Summer Reading on Maternal Care:
Mis-Steps and Steps Forward….
As a medical sociologist interested in childbirth practices, I’ve got a library of fiction and nonfiction that has grown exponentially over the years. I’ve read all the usual suspects but recently have come across some compelling gems that somehow I missed over the past few years.
Now that I’m working with the California Maternal Quality Care Collaborative on the issue of maternal mortality and morbidity, I’ve been drawn into the world of quality improvement, patient safety and that bogyman of defensive obstetrics, ‘liability and malpractice.’ So imagine my delight when I discovered What do I say?: Communicating Intended or Unanticipated Outcomes in Obstetrics by James R Woods and Fay A Rozovsky — an obstetrician and a lawyer, respectively. Their book (Jossey-Bass 2003) is designed to help obstetricians improve communication about bad outcomes while avoiding liability. It’s an interesting, if ultimately unsatisfying, book because it is very narrowly construed along those lines. While it fulfills its own goals admirably, for me it doesn’t take the issues further by examining the lack of communications and teamwork skills in medical school curricula or the real patient safety issues that emerge with some standard obstetric practices that are not evidence based. The case examples are very interesting though. How does an obstetrician who fought with a nurse about the appropriate course of action in the hearing of the laboring woman, discuss the adverse outcome with the new mother afterwards? I think I snagged the last used copy at a reasonable price off Amazon but perhaps your local library can get you a copy; it’s worth a read.
The next book I read followed as a perfect complement: the story of an obstetrician and her journey through self-discovery and healing after she is sued in the course of her work. Delivering Doctor Amelia The Story of a Gifted Young Obstetrician's Error and the Psychologist Who Helped Her (Vintage 2004, and many cheap used copies online). Dr. Amelia Sorvino is a well liked obstetrician who has been in practice a few years when, in order to respect her patient’s desires for a vaginal birth, delays a cesarean section. Subsequently, her patient’s baby is diagnosed with cerebral palsy; she loses her nerve, stops practicing and faces a lawsuit. The narrative structure centers around the therapy sessions with the author Dan Shapiro and Dr. Amelia, and the story is told through the psychologists’ lens. So many issues emerge that struck me as very illuminating in terms of how current medical training gets in the way of self-knowledge and personal growth of these young, hard working men/women. It fails to help them see the larger structures of politics/law/medicine, etc., affect their work (ok, the sociology of it all...). It’s a gripping read. I feel like we are missing the sense that doctors, yes, even obstetricians, are people, not perfect clinicians all the time, and our health care (and liability) systems are not set up to allow authentic engagement on a number of levels.
There is also a good novel about a
The issue of ‘trauma’ among obstetric clinicians regarding their experience and fear of lawsuits is an interesting counterpoint to the ‘trauma’ experienced by birthing women — see this nice piece by an Australian journalist, Hard Labour, which really captured some of these issues.
I’m starting now to read Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out (Hudson Street Press, 2010) by Peter Pronovost and Eric Vohr, a book about patient safety initiatives that were started at Johns Hopkins after poor communication, inflexible hierarchy, lack of appreciation for team perspectives and medical egos resulted in the preventable death of 18 month old Josie King. Not about maternal quality care or obstetric patient safety per se, but I see plenty of parallels in terms of the practices engaged in maternity care systems that put everyone at risk. Probably the only reason more pregnant women aren’t harmed by some of these practices is that they, unlike most hospital patients, are relatively healthy to begin with. The big insight for Pronovost is that hospitals, and the units within them, have their own culture, and this affects how patients are cared for. This isn’t news to medical sociologists and anthropologists (or doulas), but physicians are discovering it for themselves. It’s also a clear ‘news’ item in the quality improvement literature.... interesting.
Next on my list, where it’s been for some time, is medical anthropologist Elisa J Sobo’s excellent foray into this literature, Culture and Meaning in Health Services Research (Left Coast Press, 2009). All this to gear me up for thinking about the book in my brain after years of research on maternity care advocates – the doulas, childbirth educators, midwives, and now at CMQCC, obstetric and neonatal clinicians who want to make birth better for women and their babies.