Physicians talk about new ACOG guidelines on VBAC

Obstetrician Maria Rodriguez (MD, MPH) recently wrote about the new ACOG guidelines on TOLAC for Medscape Blogs. She summarized the new guidelines, pointed to an evidence-based tool she uses for counseling her patients about VBAC, and then posed these questions:

What role does VBAC play in your practice? Do you think the updated guidelines will impact access on VBAC for women? While I would like to see VBAC be an option for more women, and support the College's updated guidelines, I am skeptical that they will have a large impact on availability for women of a trial of labor following cesarean without a drastic change in our medicolegal environment. What are your thoughts?

If you log into Medscape, you can read the responses to these questions and to a poll she created. Obstetricians, anesthesiologists, nurses, and more have weighed in (and sometimes taken the discussion a bit off topic) on VBAC and liability.

For another great post (& discussion) by Dr. Rodriguez about autonomy, informed decision-making, and patient compliance, visit her guest blog at At Your Cervix.

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What explains physicians' beliefs about home birth?

I've been corresponding with Lara Freidenfelds, author of The Modern Period: Menstruation in Twentieth-Century America. She posed me the following question about the dissonance between obstetricians' perceptions of the safety of home birth, versus the research evidence. She wrote:

As I've been teaching about the controversies over maternity care, students have asked me some crucial questions I have not, so far, been able to answer. I'm wondering if you might be able to help, since you know the literature so well. Basically, my students (and I) want to know why the doctors' concerns about sudden extreme complications do not seem to show up in the morbidity and mortality numbers for home births. Are they simply mistaken about what can go wrong, and how much of an emergency it constitutes (i.e., do home birth midwives get these patients to the hospital anyway)? Are physicians/hospitals not actually very good at addressing emergencies either (i.e., all the monitoring in the world doesn't actually catch the impending stillbirths; hemorrhages are not noticed and addressed quickly enough)? Are the causes of maternal and infant mortality and severe morbidity in home and hospital births the same, or different (i.e., is home birth maternal mortality/morbidity the result of hemorrhage, while in the hospital it's the result of c-section complications)?

I tell my students that my guess is that a well-staffed and equipped birthing center would likely be the safest option, since women could have low-intervention, midwife-supported care with emergency backup immediately available. But the one study you cite which included birthing centers did not seem to support this theory. Would it be reasonable to argue that the various kinds of support offered by home birth actually reduce risks for drastic emergencies by a big enough margin to offset the dire results when a drastic emergency actually does happen out-of-hospital?

Basically, I want to understand why physicians' intuitions seem to be so far wrong. While I think the physicians' organizations are quite self-serving, the individual doctors I've talked to seem quite earnest, not at all cynical, in their concerns about home birth, and they always call up examples of times when they believe they were able to save a mother's or baby's life only because they had a physician's skills and hospital equipment at the ready. Are they wrong because many of these emergencies were iatrogenic? Or because they are wrong to write off other cases of mortality and severe morbidity that they do not realize were iatrogenic (or at least avoidable in a home setting)? What, besides self-interest, might explain the divergence between physician's experience-based intuitions and the large-scale studies?

I'm guessing these aren't easy questions, or I'd have seen them answered somewhere. If you'd be willing to hazard a guess, or outline the limits of the data so far available, I'd appreciate it tremendously.

I'm particularly interested in hearing from my blog readers, especially those who work in a hospital environment: OBs and family physicians in particular, as well as CNMs and nurses. Could you please chime in too? Correct me if I'm wrong, add to what I have to say, offer new perspectives I haven't thought of, etc. I know I have OBs and family practice physicians reading this blog. If you're one of those, please take a minute to answer Lara's questions from an insiders' perspective!

Here's my reply--or rather, a preliminary attempt at tackling this large, complex question.

