if my words have given you any other impression.

I am always looking for better words to express my thoughts and if you have better words to describe obstetricians, family practitioners and midwives collectively, other than “obstetrical care providers” please let me know.

I don’t know how to stop the lies, ignorance and lack of time but I do know how to deflate a superhero, track their outcomes. It has been said that in knowledge there is power and I believe that the knowledge provided by hundreds of thousands of prior deliveries will empower us.

D. Lane – Thank you for your words and I couldn’t agree with you more.

Dr. San Roman. I wasn't referring to anyone specifically. You clarified how the software will work which is what I was curious about. Thank you!

May 13, 2011 | Unregistered CommenterSteph G.

Fogedaboudid- I agree with the spirit of your post in that a large part of the problem from how women see it is that doctors are not advocating for and resprecting their patients. However, as much as we yell and scream about how messed up the maternity care system is, if the OB community doesn't see a problem that aspect will not change. I don't think Dr. San Roman is trying to say hiis work will fix all our problems, but it does offer a unique solution. He is actually trying to reach the OB community on terms they will recognize as legitimate: real numbets. And not just real general numbers: he offers a way to analyze specific practice patterns. I have some skepticism about how this will be received and implemented, but, as far as I know, it's a solution to one part of the puzzle that we haven't tried yet. Go for it, I say! Any help we can get that might enlighten OBs in a manner they might actually be receptive to is welcome in my opinion. And your statement about child molestors is ridiculous!

May 13, 2011 | Unregistered CommenterSteph G.

i understand the intent of the efforts described here and applaud them. There is a need to characterize inherent risk based on available evidence and not just published reviews which have their own biases and issues with generalization. Scientists crave algorithms and nomograms, and there is a place for these tools in medicine to help us better understand the various aspects of patient risk and contributors to adverse outcomes. However, I do think that the potential for abuse and misuse of these tools is high since many care providers (and healthcare administrators) tend to lean heavily on statistical crutches rather than also incorporating the more subjective and "soft" science of a holistic approach. The danger with these types of formulas is that they are often viewed as The Answer rather than simply a piece of the entire puzzle. There are many, many factors (extrinsic and intrinsic, physical and emotional, societal and institutional...the list is endless) that are woven together to create the childbirth experience for any one particular mother-baby pair. If the problem is mainly inherent risk, why do we have scores of low-risk women mysteriously "failing" at normal, non-surgical childbirth? Our species did not suddenly become incapable of undergoing normal mammalian birth, and the declining health status of our population is not enough to explain the implosion of the process. This focus on inherent risk ingnores the extremely important (I would venture to say the most critical) factor of iatrogenic risk - the risk that is introduced through "treatment" of the "condition." The technique of root cause analysis is often applied in the business world, and maternity care could use a good dose of this as well. We need a good, honest look of the gestalt of patient risk and it is dangerous to look at any aspects in a vacuum - dangerous to our attempts to fully understand and ultimately to all childbearing women harmed by our lack of understanding. Thank you, Dr. Roman, for your work in helping to uncover the root causes of the crisis of maternity care in this country. But let's all be sure that we don't lose sight of the forest when examining the trees.

May 13, 2011 | Unregistered CommenterAngela Quinn

Hi Angela Quinn – You are right on target. My lament is that we have forgotten that labor is a physical process but by no means is it the only aspect of the process. I didn’t want my lament to be about my software but rather the concept behind it. By accounting for the inherent risk of laboring women we will finally be able to measure the iatrogenic risk. I agree that a lack of understanding can be very harmful. Currently, many people are measuring the iatrogenic risk by looking at a hospital’s cesarean delivery rate and these people are advising women to go to hospitals with lower cesarean delivery rates. This advice is based on the lack of understanding that BOTH inherent risk AND iatrogenic risk will significantly affect a hospital’s cesarean delivery rate. Therefore, the reality is that a hospital with a lower cesarean delivery rate may actual perform more unnecesareans than a hospital with a higher cesarean delivery rate.

