Friday, June 25, 2010

Kingsdale Gynecologic Associates: Doula Ban and Birth Plan

Remember back when  the Aspen Women's Center banned "doulahs"? There's another obstetrical practice that has not only banned doulas, but also written up a one-size-fits-all birth plan.

Yes, despite the very strong evidence that doulas have significant positive effects on the course of labor, on intervention rates, and on women's experiences, Kingsdale Gynecologic Associates has banned doulas "because of concerns for increased risk to you or your baby." Their "thoughtful, unanimous decision" to ban doulas comes down to this: "It has been our experience that they may serve to create a state of confusion and tension in the delivery room, which may compromise our ability to provide the safest delivery situation possible for you and your baby."

Not only does the pregnant woman no longer have access to a companion of her choice during labor, she has to sign the physicians' birth plan. Among other things, this birth plan notes that IVs are necessary for a safe labor, that you will only be allowed ice chips and popsicles, that you'll probably want drugs, that they will cut episiotomies to avoid bad tears, and that continuous fetal monitoring provides the "safest possible delivery."
Evidence-based medicine has been tossed out the window.

But this one takes the cake:
The labor and delivery nurses and doctors together act as “doulas” in a sense that we will be your advocate to provide positioning options, pain control and pushing techniques to make the process as easy as possible.
Yes, the physician who arrives when the baby is crowning and the nurses who are tending to several laboring women and spending almost no time doing direct labor support are somehow the equivalent of a doula--a person who knows the woman well, whose entire task is to provide continuous support and information and encouragement, and who never leaves the woman's side.

I'm sure a lot of us could come up with snarky/sarcastic/witty remarks to the doula ban and the birth plan (hey, it rhymes!). But better yet, I'd love to see someone edit the documents purely from an evidence-based medicine point of view, complete with up-to-date references. Perhaps we could create a wiki and work on this together? I'd be more than happy to send the completed documents back to Kingsdate Gynecologic Practice.

You're also free to write directly to the physician group and voice your thoughts:
Kingsdale Gynecologic Associates
1315 West Lane Avenue
Columbus, Ohio 43221
Click here for Directions

Phone: (614) 457-4827
Fax: (614) 326-0250
Still, the best reaction is if pregnant women leave Kingsdale Gynecologic Associates in favor of a provider who respects women's wishes and supports evidence-based care. For example, CNM Emily Neiman wrote that her midwife/physician practice, Women's Contemporary Health Care, would be "happy, thrilled, ecstatic to have these women transfer to our practice. We have no issues with doulas, 'allow' you to write your OWN birth plan, and provide continuous labor support."

25 comments:

  1. This is really ridiculous, I'm not saying it's not. But if I had no other choice, I'd hire a doula and call her my aunt.

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  2. honestly I gotta say as much as it irks me, it's only happening b/c woman allow it. truth is most woman don't want a doula, or don't want to pay for a doula.... or don't even know what a doula is. (I'm a doula so I speak from experience) so they ones that do just wont go to that office.

    that said, I would MUCH rather see an office put a ban on doulas upfront so you now what you're getting into... the worst thing is to get to the delivery room with a client and have the doctor make snide nasty remarks to you in front of the client making the most uncomfortable, and stressful environment for the client.

    I'd rather be told upfront "you are not wanted!" then to have a client be put into an unfair stressful place any day. (been there, done that!)

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  3. No surprise to me this is happening in Columbus, which is a VERY birth unfriendly city, in a midwife-hostile state.

    What really disgusts me about this is that it's clearly an effort to reduce women's ability to advocate for themselves, since this is one of the primary roles of a doula in a conventional hospital situation (not to make decisions but to provide an alternate voice, to try to make sure the birth plan is followed, to help the laboring couple advocate for themselves). It is a naked attempt to reduce women's autonomy in the delivery room and to hold her hostage to whatever totally nonsensical medical magical thinking her OB puts forward. Women of Columbus, HAVE YOUR BABIES IN DAYTON AT MIAMI VALLEY'S BIRTH CENTER. YOu won't regret the drive. I didn't.
    -Erin

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  4. Women on the east side of Columbus have very few options. (An hour east of Columbus makes Dayton a 3 hour drive.)

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  5. Emily Neiman, CNM6/25/10, 3:53 PM

    Alright, so I'm really geeked about being mentioned on your blog, Rixa. But I'm glad you're shedding light on this issue and I know you have a large readership.

    I do have to give Kingsdale credit for telling women about their policy openly. It helps women make an informed choice about their care provider.