Let me first mention the research or published material that already addresses this. The first resource that comes to mind is chapter 7 ("Obstetric Training as a Rite of Passage") in Robbie Davis-Floyd's book Birth as an American Rite of Passage. I'm in France, so I don't have my book to refer to directly. But I remember that she discusses how obstetricians' first-hand experience, especially in scary/dangerous/traumatic situations, often supersedes their numerous encounters with "normal" birth. In other words, one bad hemorrhage impresses itself far more vividly upon their minds than the hundreds of births with no excessive bleeding. This translates into a tendency to act (react?) with the worst possible situation in mind, even when the current situation does not warrant that specific reaction. For example, imagine a physician who, after experiencing a uterine rupture, will no longer attend VBACs at all. Never mind that most VBACs occur without serious complications and that there is the possibility of something going wrong in a cesarean--that one bad experience governs thoughts and actions far more than the hundreds/thousands of good outcomes. Not too surprising, really. This kind of thinking is part of human nature.

Probably the only research specifically examining obstetricians' perceptions of home birth (midwives) is by Melissa Cheyney. I referenced her work in my recent article "Attitudes Towards Home Birth in the USA," so I won't repeat it here, except to say that it's a great resource.

I also did some original research of my own into what physicianss think about home birth (quoted from my article):

To discover additional physician perspectives on home birth, we read through five years (Jan 2005-Oct 2009) of discussions about home birth in the OB-GYN-L archives, a list serve for OB/GYNs and maternal-fetal-medicine specialists and the occasional family physician or midwife. Although this discussion group is not a representative sample of obstetricians, the themes serve as a starting point for future research about physicians’ attitudes towards home birth.

First, legal and political constraints played a significant role on limiting physician involvement with home birth, either direct (attending home births) or indirect (providing collaboration, consultation, or backup to home birth families and midwives). Several physicians wanted to provide backup and/or collaboration with home birth midwives, but their hospitals or malpractice carriers specifically forbade these actions. In addition, many physicians on this list could not move beyond an adversarial view of all patients as potential litigants. Besides having to protect themselves against (real or potential) lawsuits, physicians dealing with home birth transfers often faced the brunt of the families’ anger, disappointment, and hostility. They did not enjoy being seen as the “bad guy” in situations they sometimes described as “train wrecks.” And, since home birth midwives often do not carry malpractice insurance, physicians are more likely to be sued for a negative outcome in a home birth transfer. In sum, physicians often characterized themselves as victims of out-of-control legal and bureaucratic systems, forced to adhere to regulations that benefit hospital administrators and trial lawyers at the expense of patients’ wellbeing. In addition, some OBs on this discussion list suggested that the ACOG’s and AMA’s disavowal of home birth was motivated less by safety concerns and more by licensure and professional recognition issues.

Second, physicians held a wide range of opinions about the safety of home birth. Some physicians adhered strongly to the ACOG position that birth outside of a hospital setting can never be as safe, because of the unpredictable nature of birth complications and the access to monitoring and emergency treatments that a hospital can offer. Some characterized home birth as an inherently risky and selfish behavior, on par with smoking, drug abuse, or other dangerous lifestyle choices. Other physicians questioned these definitions of safety, turning instead to research on home birth and discussing the strengths and weaknesses of various studies. Other list members suggested that physicians could benefit from interacting with home birth midwives, who consistently achieve high rates of spontaneous, unmedicated vaginal births. They also noted that improved communication between physicians and home birth midwives would make home birth safer. Others proposed revising certain hospital practices that currently drive some women towards out-of-hospital births.

Another place to discover, indirectly, why physicians feel the way they do about home birth is to look at legislative testimony about direct-entry midwifery. One thing to keep in mind, though, is that physicians' public testimony might not accurately reflect their real concerns about home birth. For example, in the mid-1990s, Dr. Marsden Wagner gave a speech in Des Moines about scientific literature on the safety of midwife-attended out-of-hospital births. He wrote this in a letter to the Iowa Scope of Practice Review Committee on June 6, 1999:

After my speech two Des Moines obstetricians took me aside and chatted with me in the extraordinarily frank manner often found when physicians talk privately with each other. They told me that while they were aware of the research I had quoted proving out of hospital birth to be a safe alternative, they nevertheless frequently use lack of safety as an issue in order to frighten politicians and the public in order to maintain their monopoly over perinatal services. They then explained that the real issue for them is not safety but economic. They do not like the economic threat that midwives and out of hospital birth represent. As they put it to me: “We will not have these midwives taking money out of our pockets!”

I'm sure that many physicians are sincere in their beliefs and perceptions about home birth--however accurate or misguided--but we cannot forget the factors that influence how physicians portray home birth in a public setting.

