Obstetricians Study Themselves

It is my privilege to share another thought provoking article by Jacqueline Levine, LCCE, FACCE, CD(DONA), CLC

Your obstetrician is afraid of being sued.

imsssagesShould that fear guide the way you’re treated during your pregnancy, labor, and the birth of your baby? Should fears of litigation have a direct effect on the rate of cesarean section in our country, and should your risk of having a c-section depend on your OB’s personality?

How about best-evidence optimal maternity care? Do you believe that the maternity protocols in use by OBs reflect the best science, using “Level A” evidence-based protocols and practices? And if there’s a proven, effective training program that takes just two days and lowers c-section and morbidity rates, shouldn’t that training be in use in every hospital and everywhere women have their babies? Common sense and our general understanding of ethical behavior make us want to answer those questions with confidence, just as you think they should be answered.

The dismal truth, however, is that those questions must be answered in just the unequivocal opposite of what your good sense tells you.
The cesarean rate in the US seems to have stopped rising and has leveled off, as reported last year by the Center for Disease Control and Prevention (CDC). The information came from the National Center for Health Statistics, and it says, in sum: “After 12 years of consecutive increases [1998 to 2009], the preliminary cesarean delivery rate among singleton births was unchanged from 2009 to 2011”; the report cites the current rate as 31.3%. That the rate has stopped rising is good news. And that the rate is too high is not in dispute. The World Health Organization (WHO) and other orgs that promote and support optimal maternity care have been making that case for a good while.
Now, famously, ACOG has come out with a position paper, a report entitled “Safe Prevention of the Primary Cesarean Delivery”, with guidelines meant to prevent a first-time c-section; the study calls for “revisiting” the list of the “common indications” for cesarean. Those various rationales for section have held sway in maternity care for years. We understand that the new guidelines are a hard admission that the rate of surgical birth is indeed far too high, and that current practices do not promote the general health of women and babies. ACOG wants to “prevent overuse” of c-section. (See Obstetric Care Consensus Number 1, March 2014, entitled “Safe Prevention of the Primary Care Delivery”, from the American College of Obstetricians and Gynecologist, along with the Society for Maternal-Fetal Medicine.)
We should understand that the forces driving maternity care are not totally about optimizing the health of mothers and babies, but rather respond to other imperatives. Examples follow.
At the 57th Annual Clinical Meeting of the American Congress of Obstetricians and Gynecologists (as reported in Medscape Today; Medscape Medical News, May 12, 2009), there was discussion of an article entitled “Liability Fears May Be Linked to Rise in Cesarean Rates”. I’ll just quote it directly so that you can have the very words of the study as reported (bold emphasis is mine):
PhysiciansBenefitCopingSupport“It has been suggested that medical-legal pressures are a factor in the high number of cesarean deliveries. A number of studies have borne this out. Localio and colleagues (JAMA. 1993; 269:366-673) found a positive association between medical malpractice claims risk and the rate of cesarean delivery. Murthy and colleagues (Obstetrics & Gynecology 2007; 110:1264-1269) found an association between professional liability premiums and rate of cesarean delivery — for every $10,000 increase in insurance premium there was a 15% increase in the rate of cesarean (s)delivery. Dr. Barnhart said “First of all, I applaud the abstract, in that it quantifies a perceived problem,” “We all anticipated that defensive medicine might be a reaction to litigation, and this paper demonstrates that that is indeed the case,” “So don’t just blame the doctor for doing a C-section, recognize that there’s probably a reason that [he or she is] doing it. And that fear of litigation is the reason,” Dr. Barnhart concluded.”
This article is really a confession. It’s a way to say “You see, it’s not our fault that we have to do all these c-sections. We’re just human and fear is making us do unnecessary surgeries, just in case we get sued” and puts the OB in the role of victim. It’s “defensive” medicine…and where might this kind of medicine be taught in the medical curriculum? It’s an admission that what is being done in the way of care may be for the welfare of the OB, and not for the welfare of the women in his care. Do docs acknowledge the possible effect of malpractice insurance on birth options?
We assume that the most fundamental tenet of care is that what a doctor does is for our benefit, and not for her or his well-being, convenience or safety. We are right to feel that any doctor who picks up a scalpel and performs surgery for these “defensive” reasons is behaving in a way that is the antithesis of ethical behavior, a betrayal of our trust in the doctor-patient relationship. It’s easy for the OB to use cesarean delivery as an answer to all potential problems, to say that something might be wrong, do the surgery, and when of course everything turns out fine, mother and family are just relieved.
But should you have to give up your right to be treated according to your genuine health status, and have to risk the many documented hazards of c-section for both you and your baby, and perhaps compromise your future reproductive health to protect the personal welfare of your doc? So yes: your OB may treating you to promote his or her own personal, financial interest, since that study shows a willingness to admit that one of the reasons for the high cesarean rate is fear of litigation.
Another example: does your risk of c-section depend on your OB’s personality? Again, the answer is yes. A disturbing article, called “Women’s Risk of Having C-section May Depend on Her Obstetrician’s Personality”, discusses a study published in the Journal of Obstetrics and Gynecology in 2008. (Here is the citation: Allcock, C., Griffiths, A., & Penketh, R., The effects of the attending obstetrician’s anxiety trait and the corresponding obstetric intervention rates. Journal of Obstetrics and Gynecology, 28(4), 390-393. [Abstract]). “Trait anxiety” is an integral and unchanging part of the human personality and is very different from “‘state anxiety’” which happens in response to a particular situation
