7.09.2010

In Defense of Doctors


I wanted to talk just a bit about obstetricians. In their defense, they are only working within their training and nature. Most don't go out of their way to be bull headed, opportunistic, business-minded, opinionated, god-complexed individuals. They are simply doing what they were taught to do: stand in the way of birth.

The typical course of study for a med student hoping to become an obstetrician includes, roughly:
  • Undergraduate degree (BA or BS, 4 years)
  • Medical school (4 years)
  • OB/GYN residency (4 years)
Very early on in their career choice to become an OB-GYN, for a very short amount of time, the medical student learns anatomy, biology, and physiology of normal, natural pregnancy, labor, and birth. The rest of their career is a stringent desensitization to normal and natural and an indoctrination of the risk, diagnosis and preventative medicine, variable obstetrical and gynecological conditions, procedures (including operative), business ethics, and professional ethics.

In other words, whereas a midwife spends her whole career focusing on the normal and natural, and thus are experts in normal, natural childbirth. Obstetricians are experts in risk and conditions of pregnancy and birth.

Because midwives are experts in normal pregnancy and birth, they will see deviations from normal and natural pregnancy and labor/birth early on, be able to assess these variations, and take immediate and early precautionary measures to ensure your safety...

Because obstetricians are experts in risk and conditions associated with pregnancy and birth, they will be seeing the process as 'guilty until proven innocent', watching expectantly for these conditions to crop up, managing and attempting to control the event so that they can, in their trained minds, control the outcome.

Unfortunately, studies have found that the more we 'do' to pregnancy and birth, the more active management we try to assume over nature, the more unnatural and risky the event becomes. In other words, the very thing that doctors set out to avoid becomes reality - iatrogenic complications.

This training is amazingly beneficial for when true emergencies arise, when we truly medically need these services, when natural acts up. But, when nature takes it's normally uneventful course, obstetrics can really mess things up.

The very word 'obstetrics' comes from the Latin root obstāre, which means to stand in opposite/opposition to, obstacle. Medicine.net states that the clinical definition of obstetrics is: The art and science of managing pregnancy, labor and the puerperium (the time after delivery).

Doubly unfortunate is that, because of their training, most doctors loose sight of what is truly going on here: the miracle of life through the conduit of the feminine form. Oftentimes, they forget that the majority of pregnancy and birth IS normal and natural

Likewise, often they forget the autonomy, as well as the humanity, of the individual giving birth. For 12ish years they have been staring at diagrams of parts of the female anatomy, illustrations and models of the reproductive organs of the woman, not the person of the woman.


Not all doctors are ready to cut, or probe, or induce; I have been blessed to meet and work with many obstetricians who are midwives in wolves clothing, and you can find them every once and while in the blogsphere.

Not all doctors are ready to cut, or probe, or induce, or whatever... but the majority are. And, I cannot blame them, it is what their training has prepared them to do - to stand in the way of.. I cannot blame them, and neither can you. They are simply doing what they were taught to do: stand in the way of birth. And, if you don't want them to, then why did you hire an Obstetrician?

On the other hand, you have no one else to blame except yourself if you choose this model of care for your health care and should not feign surprise at the outcome of your experience.

This is just one more reason to be sure that you trust and are happy with your choice of care provider. If you aren't, then find another who you can trust and who does reflect your believes and ideals.

19 comments:

Sheridan said...

So very true. I have a friend whose DH is an OB resident. His training is so geared towards finding and fixing problems. Which is ok if there are actually problems (he is at a high risk hospital, so there are a lot) But when he moves to practice on his own, will he be able to change his focus?

mamapoekie said...

You are right, however, I think we should all face the fact that for a lot of women, another choice of care than obstetrics is simply outside their radar. So I think saying they only have themselves to blame is wrong.
We should blame the system for directing women to care they do not need.
If all systems were like the Dutch systems where healthy pregnancies HAVE TO be followed by midwives, there would be a lot less guilt and blame

putting this in sunday surf

Ritsumei said...