Now that I've mentioned what little research exists explaining the dissonance between physicians' beliefs and research evidence on home birth, let me leave the safety of citations and delve a little further.

Robbie Davis-Floyd's research already touched on the power of anecdote and personal experience. I want to reiterate how tremendously important this is in framing how we perceive the world around us. Think, for example, of the multiple factors that influence how pregnant women make decisions about their care. I don't think any pregnant women makes her decisions entirely--or even mostly--upon the statistics from randomized controlled trials. Her family and friends' birth experiences, her personal beliefs and values, her birth culture, and her relationship with her care provider are all powerful forces shaping which choices she will or will not make. The same is true with physicians. Evidence-based medicine play only a small role in clinical decision-making. Experience, personal judgment, anecdote, fears of litigation or failure or of a bad outcome...all of these influence how a physician perceives home birth.

Most physicians form their beliefs about home birth without ever having attended one. On the other hand, almost all midwives, doulas, birth advocates, childbirth educators, etc have witnessed both home and hospital births, either first-hand when they were giving birth, or in the role of doulas, friends, etc attending other women. This gives "home birth advocates"--how I hate that term, since it's a gross generalization and easily turns into caricature--much more ground to stand upon than physicians when discussing the relative merits or disadvantages of home and hospital birth.

Physicians who have been fortunate enough to attend home births usually come away transformed from the experience. This happened to Dr. Marsden Wagner (who, to be fair, is dismissed as a kook/raving lunatic/etc by his detractors). Upon the invitation of a Danish midwife who worked primarily in a hospital setting but who also attended births at home, Dr. Wagner began attending home birth. He wrote:

It would be impossible for me to exaggerate the influence of my experience with homebirth on my opinion of obstetrical authoritative knowledge and practice. Home birth is as different from hospital birth as night is from day. Trying to describe home birth is like trying to describe sexual intercourse - you can give the outlines, but you can never adequately describe the personal dynamics, feelings, ambience. (Childbirth and Authoritative Knowledge, p. 370)

In Carol Leonard's memoir Lady's Hands, Lion's Heart, this same transformative experience happened to her OB husband, Dr. Ken McKinney when he attended a home birth for the first time. (At this point, she and Ken were not yet in a relationship.) Here is Carol's account:

Jessie's labor goes without a hitch. She paces up and down her crate [Jessie lives in a converted shipping crate] like a caged tigress, stopping only to pick dead leaves off her houseplants. During the hard time of transition, she lies on her side, panting heavily like a great cat. I sit beside her, rubbing her back and giving her sincere words of praise and encouragement. Out of the corner of my eye, I watch Ken as he sits in a chair, nervously flipping through magazines, pretending to be nonchalant about the whole thing.

A slight smile creeps across my face. I really am fond of this man. I know he is worried that all hell is going to break loose, and he will have to bail me out. As Chief of Obstetrical Services at MVH, what would be the consequences of his being caught attending a crate-birth with a maverick, lunatic-fringe midwife? His credibility within the medical community would be shot. This really is a huge risk for him. I admire his courage. I look at him, studiously engrossed in Woman's Day, and I feel a rush of tenderness...

When it comes time for Jessie to push her baby out, she spontaneously gets up into a huge, old, overstuffed armchair and drapes her legs over each arm. She says this feels the best to her. It is great for me; I can see clearly without doing the usual gymnastics. This position seems to bring the head down quickly. Soon, I am oblivious to Ken and anything else in the room. I ask Jessie to slow her efforts down, to blow out through her mouth instead of blocking her breath.

I say, "Beautiful. Gentle, Easy now. Nice!" over and over as the babe's head slowly stretches Jessie's skin taut. As always happens at this point, my focus becomes so complete on the crowning head, that when Jessie's baby girl slides into my hands, there is a stillness behind all motion. I hold my breath until she takes her first, as if my very will can coax the living spirit into her glistening body. Her color changes rapidly, going through a rainbow of hues until it is a healthy rose. I quietly hand her up to her skunk-haired mother.

It is only now that I become aware of Ken's watching intently over my shoulder. I turn to grin at him. He gives me a triumphant thumb-up....Ken is excited and energized by the experience. He talks the entire way back.