The results of the study are very concise, and as before, quoting directly makes things abundantly clear: The obstetricians with the least anxiety had the lowest emergency cesarean rates. imagesThe obstetricians with the most anxiety had the highest rates.”
Statistical analysis revealed that the doctor’s trait anxiety levels were highly correlated with cesarean rates. It’s unlikely that the human condition and the pantheon of measureable personality traits has changed much since ’08. It’s likely that there are still discernible anxiety levels among OBs, that might cause them to react to those anxious feelings and perform sections for that anxiety.
These studies document just two of the many factors that affect a birthing mother’s chances of having a cesarean, and how many of those factors have to do with a mother’s or baby’s actual health status? Of course there’s literature that proposes other reasons for the high c-section rate, but the studies discussed here expose a side of obstetric practice that is particularly damning. Each doctor makes a choice either to treat ethically, or alternately, with regard for his/her own interests and inclinations.
Here’s some mixed news from the industry. It’s the publication of the study entitled: “Scientific Evidence Underlying the American College of Obstetricians and Gynecologists Practice Bulletins (Wright, Jason D. MD; Pawar, Neha MD; Gonzalez, Julie S. R. MD., et al), published in Obstetrics and Gynecology in 2011”. This study examines the protocols and guidelines used in obstetric care as to their basis in good science. We can only applaud OB’s decision to examine their own guidelines and protocols, no? This quote comes from the Abstract of the study: “We examined the quality of evidence that underlies the recommendations made by the American College of Obstetricians and Gynecologists (the College)”. So far, so good
But the words that cause that frisson of anxiety are in the conclusion of the study: “One third of the recommendations put forth by the College in its practice bulletins are based on good and consistent scientific evidence.” That evidence is called “Level A”. That can only mean that the remaining two-thirds are not. That’s 70% of the care protocols used on birthing women are not based on the best science! Doctor #1What does this mean to each birthing woman? Must she be on the lookout for practices based on anecdotes, opinions, traditions and other poorly supported evidence? How will she know? And why should she ever even have to worry?
Making that point even more painfully is this study from the Society for Maternal-Fetal Medicine’s 34th Annual Meeting, presented February 6, 2014, with this title Training Reduces Cesarean Delivery and Neonatal Morbidity, and published online in Medscape Medical News © 2014 Feb 07, 2014. This important study needs to be quoted:
“A multifaceted intervention program for health professionals aimed at reducing the rate of cesarean delivery succeeded in doing just that, according to a new multihospital study…. “Our hypothesis was that intervention at the right time would provide the chance to improve the quality of obstetrical care and reduce morbidity. “… ” The program involved a 2-day on-site training workshop for health professionals that focused on the best clinical practices for intrapartum care…. and that did significantly reduce neonatal major morbidity (OR, 0.81; P = .028) and effect minor morbidity (OR, 0.88; P < .001). …
“This study of more than 100,000 women shows that an interventional program can not only reduce the chance of cesarean delivery, but can also reduce neonatal morbidity, noted William Grobman, MD, professor of obstetrics and gynecology-maternal fetal medicine at the Northwestern University Feinberg School of Medicine in Chicago.
“The important thing is that this did not involve new therapies or methods. This was totally about the delivery of health services,” Dr. Grobman told Medscape Medical News. “We often focus on new treatments, but sometimes it’s the relatively simple things — education, quality improvements, quality control, and feedback — that can substantially affect maternal and child health.”
Shall we assume that nurses and docs just don’t know “best clinical practices’ without this extra training, or forgot them, or find it inconvenient to use them? If it takes only two days of training to correct bad practices, what can we think?
Is the problem not clear? Bad practices based on less-than scientific evidence and unethical behavior and personal character traits and fear of litigation and ignorance…the “ignoring” of best clinical practices, can guide maternity care. If only a third of maternity protocols…for both mother and newborn…are based on best-evidence science, what about the rest of the care woman and their babies receive? And if that unscientific behavior can be remedied by a mere two-day course that reminds docs and nurses how to observe optimal care practices and can fix the huge problem of high c-section rates and other insults to the health of mother and baby, how can a mother make her way through this system without coming to some kind of harm? We have the words of the maternity caregivers themselves to read and ponder.
OBs are ducking questions about the morality of performing cesareans for defensive reasons, and ducking patient’s questions about best-evidence care, but somehow we have to make them face this reality: “Approximately one-third to one-half of maternal deaths can be attributed to the cesarean procedure itself.” And: “There are no well-documented prospective trials demonstrating benefit to the fetus or to the mother that would justify the extent of the increase in the primary cesarean rate.” These quotes are from Obstetrics: Normal & Problem Pregnancies, 3rd Ed. Gabbe et al. p634).
There are many caring and dedicated practicioners who stay current and give only best-evidence care. We admire the ethical caregivers who do not rely on routine interventions and who use surgery only to save the lives or health of babies and mothers, and not for their own welfare, but the high section rate illustrates the fact that they may just be a minority.