Not sure why you titled this "defense" of doctors... it's the same stuff as always. Maybe my doctor and his practice ARE that exceptional, but the things you're talking about - the standing in the way of natural birth - has NOT been my experience.

And I don't have a ton of choice about hiring an OB: my insurance doesn't cover homebirth at all, and isn't really friendly to midwives & birth centers. I simply can't afford to do anything else.

I grow weary of the doctor-bashing on the natural birth blogs.

Nicole D said...

Ritsumei -

It is a defense, a defense of why they (by and large) practice the way that they do.


I have been very fortunate to have had a great ob, and have worked with many great obs.. but there is a reason I had to interview 20 additional obs before finding the one that I did. And there is a reason why the majority of women I work with who choose hospital births run into issues with doctors practicing preventative medicine that only, from medical studies, have shown to increase risks.

I sought to give some insight into WHY so many obstetricians treat pregnancy and birth (and thus, women) the way that they do and achieve the outcomes they do.

Indie said...

I do think its a little too much to say "you have no one to blame but yourself..." You really have to go out of your way to find this information, especially if you are poor and don't have access to the internet. And then you have to get past an immense amount of social conditioning that is not unlike the conditioning that the doctors have been through. Blaming women for not choosing something they've never heard of or don't have access to isn't really fair. As it stands in this country, things like homebirth, doulas, etc. are much more accessible to the educated and well off than they are to the general population.

Nicole D said...

Indie -

I write that on the assumption that, if I am speaking to them ('you'), then they are reading this blog and, as such, do know better, have more options, are educating themselves, and are working to reverse cultural preconditioning. :) IOW, I am speaking to those reading this... they really HAVE no one to blame but themselves.

erandles said...

this post very much conincides with information i needed a few weeks ago. my OB released me from their care at 32 weeks because i refused something that the entire practice didn't think i had a choice on. i now found an OB who told me that i am the boss and he is just there to assist me. i feel much better going to him than i did with the other practice. i feel like it's a tad harsh to say i have no one to blame but myself... my husband is against a home birth and i don't know much about finding midwives... that search was harder than finding an OB to "assist" instead of "control."
now that i read your defense to the "blame claim." i guess you are right. i would be a moron to go back to such a controlling type of OB. ;)

Anonymous said...

Its true. Most women who are having traumatic birth experiences are simply "trusting their doctors" as we've all been told to do. Well... that's what you get for it. Early induction, c-section, and a NICU stay. How's that trust thing working out for you?

99% of these women have internet, email and know how to do a google search, but they just didn't bother. It does sound harsh, but its true - reality is, if you want your best interests served, you have to take some initiative and responsibility. If you hand over ownership of your health to someone else completely there are just no assurances that they will be competent and completely self-less in their care of you as too many assume.

Trust and ignorance is expensive. And in this age of the internet, there really is little excuse.

Kate said...

As much as you claim these doctor are "indoctrinated" so are women in general. Even if I do search out more natural non interventionist care, I have to sift through tons of contradictory material regarding interventions - information that my all knowing, 12 years of schooling doctor then dismisses. I should be able to trust that my doctor has my best interests (and evidence based care) in mind when they speak to me. I should not have to fight to get the information due to me that qualifies as "informed consent."

I think it is harsh and ridiculous to say, "too bad, it's your own fault." With that statement you've completely relieved OBs from any responsibility for the quality of care they dispense and laid the guilt at the mother's feet. We should be empowering women and validating their feelings regarding their birth experiences and helping them find better options for next time not dismissing them and telling them they are the cause of EVERYTHING.

I currently live in a small town located almost 200 miles from the nearest "big city." (That's a three hour drive along a two lane highway much of which runs through open nothing land. I sure hope you don't get stuck on the side of the road in an emergency.)

We have ONE hospital and ZERO birth centers. We have FOUR OBs in town and ZERO midwives. I don't have the luxury of interviewing 20 OBs to find one I like.