He says that this has really been an eye-opener for him. He has been on the verge of quitting obstetrics because it is so impersonal and dehumanizing; the routine of women, drugged and unconscious and unable to push, often requiring forceps. He calls it the "knock 'em out, haul 'em out" school of obstetrics. He's been getting bored and disgusted; he knows there is more to it than that. This is the way it is meant to be, with women in their power, in control of their experience.

We sit on a rock, warming ourselves in the spring sunshine. He allows as how he still wouldn't feel comfortable attending births at home. His training makes him feel most secure with an operating room, fully equipped for an emergency cesarean, just down the hall. But why couldn't women have a similar experience, even if they have to be in the hospital? Why couldn't changes be made in standard hospital procedures that would allow women to dictate how they want their births to be? His all fired up now. He turns to me and asks if I would help him identify the routines that are archaic and unnecessary, changes that will make hospital births more human. I agree, knowing that I can come up with that list in about two seconds flat.

This lack of first-hand exposure to home birth, in combination with only seeing "failed" home births (i.e., home birth transfers for reasons ranging from exhaustion to needing pharmaceutical pain relief to fetal distress or hemorrhage), lead to a very skewed perception of home birth. Many physicians probably cannot imagine any of the benefits of a home birth because it is so far beyond their realm of experience. So in their minds, home birth is simply hospital birth minus all of the technology--a scary thought indeed. What physicians likely do not understand is that home birth is not simply the subtraction of medical technology from birth, but the addition of an entirely new process that has subtantial benefits for mother and baby. Home birth really is a world away from industrialized, institutionalized birth. As such, I understand how impossible it would be for a hospital-based practitioner to grasp what home birth is like if they have never actually witnessed one in person.

What else might explain physicians' perceptions of home birth safety? Well, there are some who firmly believe that the research evidence on home birth is wrong, plain and simple. Some have argued that every study claiming to find similar safety outcomes between home and hospital birth is either deeply flawed, or that the conclusions are totally wrong, or both. This outright rejection of the evidence is not too common--usually the evidence is simply ignored.

And I've already referred to the role of litigation, both above and in an earlier post Litigation and the Obstetric Mindet.

This post is already far too long, so I will end without tackling Lara's question about birth centers and leave that to my readers. I am really curious to learn the reasons for ACOG's dramatic about-face in its position on freestanding birth centers. As recently a 2006, ACOG disapproved of home birth and freestanding birth centers for the exact same reasons. Then, in 2008, the ACOG and AMA both approved accredited freestanding birth centers--the first ever endorsement of out-of-hospital birth. Why this sudden change? Why for birth centers and not home birth (it's not as though the outcomes of birth centers are significantly better than home birth, at least that I'm aware of)? Is there anyone who knows more about the motivations for this change in policy?

Please take the time to respond to Lara's questions. I'd love to hear from you!

Replies to this post:
Jenna at Descent into Motherhood asks Do birth workers know what mothers are reading?

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Code Mec! Code Mec!

*Now with more links*

Not only are home birthers irresponsible, selfish, and reckless, they are now, according to the Today Show, hedonists who are seeking a spa treatment experience during labor! (Never mind that it's okay for hospitals to market their maternity wards' spa-like amenities...)

The Today Show recently investigated the supposed "Perils of Midwifery" and their shoddy reporting is in for a drubbing.

The ACNM responded with a discussion of The Non-Perils of Midwifery. "Not only does it follow the heart-breaking account of a birth gone horribly wrong; it exploits the couple’s tragedy—turning it into a sensationalized story that scares women and grossly misrepresents midwifery," the ACNM commented.

Nicole at Your Birth Right wrote about The Perils of ACOG: "[D]uring narration about home birth advocates they decided to use the word alleged as if homebirth advocates are somehow perhaps liars or criminals....The word alleged is somehow missing when the DOCTORS are quoted,"  she wrote.


Speaking of perilous obstetrics, Jill at The Unnecessarean noted that ACOG just released survey data indicating that many obstetric practices are influenced by fear of litigation and ultimately harm the patient.

Radical Doula wrote that ACOG is making me nauseous.

Citizens for Midwifery claimed that the Today Show is in bed with ACOG.

The Big Push campaign hit back with its own (alarmist) rhetoric: Physicians take anti-midwife smear campaign to the airwaves. (PDF)

And I love (Keyboard Revolutionary) Jill's response: Iridescent tile makes all the difference.

