Obgyno Wino Podcast Episode 46 - Changing the Culture of Hospital-Based Birth
"Love is happy when it is able to give something. The ego is happy when it is able to take something.” - Osho
Note: the term "woman" is used in this post and the podcast recording as a generic term to represent any birthing person. It is not my intention to exclude any individual who does not identify as a woman, including trans- and non-binary individuals.
The practice of hospital-based birth attendance entails countless interventions, including IV placement, vaginal exams, Pitocin augmentation, mode of delivery, and everything in between. For each of these interventions, a woman has the right to informed consent as well as the right to refuse treatment even in situations in which the birth attendants feel that intervention may be necessary to keep the baby alive. ACOG also stands by these rights (see Committee Opinions #390 and #664), yet health care professionals routinely disregard them. Liability and economics are often cited as the nasty motivators for how birth is attended to in hospitals, but culture plays an equally valuable role.
Practice culture can generally be summed up through the notion of "standard of care", which is a term used to describe how a physician or nurse is expected to practice. Sometimes this standard is determined by a collective of doctors or midwives within a private group while other times it is determined by hospital administration. In the case of labor and delivery nurses, it may exist merely as an opinion of the most veteran nurses on the unit. Either way, it often dictates the way that a health care professional practices their craft in spite of the body of medical evidence or years of professional expertise on the part of the provider.
When a physician signs on to join a medical group, he agrees - whether explicitly or not - to practice within the standard of care. He will be held to this standard in the name of safety, but, in this case, "safety" is intentionally a nebulous term. Safety, in this case, is not determined by your skill level or by your personal experiences, yet it becomes a line in the sand, and crossing this line may be grounds for loss of hospital privileges or the loss of your job.
It is not hard to see how the cultural pressures on the practices of physicians, midwives, or nurses can easily lead to violations of bodily rights. We often go to great lengths to train our patients to comply with "the way things are done here" through coercive language ("You do want what's best for your baby, don't you?) and hospital policies that put more weight on the culture of practice than the experience of its providers or published evidence. Nevertheless, fear of being perceived by your colleagues as too hands-off with a prolonged labor is not an indication for surgical birth, nor is a lack of training in vaginal breech maneuvers. Likewise, hospital policy prohibiting trial of labor after cesarean (TOLAC) becomes equatable to forced repeat cesarean delivery if a patient does not consent to surgery.
The unfortunate reality is that we have somehow lost sight of the physician's role in the physician-patient relationship. What was not impressed upon in residency was that she is actually the captain of the ship; you are merely her first mate, at best. You are not solely responsible for the outcome. Your responsibility is to provide her with evidence-based recommendations, support her in her decisions, and use non-coercive language to obtain her legal consent for any procedures or interventions, all the while not being negligent to her medical needs.
This is our job as physicians, but there is little focus on this in our training. Instead, many faculty physicians unconsciously model for their trainees the nuanced language required to persuade patients to comply with our cultural needs as health care professionals. Many even argue that consent is implied as soon as a woman enters the hospital. I have heard the same story from hundreds of patients: a woman in labor comes rolling down the hallway on a stretcher from the ED. The nearby nurse or obstetrician approaches the bed with a gloved hand, urging her to open her legs because "we need to make sure your baby is OK!" This seems like a benign scenario, but probing a bodily orifice without first obtaining consent from the patient would be inconceivable in any other specialty. Indeed, obstetrics is the only specialty in which the culture of practice predominates the rights of women.
How is it that the rights to informed consent and refusal of treatment are forgotten when a woman becomes pregnant? Without addressing a culture that has permitted these poor obstetrics practices, how will we ever achieve a truly integrated system that provides compassionate, holistic women's healthcare?
In episode 46, I’ll be talking to Hermine Hayes-Klein, JD, a Portland-based attorney who focuses on human rights in childbirth, and Brad Bootstaylor, MD, FACOG, an OBGYN who is also boarded in Maternal Fetal Medicine (“high risk OB”) about the problematic culture of hospital-based birth. We explore the physician-patient relationship, the responsibilities that come with the rights to informed consent and refusal of treatment, and how supercomputers in the hands of our patients have enabled them to view us as the enemy, and vice-versa. Most importantly, we discuss ways in which we may all begin to mend the physician-patient relationship in order to redirect the culture of hospital-based birth.
References from this show:
Hermine Hayes-Klein, JD, can be contacted through her website
Brad Bootstaylor, MD, FACOG, can be found at Seebaby.org