Oh did I also mention, that I happen to be a military wife and we are stationed here? I would love to love somewhere else and have more options, but for that to happen, I would basically have to move away from my husband for the duration of my pregnancy. Not happening. Or drive 3 hours one way (hoping that traffic cooperates once I get into the city) for care. I've chosen not to take that route mainly because I am low risk and am hoping that with the knowledge I've gained through my own research and reading I can have the type of birth experience I want where I am (even if I have to fight for it.)

Instead of absolving all doctor's of their part in the birth process by saying, "oh well, that's just they way they were taught" we should be working to expand the resources and information available standard to ALL pregnant women (without them having to decide to go at it for themselves.) The permissive idea of "that's just the way they are" if you don't like it go somewhere else is the kind of mentality that allows abuse of all kinds to continue.

I can't say I'll ever come back to read anything after this post. It's completely put me off.

Pam said...

This is most excellent!!!!! I would love to share on my blog if that would be ok with you. Of course there would be link back to your blog and you would take all the credit but just wanted to make sure that it was ok with you!!!!! I LOVE YOUR blog!!!!!!

Doula Mama Pam

Nicole D said...
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Nicole D said...
This comment has been removed by the author.
Nicole D said...

Hi Kate -

I am going to try to tread carefully, as I can see you are very frustrated. I knew that this post was going to ruffle some feathers, and for upsetting you, I do apologize. I don’t recant anything I have said though. Let me explain.

“As much as you claim these doctor are "indoctrinated" so are women in general.” I have discussed this in past posts and agree with you.
“Even if I do search out more natural non interventionist care, I have to sift through tons of contradictory material regarding interventions - information that my all knowing, 12 years of schooling doctor then dismisses. I should be able to trust that my doctor has my best interests (and evidence based care) in mind when they speak to me.” You should be able to, but their training is to DO to pregnancy and birth, which increases risks.

“I should not have to fight to get the information due to me that qualifies as "informed consent."” And I agree with this as well but, as you stated you are willing to do, you WILL have to fight if you stay with an unsupportive doc.

“I think it is harsh and ridiculous to say, "too bad, it's your own fault."” Why? If a woman knows her options but doesn’t pursue them, she makes excuses for staying with a hostile doc or one who is not mother or baby friendly, it may be harsh, but it’s true.

“With that statement you've completely relieved OBs from any responsibility for the quality of care they dispense and laid the guilt at the mother's feet.” IF they know their options and don’t seek them out, YES, it is the mothers fault. This I do NOT back down from. It does NOT absolve the doc of any responsibility, though, as I have stated in other posts on my blog.

“We should be empowering women and validating their feelings regarding their birth experiences and helping them find better options for next time not dismissing them and telling them they are the cause of EVERYTHING.” I didn’t say that they are the cause of everything, I do empower women, validate their feelings, and help women find better options.. that is the root of my practice. BUT, when a woman knows her options, she still chooses to stay under that hostile care, she HAS to own responsibility for her healthcare choices – it is HER choice. Example: if I am working with a woman who is going to a doctor that is known as the butcher (yes, I have worked with one such case), I will tell her. She then says ‘what am I supposed to do? I can’t afford a midwife (she hasn’t called any and tried to work something out), my husband is not comfortable with homebirth (it is HER body), and I am already in my second trimester (she won’t take the difficulty of changing practices ‘this late in the game’). I let her know that another great option is to hire a doula. She says she can’t because her doc only lets 2 other people in the room and it’s going to be her husband and her mother in law. She calls me 3 months later that she has had a cesarean after 20 hours of hard induction. Baby is in the NICU and showing signs of prematurity.

Nicole D said...

She had so many SO MANY options that she had an excuse for at every turn. From this point, we talk about her experience, we get her hooked up with ICAN, she works through her disappointment and realizes those options could have changed the outcome. To grow, taking responsibility for your choices is tantamount. It doesn’t absolve her doctor of being a great number of things I won’t write here on my blog… but she cannot change HIM, she can only influence and change HERSELF.
In addition, another part of educating women is making sure that they are proactive consumers in their healthcare. This includes taking responsibility for your choices! We cannot, as another commenter said, continue to vilify obstetricians and not take responsibility for choosing to go to them if we know they are not supportive of our choices. It goes with the old adage, “fool me once, shame on you, fool me twice, shame on me”.