Reality Rounds called Code Bullshit on Matt Lauer. She pointed out some of the many inconsistencies and flaws in the report, with comments of her own in italics:

• A talking male head “expert” comparing home births to spa treatments.  “Yes, I will have my full body avocado massage while I am crowning please.”
• Same talking male head talking about the “Hedonistic” style of birthing.
• Flashy pictures of celebrities who have given birth at home.  Every  women I know has chosen their birthing options from reading US magazine.
• ACOG says childbirth decisions should not be determined by what is flashy, trendy, or the latest cause celeb.  But it is OK for childbirth decisions to be dictated by defensive medicine, personal golf schedules, and “because I have always done it this way,” reasoning.
• When the investigator speaks of midwives he uses terms like “they allege” medical births cause X,Y and Z.  As if the anger over the medicalization of birth is all a big conspiracy.
• When the narrator states that studies by the CDC show home births to be safer than hospital births, they leave us with this quote:  “But doctors say it is impossible to compare the safety of home births with hospital births, becasue hospitals care for so many high risk cases.”  Really?  It is impossible to compare  similar low risk patient populations’ outcomes for delivery?  It is impossible to just remove the high risk populations from the comparative study?  This is called research idiots!

Amy Romano of Science & Sensibility just wrote Home Birth: The Rest of the Story. In this piece, she argued that home birth has been held to standards that not even hospitals can meet and that implementing Lamaze's Six Healthy Birth Practices would make both hospital and home birth safer:

I continue to believe that if hospitals provided the Six Healthy Birth Practices as the standard of care and offered evidence-based treatments for women and babies experiencing complications, hospital birth would be safer and so would home birth. That’s because midwives would initiate transfers with more confidence that it would improve the outcome, women would transfer more willingly, and care at the receiving facility would be safe and effective. What’s not to like about that plan, ACOG? Now, let’s make it happen!

I have an idea for Reality Rounds: let's up the ante a little. I can think of no stickier, gooier, ickier fecal substance than infant meconium. So from now on, anything particularly outrageous or ignorant or downright stupid, when it pertains to birth, gets a big old...

CODE MEC! CODE MEC!

Anyone care to make a "Code Mec" button for me?

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Litigation and the obstetric mindset

While doing research for an article I'm writing, I spent a lot of time on the OB-GYN-L forums, where OBs and the occasional family physician or midwife discuss various ob-gyn topics amongst themselves. I read through the past five years of discussions to gather the various perspectives OBs hold on home birth. I often got sidetracked into reading threads not directly related to home birth, such as posts about about VBAC or breech. I was amazed at how terrified OBS are of being sued. Over and over, the OBs on this forum caution each other to be careful, that every patient is a potential litogen, that if any little (or big) thing goes wrong, the patient will turn around and sue, claiming that they were not properly informed of X or Y risk. And, unfortunately, this does happen often enough to somewhat justify that fear.

I identified several themes arising regarding litigation and home birth. Many OBs are more supportive of home birth personally than they are professionally. In other words, if their malpractice insurance carriers or hospital administration allowed it, more physicians would be willing to collaborate with or backup home birth midwives and their clients. However, in today's litigious climate and with the restrictions dictated by the hospitals they work at, they are unwilling to risk a lawsuit, termination of employment, or "going bare" (working without malpractice insurance) in order to provide support to home birthers. From a November 2006 OB-GYN-L conversation about the legalities of backing up home birth midwives:

Anna Meenan, MD, FAAFP: The legal system is definitely the stumbling block, but if OB's were really serious about working with and supporting midwives, it might be possible to put in place legislation protecting receiving hospitals and OB's in all states.

Ronald E. Ainsworth, MD, FACOG: It's not just the legal system per se. My malpractice carrier will not cover me for any birth that is a planned out of hospital delivery that I agreed to provide backup coverage for. I'm a proponent of patient choice and autonomy, but not at the risk of my career or financial ruin to myself and my family....It's not just "boost rates or cancel insurance," my carrier excludes any coverage for malpractice arising out of a prearranged relationship with a patient who attempts out of hospital delivery. That means I would be practicing bare. NO THANK YOU!!

