Who is responsible for "educating" pregnant women?
Thursday, June 16, 2011 at 10:30AM
Guest post by Jennifer Zimmerman
This just in: pregnant women are completely dense, says recent study. Or, at least that is what this Los Angeles Times article seems to be implying. Actually, the real title is, Pregnant Women Show An Amazing Lack of Knowledge About Childbirth Options, Study Shows. Who knew that pregnant women were so amazingly ignorant? Who’s fault is that? The article enlightens us on that very question. It is the women’s fault of course!
Apparently, pregnant women “appear to be quietly following whatever advice the doctor or midwife recommends.” Out of 1,318 pregnant women surveyed, “they found many seemingly unprepared to make their own decisions regarding childbirth options, such as whether to have natural childbirth or a Cesarean section.” And, “a shockingly high number could not answer basic questions regarding the pros, cons or safety issues associated with epidurals, episiotomies, Cesareans and other childbirth options.” The article quotes the lead doctor involved in the study, Dr. Michael Klein as saying, “[E]ven late in pregnancy, many women reported uncertainty about benefits and risks of common procedures used in childbirth. This is worrisome because a lack of knowledge affects their ability to engage in informed discussions with their caregivers.” And lest you don’t realize why it is incredibly dense of pregnant women to not know these things, the article states: “The type of provider mattered greatly in terms of what kind of care women received. The researchers published a related study in May in the journal Birth that showed younger obstetricians were much more likely to favor the routine use of epidurals and expressed more concerns about the safety of vaginal birth compared with older obstetricians. The younger obstetricians seemed to view Cesarean sections as the preferred option for childbirth, the authors noted. In the United States, efforts have begun to reduce Cesarean section rates. About one-third of all U.S. women have a surgical birth.”
So, basically the gist of the article is, “pregnant women don’t know anything. It’s really shocking how little they really know! Due to the fact that they are so completely ignorant about childbirth, they just submissively do what their provider tells them to. Therefore, they can’t effectively talk about birth interventions with their providers, and since many providers prefer doing cesarean sections, the ignorance of pregnant women is probably what is raising the cesarean section rate.” Isn’t it nice how journalists are always finding novel ways to blame women for the rising cesarean section rate? It seems pregnant women are supposed to be completely knowledgeable about all of the childbirth “options” they may be offered. The article would have us believe that lacking this knowledge is the pregnant woman’s fault alone, and may even be contributing to the rising cesarean section rate.
In reality, the issues involved are so much larger than pregnant women failing to take a good childbirth class. Informed consent is the legal right of every pregnant woman and it means that she will be told the risks, benefits, and alternatives to every proposed procedure and will have the right to choose or refuse the procedure. By the time she is late into her pregnancy, if she is not being informed adequately about birth interventions, then shouldn’t we question why the provider is not granting women their legal right to informed consent? If the provider does not have the time or the inclination to inform these pregnant women about common interventions, then why aren’t they offering a comprehensive childbirth education class where they can obtain the information the provider is legally obligated to give? Why is the article blaming the women for not seeking out adequate knowledge? How are women to know that there is information they don’t know?
It is common practice for maternity care providers to encourage women to listen to the provider’s advice alone over any other sources of information. They may even downplay the legitimacy of information that the woman obtains on her own. They may even discourage reading books, browsing the internet, or taking childbirth classes that are not sponsored by the hospital (and simply meant to teach women how to be good hospital patients, not actually provide them with the risks, benefits, and alternatives to common interventions). Most pregnant women simply are not aware that their maternity care provider may counsel her about her options with other motivations in mind aside from the health and wellbeing of her and her baby. Pregnant women are trusting of doctors. This is a culturally ingrained idea and I doubt it will be overcome by telling women how stupid they are for trusting the information imparted to them by a well educated and respected member of society.
Photo credit: NBC.com (screencap)
Reader Comments (26)
"Most pregnant women simply are not aware that their maternity care provider may counsel her about her options with other motivations in mind aside from the health and wellbeing of her and her baby."
