I just got back from the Doulas of North America international conference in Atlanta where I gave a talk called “how OBs think.” The doulas seemed to find the title humorous but they still came to hear what I had to say. I gave the talk because I’ve gotten interested in exploring the scientific data to support physiological childbirth (birth without medical interventions) and I wanted to think through how to introduce ideas to the OB community that might shift beliefs a little.
So what exactly did I say about how OBs think? First I explained how doctors are trained to think like scientists and how we like scientific evidence to support our practices. We weigh risks and benefits before making decisions. But we are also human, and under pressure to always get “good outcomes”. We live in a zero tolerance environment, even for very rare unpredictable complications. And we worry about malpractice suits. So risks loom large, and when we weigh risks against benefits most OBs are not convinced that low intervention physiologic birth has specific benefits. This imbalance between perceived risks of allowing labor against the benefits of spontaneous vaginal birth plays a big role in the current high rate of cesarean section.
I gave an example of a typical high intervention hospital labor that ends with intrauterine infection, cesarean section, separation of mother and baby (NICU), and then short term breast pumping but never breastfeeding; Everyone agreed this sort of scenario isn’t that unusual. I asked the question “How did we get here?” We are supposed to be guided by the principle First Do No Harm, but I think that concept has been subjugated to a risk-based intervention approach to managing labor, without totally understanding all the implications of the management decisions. No mother wants her baby to have problems just so she can have a good birth experience. But that is often a false choice.
Birth is a physiological process and is designed (by survival of the fittest) to go well. Most births shouldn’t require interventions, just support, attention, and a safety net in case of emergency. Birth isn’t just a medical experience. It becomes part of each woman’s personal story. We need to better understand the downstream impact of our obstetrical care: any long-term risks to mother, baby, and future babies from our routine practices; the emotional consequences on the mother and the family of experiencing birth as a medical event; the effects of common practices on breastfeeding and parenting. It sometimes feels like our routines appear justified by community norms, but when they add up they may cause more problems than they solve.
So this is what has been keeping me up at night (when I am not at work being kept up at night by the usual things that keep OBs awake). I’d love to hear other people’s thoughts.
3 responses so far ↓
1 anna // Aug 18, 2009 at 8:26 am
I’m a little confused by this post and would love if you could clarify it a bit! You say that docs are trained to think like scientists and make decisions by weighing risks vs. benefits…yet there are A TON of studies out there showing that physiological birth is best for moms and babes. You say that you’ve been thinking through “how to introduce ideas to the OB community that might shift beliefs a little.” Anyone with half a brain and an interest in birth could figure out that evidence-based care is better than the please-don’t-sue-me heavy intervention model. And most OBs are pretty smart, and most OBs want the best for their patients, so how is it possible that OBs are really that clueless? Kinda scary.
2 Marjorie Greenfield // Aug 18, 2009 at 12:21 pm
I totally hear and feel your frustration.
I agree most OBs want the best for their patients, so I think this boils down to a very entrenched belief system. OBs see all the worst things that can happen and want to prevent those rare occurances where the fetus doesn’t tolerate labor. Intrapartum care focuses on watching for and preventing serious sudden fetal events. OBs don’t have experience with the benefits of physiological birth, so all they see are risks. This belief system leads to a very different paradigm than what you might create if you looked at all the data (much of which is in the midwifery journals not the medical ones) and saw the benefits of non-intervention. All I can say is that it is very hard to change a culture based on deeply held beliefs.
3 anna // Aug 20, 2009 at 6:36 am
What you’re saying is disappointing, because I’d like to think that OBs want to know as much as possible about birth and have a certain amount of intellectual curiosity. I’m not naive; I’m a doula with a bunch of kids, so I’ve seen some bad OBs, but I’ve also seen a lot of good ones, and I’d like to think they’d be interested and proactive about this kind of stuff. But I hear what you’re saying about a deeply entrenched belief system. And I WANT you guys to be vigilant about protecting babies, and I’m so grateful to be alive in a time and place where this kind of care is available.
Regarding this paradigm shift you were talking about, I wonder if it would ever come about from OBs themselves. I would think it’s more likely to come from patients actively seeking a certain kind of care. Historically, that’s been the case.
The problem is that most patients aren’t looking for evidence-based care; they accept whatever the doc/nurse/hospital policy says. A patient typically has 15 minutes at her appointment, it’s so rushed, and docs don’t have time to really educate their patients. (You could argue that that’s not their role; I think it should be, but I can see how a lot of people would disagree.) But here’s what I would love to see: an OB who hands out an information packet to her patients at their first appointment, and invites her patients to email her with questions about the info in the packet. And the packet would have easy-to-understand info about physiological birth, among other things, so patients could truly make informed decisions about the kind of birth they want. Would you ever consider doing that in your practice?
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