One OB, Garry E. Siegel, described how a malpractice attorney advised his practice to specifically state that they did not participate in home births in any way, as a cover-your-butt policy:

A couple of years ago we had a little "run" of home births, likely planned, in our CNM patients. Long story short, while not debating the safety of home birth (because there are studies that likely prove it is OK in low risk patients, though it would take a gigantic study to show a difference if one exists), a wise attorney from our Med Mal carrier asked us if we TOLD patients up front that we don't participate. Well, we didn't, but now all new OB patients read and sign a form that includes, among other things, a statement that says:
This practice does not participate in home births in any capacity.
If patients want to discuss this, we don't accept them or discharge them.
If they deliver at home "behind our back," we were up front! (Jan 28, 2008)

Obstetrician Barbara Nichol talked about how terrible it is to be sued--something that almost all OBs experience at least once during their careers. Her remark was set in a longer comment about the need to treat home birth transfers respectfully, rather than antagonistically:

90 percent of us get sued. It's an unbelievably awful experience even when you did nothing wrong, and it's worse when there's some real question on that point. I admit to a lot of frustration and upset when an obvious litogen (e.g. local favorite: refusing GBS prophy because 'antibiotics cause asthma', don't get me started on this nightmare of junk science) walks through the door, but communicating those emotions to the patient just starts things off on the wrong foot altogether, as I'm sure y'all know already.

Litigation isn't always about who is truly at fault, but about who has the deepest pockets. Because many home birth midwives choose not to carry malpractice insurance--including the CNM I used for Dio's birth--if there is a lawsuit, it will often pass onto those with the largest insurance premiums, regardless of fault. From a discussion about liability when a physician assumes care for a home birth transfer:

Unfortunately, IMHO, the hooker here is the legal system. When a patient who chooses OOH birth does have a problem, and is brought to the hospital (as RESPONSIBLE midwives will do), it's often the physician and the hospital who bear the brunt of the family's anger and frustration, and often find themselves in a lawsuit, brought on by a patient with whom they have not had the opportunity to develop rapport, etc. That's why many obs are unwilling to support this situation. Is this fair? probably not. It is, however, sometimes a matter of self-preservation. (Larry Glazerman MD, St. Luke's Center for Advanced Gynecologic Care, Nov 26 2006)

A midwife on the OB-GYN-L list responded to Dr. Glazerman:

Unfortunately, Dr. Glazerman, you're correct. The distrust and antipathy goes both ways, though. Women who transfer from a home birth are often treated very rudely by physicians and hospital staff, even to the point of having CPS called b/c they attempted home birth. Midwives' records are ignored and patients treated as if they had no prenatal care. Time is wasted and valuable information ignored. (Jamie, Nov 27, 2006)

Another physician, D. Ashley Hill, joined the conversation and added these remarks:

As the recipient of several surprise train wrecks from planned home deliveries or lay birth deliveries gone bad, I agree that very often "the hospital" and "those doctors" end up being the bad guys. Most patients are not pleasant after 6 hours of hard pushing followed by an eclamptic seizure and postpartum atony with hemorrhage. Typically they don't like hospitals or physicians to start with and are on the lookout for anything else to go badly.
What many of our non-US colleagues may not know is that in our legal system the lawyers preferentially attack the party with the best insurance, regardless of the level of fault, therefore there is little impetus for lawyers to go after the person who attended the home delivery. Instead, they go after the doctor and the hospital where the patient ended up when things went awry at home. (Nov 26 2006)

I was also surprised that many OBs feel trapped by the system, portraying themselves as victims and malpractice lawyers as The Big Bad Guys. Physicians comment about how ACOG "is a hostage of the legal system," how "the legal system is the king (or queen)," or how "trial lawyers run the whole show."

If you want some really fascinating reading, browse through the OB-GYN-L archives and read threads about VBAC or home birth. It's kind of like watching a car accident--you know you should turn away, but it's just so morbidly fascinating that you can't stop looking. (Select a month, and then click on "thread" view. Read from bottom to top, since the earliest posts are on the bottom.)