“We have ONE hospital and ZERO birth centers. We have FOUR OBs in town and ZERO midwives. I don't have the luxury of interviewing 20 OBs to find one I like.” You do have options though: do you have doulas? Have you looked into unassisted birth? In the ‘big city’ do you have a friend that you could stay with for the last 2 weeks of your pregnancy and plan on going to another hospital, birth center, or home birth? Is there a midwife willing to travel to YOU at the onset of labor (a friend hired a midwife 2 hours away from her)?

“ I've chosen not to take that route mainly because I am low risk and am hoping that with the knowledge I've gained through my own research and reading I can have the type of birth experience I want where I am (even if I have to fight for it.)” If you are willing to fight for it, and have a supportive birth team (husband, friend or doula, etc..) then you can get good outcomes with bad docs… but it is a fight that many women are simply not up to when they are bullied and coerced.

“Instead of absolving all doctor's of their part in the birth process by saying, "oh well, that's just they way they were taught" we should be working to expand the resources and information available standard to ALL pregnant women (without them having to decide to go at it for themselves.) The permissive idea of "that's just the way they are" if you don't like it go somewhere else is the kind of mentality that allows abuse of all kinds to continue.” Again, I know you’re upset so I am trying to not upset you more, but this is a very assumptive statement. If you read my blog in any depth, you would know that that is not my beliefs. I never said ‘that’s just the way things are and if you don’t like it go somewhere else’. You DO deserve more options, resources, and information. Women such as doulas, midwives, childbirth educators, and other moms are working toward that, including me. But, if you know your options, and don’t pursue them, then you have to take responsibility for the outcome. They do as well, but YOU DO TOO. (not you, specifically, EVERY woman does). Just as I am not going to absolve the doctors of their responsibility (see past posts), I won’t absolve women either.

“I can't say I'll ever come back to read anything after this post. It's completely put me off.” I am sorry to hear that, I am also sorry for the hurt and upset you are feeling. I am also encouraged to hear that you are willing to fight for the birth you want with the limited resources you have.

Nicole D said...

PS., sorry for the deletes, my site went haywire and reposted numerous comments at once. LOVE technology. :)

Heather said...

@Kate:
Yes, options can be limited in a rural area. Believe me, I know! My first birth was planned to be a homebirth with an (illegal, but VERY busy!) midwife in my very rural area (population of my county was under 30,000). Then, I got into a wreck on my way home from lobbying the legislature to change the midwifery law, and ended up having to give birth in a hospital in our state capitol, which is just a big town in a very rural area, and midwifery had been a VERY hot-button political issue, so I was very worried about what sort of care I would receive, being as I was publicly on the "wrong" side of the argument. However, I was VERY informed about labor and birth, as was my husband, and this went a long way toward my having about as natural a birth as anyone can get in a hospital these days. Among other things, I figured they were going to have a tough time making me stay in the bed (where they wanted me) with my husband right there (he's large & can look intimidating if necessary--and has my back all the way). So I didn't. I also ate and drank. I did NOT ask permission. I was hungry, so DH ordered pizza & I ate.
You will get better care in ANY setting, if you are well-informed and not afraid to say NO! and make it stick.
If you are in a very rural area, there are likely to be Amish folks around. Where there are Amish, there will be midwives. (If you happen to be at Ft. Leonard Wood, pm me & I'll tell you who to talk to) Due to variation in legal structures, finding midwives may be more or less easy. In MO, for example, they have only been legal for 2 years, and the advertising may not be up to speed yet--they've been plenty busy without.