    There ARE other choices in Columbus for a low-intervention, respectful, hospital birth experience. I'm proud to say that my practice is one of those choices.

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  6. This is just such a step backwards!

    My Dr exclaimed, "GREAT!" when I told him I would have a Doula at my VBAC. He even invited her to join us at an appt or 2 during my pregnancy. He was very cordial to her also when she did join me. Counting the days now.............

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  7. I agree with Laura..I think that the majority of women don't want a doula or know what one is, which is sad. This really stinks but I suppose that the women who find it bothersome will go somewhere else. I know there are other options in Columbus. This is an all MD practice and I know there are some GREAT DO practices/groups in Columbus that deliver at Doctor's. I do not personal like Ohio State's hospital's birthing practices. There are also some great midwives in Columbus.

    As a med student, I was disappointed with the amount of women who don't have an plan or idea of what they want their birth to be. It felt sad when so many of them begged the OB I was with to be induced because they were uncomfortable (he would not do this most of the time). Some women even asked for a C-section, which I find crazy and so did my doc. So, what I am saying is that I don't think there will be many that care about this or even notice it...wish it was different.

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  8. don't forget that it mentions babies WILL have the eye ointment.

    pardon my language but they can kiss my arse.

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  9. Columbus, Ohio is just a little too close to my home. We live in quite the hostile little community. If I weren't so busy trying to rid the world of antepartum injustices, I would have to write that practice a nice, lengthy letter.

    I agree, though, that in some ways it is good that they tell you right away that they do not want a woman to have a doula. In this way, you can't be suprised if you end up getting f****k up when you deliver.

    It is sad that people do not know what doulas are. The OB manager at the hospital that I work at didn't know what a doula is. Yikes.

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  10. Call me crazy, but I don't think that this "plan" sounds unreasonable.

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  11. Oh wow! I always read things like this and think to myself, 'Do they hate women?' I mean really, I sometimes wonder what else can be concluded from their policies?

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  12. I'd love to collaborate on an evidence-based response to this, Rixa! All of the snarkiness on the blog has been a great way for me to vent my frustration to the world, but it obviously wouldn't be the world's greatest (or most effective) way to convince Kingsdale to change their practices. :-)

    (By the way, for helping to spread the word!!)

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  13. yikes! I went to my first prenatal appointment there, and did not have a good experience. I ended up at Women's Contemporary Health Care, and had a great pregnancy and birth experience (Emily Neiman attended my birth).

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  14. The plan isn't entirely unreasonable from a generally acceptable medico-legal perspective, except that it is a cookie-cutter plan that attempts to stop women from asking for anything to be done differently with their birth. As well, it is clearly attempting to pre-empt any criticism about treatment during birth. The message I get is, "What we do for your birth is for your own good, no matter what happens." I'm sorry, but a lot happens that is not just for the mother and baby's own good, but rather just the circumstances at the hospital taking into consideration the staff, mood of the staff, resource constraints, legal policies that patients aren't completely aware of up front etc.

    For example, a woman can say okay to the hepwell, but no to routine IV drip. How about allowing soup, or tea with honey? How about assuring a woman that he/she will not do an episiotomy if a woman is completely opposed to it and there is no ventouse or forceps being used. How about allowing frequent hand held doppler fetal monitoring instead of continuous EFM? How about allowing a woman to have a birth companion of her choice? And what is this about "attempting skin to skin contact"?

    The wording is revealing, and not much of an attempt seems to be made to appeal to the crowd who prefers as little intervention possible and an unmedicated birth.

    So essentially, it is good they are honest, but they clearly do not support women who will not submit themselves completely and unconditionally to the doctor and hospital personnel's care.

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  15. So I am actually a physician. Doula's may be beneficial in some situations, but you all must remember that the role of a physician is to provide good medical knowledge and advice based on evidence. Where Doula's may be thought of as positive most have zero training and often times may give inaccurate medical advice which is out of their scope of practice. If people want Doula's there should be a government agency licensing those individuals. As you wouldn't want just any person playing your doctor the same gaves for those helping. If they obstruct what we are trying to do they are not beneficial and can ultimately hurt you. Further, they do not have any medical liability. If you want a Doula they should accept medical liability for the 18 years that OB gyns do. In regards to birth plans. They are all nonsense. When it comes to the delivery room most if not all mean nothing. Your in pain you said I don't want drugs you change your mind you get drugs. Happens everywhere all the time. Look the most important thing is not extra personnel in the delivery room. The important thing is a safe and healthy delivery for both the infant and mother. Any mother or father for that matter that thinks anything else is more important should not have children till they get their priorities straight.