I am trying very hard to understand the obstetric mindset when it comes to risk, malpractice, and litigation in relation to choices such as VBAC or home birth. I can kind of understand why OBs act and think the way they do, and I have been trying very hard to see things through their eyes. But on the other hand, their attitudes and behavior directly impact women's bodies, women's birth experiences, and women's range of childbirth-related choices. But still, I do understand what a hard place many of them are in, and the blame is multivalent: partly from patient litigation (real or imagined), partly from malpractice insurance or hospital policies, partly from personal experience (such as attending a VBAC with a bad outcome), and partly from personal preference ("I don't see why any woman would want a VBAC--what's the big deal about having a cesarean?").

I was discussing this with a family doctor friend. Below are her perspectives on OBs and litigation, from the experience of a family physician trained in a medical setting and who works alongside OBs, but who herself practices with a very holistic, minimally interventive style of care. Below are her comments, reposted with her permission:

*****

On OBs and lawsuits: I can understand part of it, and part of it is an incomprehensible mystery to me. OB, as a surgical specialty, has a much different "flavor" than the FP [family practice] world I trained in. OBs are surgeons, and many have an "I can fix that!" kind of personality, where issues are seen as black and white, and they rely heavily on their judgment and skills and quick decision making. Surgical training is much more hierarchical than generalist training, and I think that builds in much more of the power issues that we see in medicine so much. OBs primarily view their clients as patients, and their decisions as scientific and don't concern themselves with the softer, social/emotional issues. Because of the power play issues and the idea that the OB is the knowledgeable important person in the relationship, I think this leads to a lot more worry on their part of the consequences of their decisions. The average OB is trained and socialized to be the decision maker and leader in the doctor-patient relationship, and to bear the responsibility for the outcome. They are also socialized to be very risk aversive - but only the risks that impact them the most. There is this overriding cultural expectation that OBs are expected to produce a perfect baby every time - but in reality, I think OBs propagate this much more than their clients do. I think so much could change if OBs (and many other kinds of doctors) could let go of the power differential and allow themselves to be seen as human.

As a family doc, even though I trained in a highly traditional medical setting, I was still trained by family docs, with a strong flavor of know-the-evidence, partner-with-your-patients type style. I think midwives, of course, lean even farther into the psychosocial part of their relationship with clients in their training. I think the more partnership or service style of practice leads to less fear that you will be held solely responsible for your decisions. Our generalist training, and in midwives' case, their woman-centered training, shifts more responsibility onto clients themselves, and I think leaves us feeling less worried about litigation, and more worried about quality care.

Of course these are big generalizations, and there are exceptions to everything, but in general the culture of the surgical specialty of OB is just so different than the culture of midwives, or even family docs.

I don't worry about getting sued very much. It rarely enters my mind as a factor in decision making. I worry a lot more about educating, and about encouraging my clients to make their own decisions. I worry about forming good relationships, providing room for disappointment to be expressed when things don't go the way we hoped, and making our decision making processes completely transparent and understandable to my clients. I worry about making sure my clients understand that there is a lot of uncertainty sometimes in what we do, that no outcome is guaranteed, and that I strive for excellence and hope for luck along the way, too. I hope that the relationships I form with my clients will mean that they can tell the difference between malpractice, and an honest human being doing their best.

Part of the lawsuit crazy fear really does seem incomprehensible to me, though. When I was pregnant with my fourth child, I went to a friend (or more acquaintance) who is an OB for prenatal care, and we had the weirdest argument over me being tested for gonorrhea and chlamydia in early pregnancy. I didn't want to be tested because I have zero risk, and it costs money. She kept saying that it was important to be tested, regardless of risk, because of "medical legal reasons." We went around and around until I finally said: "Look, 'medical legal reasons' only come into play if I sue you, and I can assure and guarantee you right now that I'm never going to sue you for not testing me for gonorrhea and chlamydia. I understand the risks and benefits of being tested, and I refuse. Period." She was terribly flustered that I'd brought up the word "sue" and terribly flustered that I said "refuse" and was clearly uncomfortable and it was so strange to me. In my practice, I matter-of-factly explain the benefits of being tested, and if clients choose not to be, I feel quite content that even if they are making the wrong decision, it's their decision and their consequences so I don't have to be personally invested in it - while she clearly couldn't let go of the idea that by not following the "standard of care" I could somehow accuse her of malpractice later. I still can't understand why so many OBs are so terrified of being held responsible for outcomes they can't control - why are they so frightened of allowing the decision making to rest with the folks who have to live with their decisions!?

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