I agree with this...but at the same time...Do you walk into a car dealership & expect the salesman to tell you the truth about a sale? What about when you ask for a lower price and he "talks to the manager"? Before I bought a car...I found consumer reports...I looked at product reports...safety ratings...Government sites that had info. I pulled up websites for my local area that would show what the prices were in my area...to see if I could ask a nearby seller to lower their price to match an out of town seller.
I read books about pregnancy...but none about childbirth. I didn't even ask my mother about it. I don't even think I really discussed it with my care provider. Just something like, "I don't want drugs...I won't do that." And when he nodded and said, "That's fine, that's your choice." I felt good that he "listened to" and agreed with me. Just like a salesman listens to you...and agrees you need a safe reliable vehicle to get your family around. Because they just want you to hand over the check & drive away.
Women HAVE to know more about what they're getting themselves into. YES, providers SHOULD BE MORE CLEAR about informed consent...about actually INFORMING when they're getting consent. But you can't rely on ANYONE ELSE to look out for you! They're not the ones invested.
I agree with what you're saying...to a point... nobody is souly to blame here...and women DO have a responsibility to educate themselves on what is happening to their body and their baby. It drives me nuts that most people do more research when they are buying a car, tv, cell phone, or whatever else that requires cost comparison than they ever do picking out a caregiver and educating themselves on what is happening to their bodies. A copy of "what to expect" isn't good enough...that's like going to ONE dealership and not checking the rest of them out trusting that this one dealership that you walked into has the best prices in town. In all reality you cannot expect an obstetrician to sit there for hours on end explaining to a woman every intricate detail and options available during pregnancy, childbirth, and post partum. An obstetrician is going to tell the woman what he feels is best (whether best for him or best for the mother and baby is debatable) and move on to the next patient. That's what consultants do, they give their opinion and then YOU are the one responsible to make the final desicion. If you want complete informed consent, then ask the hospital for the registration paperwork ahead of time, ask them for the paperwork you'd need to sign if a c-section would become necessary, ask for a copy of hospital protocol. All hospitals DO have this information available to you, you just have to ask for it. This is a two way street. Women HAVE to do their research and doctors HAVE to be able to in at least one appointment sit down and discuss with the woman what her choices are. If you find that you and your doctor disagree, have different opinions on what should and shouldn't happen (just like you'd negotiate the price of a vehicle) then it's time to cut your losses and move on to a different caregiver. Above all women need to recognize that an OB is a consultant that they are paying for. You wouldn't let a home renovation contractor, or the sales person at the car lot boss you around and tell you what to do and expect you to just say "ok". No, you'd expect them to carry out your wishes to the best of their ability. Maybe if us women would hold our obstetricians accountable, the whole birth scene would be a bit different. After all...we didn't get the right to vote in this country without a fight.
I don't think the article is saying it's pregnant women's fault at all.
I think the article is indicitive of the trend of people to put blind faith in their doctors. They're doctors after all, they went to medical school, they're educated, they must know what's best.
I think women follow the advice of their peers and when the majority of their friends are having c-sections, they see it as "no big deal."
I had a friend who told me that C-Sections were safer than vaginal births. I pointed out that it was major surgery and there were all sorts of risks involved. "Oh, I didn't know that."
I had an aquaintence who is a new doctor argue with me that c-sections are by far safer than vaginal births.
The article is just stating truth.
Are there women who are proactive about their pregnancies and health care and investigate the options? Of course. And I would argue that those are the women that read this website and are not the subject of this article.
A friend of mine had her baby; a year later another friend was pregnant. When pregnant friend would tell us about things her doctor told her about her pregnancy, mommy friend would say, "oh, my doctor never told me that." or "Wow, i didn't know that."
How much of the responsiblity for YOUR healthcare should be left in other people's hands? Don't you think people should do their own research?