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  16. I have had Dr. Shepherd deliver my two girls and I have to say that I have never felt more taken care of by a doctor. She not only does a wonderful job as a doctor she takes time to talk, not just about the baby, but me as the mom and how I am doing and feeling. She hugs me as she walks into the room and personally calls when important information needs to be relayed. Many of my friends and sister have had this same experience with her. We LOVE her and have had nothing but positive experiences with her and the practice.
    I understand that many women want to have the option to choose who they can and can't have in the room, but I just thought that I'd throw my two sense in, that Dr. Shepherd and Kingsdale as a whole are Wonderful!
    P.s. Your post was written on the day she delivered my little girl :)

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  17. Argh, so frustrating. I want to send them the link to this study, my favorite study by Berghella et al on Evidence-based labor and delivery. Episiotomy = harmful, based on excellent evidence. Doulas = the most useful intervention to improve outcomes, also based on excellent evidence. How is this even controversial? Sigh.

    As for it making sense from a medico-legal perspective, and the physician's response above, I am afraid I think they are both wrong.

    There is significant evidence that doulas, trained and not licensed, as is the current situation, are well documented to improve outcomes. Also, they don't provide any medical treatment, so why should they carry malpractice insurance and be liable for 18 years? They can be sued like any other nonphysician, and are not immune to liability.

    Also, depriving nutrition by mouth and episiotomy are not evidence based. There is plenty of literature out there discouraging these two interventions, including an editorial in the Green Journal (ACOG's journal) recently criticizing restricting food intake during labor, and a strongly worded meta-analysis in JAMA saying episiotomies should be avoided in ALL circumstances. There is a Cochrane evidence review supporting using doulas.

    Birth plans are no more nonsense than physicians inducing women with low Bishop's scores at 39 weeks (if they wait that long!) for convenience, depriving women of all nutrition by mouth for 3 day inductions and only putting lactated ringer's in their IV, cutting episiotimies and risking 3rd degree tears, making women push flat on their backs...need I go on? If obstetricians are not practicing evidence based medicine, I am not sure why women should be chastised for having a birth plan that may include a very reasonable request to not offer drugs.

    If a healthy baby and healthy mom is the outcome of interest, who has messed up priorities, the one who is follow evidence by wanting a doula or the physician who won't look at the evidence and seems to think analgesia improves birth outcomes (it doesn't) and that all women want it (we don't).

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  18. Argh, this is so frustrating. Rixa, excellent post. I have some points in response to the actions of the Kingsdale Gynecologic Group, their birth plan, and the replies from "B" and the anonymous physician.

    First, I'd like to point out that using a doula as they currently exist, with their current level of training and lack of licensure, has been rated as one of the most effective labor interventions for improving birth outcomes, based on excellent evidence. Here is the article by Berghella et al on Evidence Based Labor and Delivery Management that covers this intervention (along with many of the other interventions mentioned in the original post and the comment thread.) It states that having a doula is one of the most effective interventions available. How a physician could criticize this practice, which has an evidence rating of A, but defends analgesia, which has no positive effect on birth outcomes, is beyond me.

    Doulas are not immune from liability. They can be sued just like any other individual. They do not provide medical treatment, so do not need to carry malpractice insurance. I think that is a bizarre idea. Nurses, including labor nurses, do not carry malpractice insurance. Why should doulas, who simply provide emotional support and information?

    Also, how does it make medico-legal sense to deny women the choice of an evidence based intervention that improves outcomes (doulas), but support interventions that are shown by copious evidence to be harmful (episiotomy) or are non-evidence based and have even been questioned in recent editorials in ACOG's Green Journal (depriving oral nutrition during labor)? Who needs to "get their priorities straight"? If "[t]he important thing is a safe and healthy delivery for both the infant and mother", why not support the evidence based interventions like doulas, especially if it is what the woman wants, instead of insisting on harmful or questionable interventions? (Sources: JAMA's Outcomes of routine episiotomy: a systematic review, which says episiotomy is more harmful than helpful, and should be "avoided at all costs", and the Cochrane Review on Restricting oral fluid and food intake during labour, which concludes that "women should be free to eat and drink in labour, or not, as they wish.")