For all ladies--if we want maternity care in this country to change, we have to vote with our wallets. When the worst OB's start getting poor, they will eventually start paying attention.
Yes, insurance usually doesn't cover midwives, but the cost is usually a LOT less, too. Both of the ones I've used were great with payment plans--and the price was about the same as a good used car.

Anonymous said...

So when something goes wrong in a home birth, as it did with a friend of mine who lost her baby within hours after delivery, do you still blame the woman? Did she deserve to loose her child because standing on principle was more important than using the disease-care world of OBs and hospitals, or is the contention that she would have lost it anyway had she gone the medical route.

Women should support the birth plans of other women rather than engage in this sort of sanctimonious judgement. Home, natural, and hospital birthers adamant about "their way" are all guilty of treating the other side with contempt, which is an absolute travesty and only contributes to the barriers to education and choice.

Nicole D said...

Anon -

First off, my heartfelt condolences go out to your friend. That is so very sad and something that no family should ever have to endure.

As I stated before, I knew that this post was going to ruffle feathers. A woman is responsible for her own health care. We don't know the specifics of her case, I cannot say if she would have had a better outcome at a hospital. Truth be told, the majority of maternal and newborn postpartum issues can be managed successfully with a trained and skilled birth attendant in the home birth setting. In those rare cases when it can't, they should be transferred.

This is not a sanctimonious judgment - this is a fair judgment. There is nothing here that says I believe myself to be morally superior to another.

If you want a low intervention, low risk birth, you should choose a home birth (or perhaps even birth center). If you don't want that, you should choose a hospital birth, because hospital births are not designed to be low risk, low intervention.

Again, as I stated to a previous commentor, if you read my blog, at all, you would know that I chose four out of my five births to occur in a hospital, and I moved to the hospital setting with my 5th after a planned home birth. AND (gasp) I had an OB for some of those births. I also HIGHLY encourage women to birth in the environment that suites their beliefs and choices...

Again, I feel so very sad for your friend. Peace to you.

amig said...

You send me here :) So here is my post 'In defense of OBs' :)
Sorry I haven' had a chance to read all the comments!
My midwives said they wished OBs saw what they see - normal healthy women having normal physiological labours and births.
A person goes to med school because they want to help people. I mean - if you just want money there are way easier ways of getting that! So why do they get it so wrong sometimes?

OBs have to work in hospitals - given the number of women they are supposed to see (around here at least). SO women are not in their own spaces. They also have to deal with a whole ward full of women in labour at once - not just one woman at a time.
They deal with lots of totally normal women - but they also have all the high risk ones too.
They also deal with women who are afraid of birth, are uneducated and don't believe in their bodies. They get the women who come in wanting the epidural as soon as they feel one contraction. ( Contrast that to the women that self select for midwife birth - especially homebirth - who are ready to 'do this'.)
Given how many epidurals are given - they then are dealing with women flat on their backs, unable to move. Pitocin is often given which can result in babies who are also getting stressed. Things like 'big babies' become problematic. If a babies shoulders get stuck - they can't just say - ok let's get you to move around a bit'.

Then there is fear. I think anyone attending a birth would have some fear. You could lose a mom or a baby. Even if we don't touch on lawsuits - just think about what the psychological impact of that is. If something bad happens - and you are the person there who everyone was trusting to make the right call - how do you feel? that's real. Doctors are human. And given how many women they see and the level of high risk they see - loss is a reality for them on a regular basis.
Then we get into lawsuits. I'm guessing - if you want to avoid being sued - you have to follow hospital policy to a T. That doesn't leave a lot of leeway.

SO ye. I don't want that job. And I suppose we should cut them some slack when they want to check for problems or start getting a little antsy about a big baby - given how probably most women they see are not committed to having a NCB.

How do we make this better? I think we need WAY more midwives and we need low risk women out of hospitals. We need them with the right care providers and we need them getting educated. Imagine if the standard birth class was a natural child birth class, most women gave birth at home and had a midwife who would spend 1/2 to an hour talking to her about how she really was doing at every appointment? And let the OBs have the time to deal with the women who actually really need them!

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