I am not pregnant, but hope to be soon. I've been learning about pregnancy and birth for the past year so that I can be prepared and make informed decisions and not just blindly accept what the doctors recommend.
Maybe the article is in part "blaming" expectant mothers--but it's also placing some of the blame on new doctors.
Perhaps instead of seeing article as "blaming" someone for the situation, it should be seen as an illustration of how today's healthcare is full of uninformed people and over-worked doctors who lack the time to explain the risks involved.
Oh come on. Babies are not cars, and giving birth (or choosing a care provider) is not the same as buying a car.
For one thing, where is the Consumer Reports issues reviewing doctors? There aren't any. In order to rank one doctor against another, you would need data on their outcomes, as well as reviews by patients. That kind of data is not really available to consumers except through hearsay, although Jill and other bloggers do strive to archive and present the data that is out there. But most doctors are a black box to their patients; if they were found to be guilty of malpractice in another state, how would we know? They are not required to tell us.
In addition, leaving a doctor mid pregnancy is both trying (especially since many doctors's offices are downright recalcitrant about handing over your records) and risky; how will you know if the new one is any better? You don't.
And then of course, even a carefully-chosen doctor may not be on call when you go into labor, and instead you get their partner, who you've never seen before but you're in labor, what are you supposed to do, demand three references between pushes?
I'm not throwing up my hands here, but honestly, to gloss over the difficulties in evaluating whether a given doctor will treat you well and competently when the chips are down is to miss the point entirely.
Interesting that we're bemoaning the fact that women "aren't informed," but if you are informed, *they* don't like it most of the time. How many women have been told to shut up and listen to me already I'm the doctor? Quite a few more IME than I'd expect. I found it unusual and refreshing in my last birth when I went to the hospital arguing for a breech VBAC that the resident considered it and was positive (once I outlined my reasons that I thought it was a reasonable way to go at that point...of course this changed when the baby started ascending and I rethought my decision).
This resident's attitude shouldn't be the refreshing exception, it should be the norm. Moreover, doctors/midwives should be presenting options, not decisions...if the care providers would ask the women to decide, the women would probably real quick get up on the research. But instead so many of them just tell you what to do and get defensive and bossy if you dare question it. They say "how many years of medical school have YOU had?" And then we wonder why women are not informed....they are actively discouraged from being informed by their care providers.
My $0.02
“Isn’t it nice how journalists are always finding novel ways to blame women for the rising cesarean section rate?”
Hmm, I honestly don’t really see journalists ALWAYS blaming women for the rising cesarean section rate. I’ve seen it mentioned mostly as a contributing factor, but ALWAYS? Nope. I’ve seen plenty of mainstream news articles questioning the doctors that perform those cesarean sections. Plenty of blame to go around here, place it on the women that take no active role or a submissive one AND the doctors that schedule for convenience.
“It seems pregnant women are supposed to be completely knowledgeable about all of the childbirth “options” they may be offered.”
Well, quite honestly – yes. They should. It’s called personal responsibility. (And no, not completely knowledgeable, but well informed and educated: YES – and it’s a woman’s responsibility to herself and her child to go out and make that happen, not wait around for a doctor or any other care provider to hand her that education. Again, it’s personal responsibility!
We have a cultural phenomenon in this country where we put an astounding amount of blind faith in our doctors and care providers. But guess what folks? We simply SHOULDN’T. Those care providers are human, they make mistakes, they get rushed, they don’t care, or they care too much and force their opinions on their patients, they push their own agendas, and they have their own histories and opinions that influence how they treat their patients and how they interact with them. Women should take a more active role in their health care (actually, this goes for men too) and participate. Ask questions, read on your own, weigh your options, talk to other women. Ask questions. Ask questions. Ask questions. Read independent and varied sources of information, and then – THINK about all of that information. Then – go ask more questions.
Anne, I completely agree with you.
And again, I think this is just a small slice of how today's healthcare works--pregnancy or not. It's a multi-faceted issue and no one side is to blame or right or wrong.