Thank you for your post. I admit to some concern regarding your software, although it's less the existence that what it will be used for with regards to laboring/pregnant women. I worry that it will become something that excuses certain behaviors or serves as an "out" for physicians. Obviously, it is not that yet, and I hope it won't be, but it is an interesting idea.

I also agree with your concept of risk; there IS some inherent in birth (as in much of life) and it's a matter of determining your risk, and how much you are willing to accept.

May 13, 2011 | Registered CommenterANaturalAdvocate

Glad you cleared that up.

It was a nitpick, I get irritated when a writer is extremely redundant and circles around points, but, I suppose you're not a writer so I should cut you some slack.

I guess your theory that the best way to deflate a faux superhero could be to show them, in a way that they respect, how they are actually the villain in many instances.. But, I think if numbers deflated docs they'd have backpeddled a while ago when we were still closer to on top with our outcome statistics, instead of lagging more and more behind countries that have found ways to improve rather than de-evolve. Of course, I think a lot of America has gone this way. Certain other countries that are improving themselves are investing in education, infrastructure, agriculture, research, and manufacturing.. whilst we're backing away and away and away from all of those good things and, for instance in favor of all of our various idiotic wars (and I'm not just talking about in other countries.. the war on drugs, rings a bell) and giving huge sums of money to the very idiots who lost it all in the first place, without punishment or any real way to ensure that they don't just squander it. I suppose it is just very en-vogue modern American to focus on the wrong things even when the statistics are mounting against you. And I think it's anyone's guess whether or not things will continue down this path or something will force the hand of change. It certainly won't be increasing maternal morbidity and mortality and evidence that unnecessary sections are being performed, with lasting consequences, that forces the hand. All of that is already happening. It'll have to be something else. Docs see the stats, nod their heads, and say "but it's not me" or "the women are unhealthy". Currently, we're heading and getting closer and closer towards a 40% section rate, which could, just as quickly, become 50%.. or greater. Something more sweeping than software that calculates a woman's likelihood of needing a section for inability to birth vaginally would have to happen.. since, for instance, many docs are fully aware that prima's or any woman really that isn't dilated or effaced at all that are being induced for X bogus reason are much more likely to be sectioned, and they just keep doing it anyway.. because they're (the doc) not really afraid of the section in the first place in order to really want to avoid it. And, they are certainly not honest with women about the risks involved.. maybe because they've swallowed the wrong colored pill at some point.. I'm not sure. Though, I do admire your optimism..

May 13, 2011 | Unregistered CommenterFogedaboudid

Jill, maternal characteristics--of which perhaps, should be elucidated--are informative, but not paramount--and often in the eye of the beholder, thus subjective and not objective.
What happened in the 1920's--and actually the late 19thc up until the 1940's--was a lot more than just not washing of hands, hence the quote "an orgy of interventions". In the early 30's a White House conference was called, and the blame sat squarely on the shoulders of obstetrics that forced birth.
". .that untrained midwives approach and trained midwives surpass the record of physicians in normal
deliveries has been ascribed to several factors. Chief among these is the fact that the circumstances of
modern practice induce many physicians to employ procedures which are calculated to hasten delivery,
but which sometimes result in harm to mother and child. On her part, the midwife is not permitted to and
does not employ such procedures. She waits patiently and lets nature take its course.”
Those midwives were attending a lot of women w/ those risks, whether inherent, or acquired--yet midwives got better results. Wealthly women who were using doctors were dying in droves--class and race did not help them here.
This conference was the forerunner of many of the conferences you now go to, and the the results much the same--mechanistic medicine has not overall improved women's lives, nor outcomes.
Women's bodies and lives are not algorithms to be placed in a formula. Inherent risk is reflective of the practitioner's relativity, that unfortunately, women's bodies are pressed into.
Tis coming up on 80 years since that White House Conference, and we are having the same conversations. Could it be because we aren't asking the right questions? Such as, what has mechanistic medicine really done for women? Is it time for a new paradigm?

May 14, 2011 | Unregistered CommenterD'Anne
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