    And, how are ALL birth plans nonsense? With obstetricians refusing access to doulas, encouraging episiotomies, and restricting food and fluids, what are we classifying as nonsense? How about when obstetricians induce women who are 39 weeks gestational age (if they wait that long!), with no medical indication for induction, and have a low Bishop's score? Then, they are put in the hospital, told they cannot ingest anything but ice chips, and their induction takes several days (due to the unfavorable cervix). Let's say they have only lactated ringer's solution in their IV, so they are not receiving any glucose for 48 hours. If the woman has no glucose, her blood sugar will plummet and she may get a altered mental state. That,pluspitocin augmentation, may lead to the frequent request for analgesia in patients that originally intend to try to avoid unnecessary medication. I wish this was uncommon. Are you really suggesting that a birth plan is nonsense here? Or the current standard of care? The Listening to Mothers survey indicates that these interventions are all too common.

    I find it really disheartening that people, including a physician and a gynecologic group, will defend harmful and baseless interventions, simply to bolster a paternalistic model of care, instead of an evidence based practice such as hiring a doula.

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  19. I also agree with acutely cherished. Dr. Shepherd delivered my son and essentially acted as a doula for me. During my pregnancy, she gave me all of my options and let me make the best decisions for me, without judging me or pushing me in a certain direction. After having experienced labor and delivery, I think having a birthing plan is a waste. You need to be open-minded, and Dr. Shepherd let me be. She was also in my room during most of my labor and during the entire delivery process, and I pushed for 2 hours. I wasn't given an episiotomy, and I did tear, so I can tell you that it is not their practice to perform an episitomy on every woman. I have been in the delivery room before with a very pushy doula who put a baby's life in danger, so I really don't blame them for banning them from a delivery room. Unfortunately, like with anything, a couple bad doulas give all doulas a bad name, especially ones who try to offer medical advice which is clearly outside of their scope--it is surely outside of mine and you would never see me offering medical advice!

    Although I considered having a doula present at my birth, I decided that my husband could do the same thing. I married him for a reason, didn't I? I was glad that he was the one who was there to support me and help me through the pain and process--it made my birthing experience one that we will both cherish forever.

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  20. I also delivered my daughter with Dr. Shepherd. With regard to episiotomies, she told me that medically it is better to tear than to be cut. She also said that she would only consider an episiotomy IF I were going to tear "up" instead of "down", in which case an episiotomy is a better option. I told her I didn't want one, she said OK.

    My daughter was born at 36 weeks because my water broke. She had respiratory distress, and even though she ended up in NICU for 9 days, I was still able to hold her after giving birth (with the oxygen mask close to her face). Please don't make it sound like an "attempt" to have skin-to-skin contact after birth is a half-hearted attempt, or that the doctors at Kingsdale don't genuinely care about their patients. Sometimes, an "attempt" is made because skin-to-skin isn't always the best option for the baby, as was the case for my daughter. Under no circumstances would I have chosen my version of an "ideal" birth situation to the detriment of my baby.

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  21. Dr. Costa delivered both of my sons and did a wonderful job. I felt well respected and cared for throughout both pregnancies and both labors.

    To each their own and if a woman wants a doula, that is fine. Kingsdale tells you up front that is not an option. To say that the policy means that they have no respect for women is ridiculous.

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  22. After a horrible experience and other OBGYN offices in Columbus, I ended up at the Kingsdale OBGYN office with Dr Shepard and I have to say that she is the most caring, patient oriented doctor I have ever seen (and I saw a lot in the past few years). I feel I'm in excellent hands with her and the other doctors in the office, and I don't feel the need to have a Doula. I am fully aware of what a Doula is and why some women want one, but I personally do not want or need one and had no problems signing the form. I was glad to see this policy up front and clearly written. I wanted the birth of my daughter to be a completely intimate experience between my husband and I and left the medical details up to the hospital staff, and I had exactly the birth experience I had hoped for. I plan to follow the same route with my second.

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  23. Our experience using a doula was very positive and we have done it twice. I think someone at the hospital probably had a bad experience with one doula and it ruined it for everyone else. Thanks for the post!

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  24. Wow, pretty telling that so many of these comments are from anonymous patients talking about how awesome this practice is. Seems a bit suspicious to me!!

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  25. Before I say anything, I am a birth doula myself.
    I think that the doctors have a valid concern over what doulas are doing. There are some strange doulas out their when they are getting in the way of medical personnel or playing medical professional. (I'm labeling us as the good guy doulas) When we arrive the staff are likely nervous of what we are going to do. Especially if they have been present when a 'bad' doula does something out of our scope of practice. I prefer that doulas were banned individually based on their actions in the birth room. If it were made that all doulas must become certified doulas that would possibly help. Don't get me wrong, I love good doulas and you are doing a great job!

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