I really like this post. It's disappointing that so few people see how inappropriate it is to blame women for not defending themselves adequately from their own health care providers. This probably isn't the best analogy, but what popped into my head is that we might as well blame a woman for being robbed at gun- or knifepoint for not carrying a bigger weapon than her attacker, as if her lack of ability to fight back with equal force is the actual crime instead of the robbery.
Without power to act on it, knowledge is a curse.
Wow, I find the comparisons of OBs to car salesmen to be very interesting. I know that when I walk into a car dealership that the salesperson's primary goal is to make the sale and get paid. But should that really be the primary goal of a medical professional? I would HOPE that when I walk into a doctor's office, the first thing he sees is not dollar signs but a human being. And I would hope that his or her primary goal would be to provide me with safe and adequate medical care. That's the difference between a salesman and a medical professional, or at least, that's what the difference *should* be.
I agree with Anne, Cato, and Ashley. We've been culturally programmed to trust that doctors have our best interest at heart. We're taught that they're heroes, and heroes are always more interested in people than money, liability, or convenience, right? It's not a woman's fault if she naively trusts someone who's SUPPOSED to be trustworthy. Suggesting otherwise is incredibly damaging to those victims.
I don't remember who said it (sorry, not going to reread all the comments to find it), but I LOVE the idea that rather than providers saying, "this is what we're going to do" and the woman having to say, "but I don't want to" which is usually followed by a "too bad" (in my experience), providers should openly put the choice on the shoulders of the woman. "Here are some of your options, here's where you can learn about them, let me know next appointment which one you want to do and we'll make a plan together." That way, the care provider can empower women to make their own decisions.
Women may very well not see the point of educating themselves if they on some level know how constrained their choices will be. And, of course, effectively that is the truth. We, the readers of this blog, are happy to spend our time talking about the rising c-section rate, reading every pregnancy book that comes along, and examining how childbirth happens in other countries. But the average woman? If she's one of the lucky ones to actually have health insurance and reliable medical care, she's still been inculcated her whole life with the idea that birth is an excruciatingly painful, disgusting, frightening and dangerous event, and only her physician is capable of saving her from her and her baby from an untimely death. Under these circumstances, unless you're a natural rebel (something hardly encouraged by our education system, I might add), what would be your incentive to learn more?
I do not at all mean to imply that women are to be blamed for any lack of knowledge, just that it's the natural consequence of the systemic state of affairs surrounding childbirth in our culture. The same goes for physicians - I don't much care for the Evil Doctor/Innocent Mom approach either.
Have any of you heard anything about having a vaginal birth after 2 cesareans (with a successful v-bac in between)?
At the end of the day, if you want to see changes in the political arena of childbirth that will effect those who don't have insurance or access to information, those of us who DO have the access and the insurance have to take the responsibility to do it ourselves. We need to stop the blaming game and start looking inward at what we need to do to make some changes happen. If you're a doula? volunteer your services to those who can't afford you. If you're a midwife? volunteer your services to those who cannot afford you. Childbirth educator? go out and offer your services to those who can't afford you. Hold your caregivers accountable, make them explain themselves. If they are uncomfortable explaining themselves, and think that you're annoying then obviously you've struck a cord within that caregiver that might later trigger some sort of change, and move on. Start sewing seeds wherever you can so that they might grow and bear fruit later on.
Is it difficult to change caregivers mid pregnancy? for sure, but it doesn't mean it's impossible. I changed caregivers three times during my last pregnancy. Was it stressful? FOR SURE! did I like being told my baby was going to die and I was going to leave my husband widower if I tried to have a VBAC, heck no. it's all about what you're willing to do and what you're not willing to do, who you're wiling to trust, and who you're not willing to trust with your body and your baby's well being. At the end of the day it is YOUR choice, not the doctor's, the midwife's, the websites, or the childbirth education class' choice in what happens to you. It is YOUR choice unless you have a court order. And it's up to you if that choice is going to be educated or not. You do what you can with what you have, and when you know better you do better (thank you Oprah).
