Lament, in Stereo

By Lauren A. Plante, MD, MPH | May 10, 2011

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.