I agree with what several posters have said above. I think the doctors/car salespeople is not a good analogy for the reasons pps outlined. I don't think you can have true informed consent and a sales mentality at the same time.
It has also been my experience that at least some care providers do NOT want women doing their own research. I was one who was on the receiving end of, "I've been through 8 years of med school....I'll make the decisions" when I dared to ask why she might want to perform an episiotomy (having read they are almost NEVER necessary and it's largely an outdated practice).
When I switched to a CNM practice at 30 weeks, I didn't really feel like I had good discussions with my providers on the pros/cons of interventions, but I did feel they listened to and supported those decisions I had already informed myself on and decided and they were definitely much more open to letting things happen naturally, so it was a better birthing environment for the kind of birth I wanted.
I think many women are not aware they HAVE choices to make. I have found prenatal care to be very different from seeing a GP or my son's various doctors in that regard. I felt like I received a LOT more informed consent (information/alternatives/risks, etc.) with getting my son's ear tubes put in than I did with most everything in my complicated end-of-pregnancy and labor. With prenatal and labor care, it seems like most providers just say, "We need to do this," and there IS no alternative provided. So if you're not aware of that info from outside sources, then you won't even know there might be an alternative.
In my case refusing treatment that was not evidence-based led to a backlash from my OBs. After that, treatments I asked for were refused, treatments I refused were imposed, etc.
I'm sure it's not uncommon.
Could I have left, sure.
But I had no guarantee of getting different treatment elsewhere or being accepted at all (I am in Canada and considered 'high risk': no midwife or family doctor would have me, it was either an OB or a 'free' birth, and I did need medical help).
The problem is the system. Not the individual care providers, although some are good and some are worse than others (a shift change playsed a big part in my c-section. That particular OB, who I had never seen before, had to have all his patients on epidural). And certainly not the pregnant women.
I did not trust my doctors blindly but I trusted them more than they deserved. The extent to which I was lied to was beyond me.
I did not know anyone who had PTSD as a result of childbirth. And honestly, how to prevent PTSD was not on my radar at the time. It's a sad state of affairs when preparing to give birth means preparing against PTSD.
The underlying bias in the article, and in many of the comments here, is that there is some correct way to be educated; that if you read the right materials and talk to the right people you'll magically become educated and empowered and make the "right" decisions. I mean basically the article is just bemoaning the c-section rate again, but the twist here is that Klein is attempting to place the blame on lack of "education" about childbirth options instead of lazy OBs or greedy trial lawyers or epidurals.
I think maybe it's time for people to talk about what education really means in this context. It's something that gets thrown around a lot, especially here, but no one ever defines what they mean by it. In the recent discussion about epidurals some people questioned whether requesting one could be an educated choice. Other people framed women choosing RCS over VBAC a a regrettable, uniformed choice. Some appear to believe that no educated woman could make those choices without coercion.
So, as a woman who read all the books you read, visited all the websites you visited, painstakingly searched through textbooks and scholarly articles, attended childbirth class, received midwifery care but still came to different conclusions than you about what was best and safest for me and my child, what did I miss? What piece of educational material should I have read?
In the process of educating myself, I came to the conclusion that there were no easy black and white answers. There were only risks to weigh against other risks. Most sources of information emphasized one set of risks over the other. Very few, perhaps none, really comprehensively addressed all the risks and concerns and choices available to me. In my experience, the information and guidance received from providers is completely tied to their philosophical and ethical beliefs about childbirth. Their practices, and thus, your choices, such as they are, will be completely circumscribed by these beliefs.
My experience was that I had ABSOLUTELY NO CHOICES whatsoever because my preferences were not in line with the beliefs of my providers, beliefs that are probably pretty close to unanimous around here. After extensively educating myself, I came to some conclusions about what I believed would be best for me. My providers had no interest in what I wanted at all because, like many of you here, they felt they knew what was best for all women. After a lot of research and soul searching, I realized that what was best for me, what I wanted, was very different from the kind of care that many of you prefer (which is fine by me, more power to you) and advocate for.
The underlying message in the Klein article is that there's some imperative to educate women in a certain way about childbirth so that they can make choices that will ultimately lower the c-section rate. The assumption there is that education automatically leads to making certain choices-- the right kinds of choices that will lead to a lower c-section rate. Hidden in that assumption is the belief that women who make other choices are somehow doing something wrong. I find that pretty insulting.
And in studies like this, it's hard to account for the non-verbal communication so often involved when you do try to have a discussion with a doctor as an informed patient. My midwife was part of a larger OB practice, and she was required to offer me all the tests, but accepted it without argument if I turned one down. So she noted in my chart that I didn't want the test for Downs and left it at that, but then one of the OBs came in to talk to me after our visit to try to talk me into it. I asked her about the false-positive rate for the test, and she all but rolled her eyes. They use every form of non-verbal communication available to tell you that they are so very very put upon to be forced to deal with someone who will ask informed questions and (politely) decline certain procedures. I would imagine that for many mothers, this is really intimidating, but they can't quite put their finger on why they took such a passive role in their childbirth experience. It's not like anyone explicitly bullied them into shutting up, but the implicit bullying is just as effective.
I'm not certain that there's an implied "right way" in this article, but I do think that there are women who are quite happy just "letting go," if you will, and allowing their provider complete control over their pregnancy, labor, and delivery. I think these women are less likely to choose midwives for providers, but do not exclusively choose OBs. I think because of that the issue of what women know at any stage in pregnancy might be a little convoluted - if a woman says, "you do an episiotomy whenever you feel it is necessary, it's up to you" to her provider, then she may not know the risks and benefits, but that's not relevant to her decision.
Do I think it's a good idea to view things that way? No, that would stress me right out. But I think it's a valid option for *some* women.
On the other hand, I would also like to know why they feel that way. Did their choose their provider specifically with that in mind, making sure that their provider would probably follow their wishes? Do they have a provider out of lack of choice, and they feel there is no point in questioning because that provider is the only one available to them? Do they have an ingrained respect or authority worship that causes them to not question? Do they just have, in their minds, more important things to deal with?
And, Rachel, I totally agree with your comment about non-verbal communication, which can express just as much as verbal communication.
The fact that one out of three women in the US agree to have a c-section seems to indicate to me that there is a lack of education regarding childbirth among American women. I mean, doctors aren't hijacking these women. These women are agreeing to the medical management of their labor & birth which leads them down the road to eventual c-section. Women educated about childbirth wouldn't allow this. Much demographic data about home birth seems to indicate a higher level of education among those that choose this route. I personally wasn't offended about the analogy about buying a car and doing your research before doing something that is very important in your life. I suspect most American women don't even know the c-section rate of the hospital in which they plan to have their baby. The analogy of some OB's being used car salesmen, also didn't offend me. I worked with them as a nurse for 10 years. I found the majority of the OB's told women very biased information that slanted it toward what the OB wanted to do. I even had a friend test the veracity of one OB that was very vocal against home birth (she planned a hospital birth). She asked him specifically, "Does this hospital have 24-hour anesthesia coverage for JUST labor & delivery?" He said, "Yes." I worked at that hospital and know that they don't. If you were on L&D in the middle of the night and the anesthesiologist was in the OR for an appendectomy, you had to wait until he was done to get your epidural. If there was a STAT c-section, you had to wait until the second anesthesiologist came in from home. I'm not trying to insinuate that ALL OB's lie, but too many of them bend the truth for my liking. My point being, that you should NOT expect to learn about your prenatal or birth choices from your OB (they don't have the time or the inclination) and with the internet, you should be able to get an awful lot of information on your own.