ifffmagesWe have only that one day, that one chance for each baby we birth,

so when deciding on a caregiver, it’s our responsibility to get familiar with best-evidence, optimal maternity care and question our health care provider about his/her practices. We need to learn the facts about normal, healthy birth, and conservative reasons for c-section based on real health status as well. Recommendations for OBs, hospitals and midwifery care from women across the United States can be found at the non-profit, all volunteer website Your prospective OB knows that best-evidence information is out there for you to see, so question him/her closely about his/her c-section rate, induction rate, episiotomy rate, and other routine and common practices that may not confer best-evidence care upon mother and baby. If you sense a defensive posture about his stats, or an air of reluctance to tell you what you want to know, politely say your thank-you’s, and head for the door.

Jackie-Levine“Jacqueline (Jackie) Levine, LCCE, FACCE, CD(DONA), CLC is committed to providing a continuum of care for underserved women at Planned Parenthood, on Long Island, NY, where she has provided free Lamaze education, birth and breastfeeding support to all the women in her classes for the last 9 years. She is a guest lecturer on Childbirth in the US at CW Post, has worked for CIMS, contributed to the Lamaze e-newsletter Building Confidence Week-by-Week , all after her 30-year career as a designer in the garment center. Jackie is a recipient of the Lamaze Community Outreach Award, mother of three and Grandmother of five.” Science & Sensibility

Please feel free to send comments/questions to Jackie:



ARE you totally comfortable talking with your care provider? Asking all those  questions you might be too embarrassed to ask someone else?

DOES this person give you the time to talk about whatever you want to talk about?


DOES your care provider validate your concerns? Make you feel like your question is the most single important question?


DOES s/he allow you to feel like an intelligent and caring parent to be?


DO you leave the office feeling like an adult who is worthy of this professional’s time? Do you leave feeling no shame?



If you answer NO to ANY of these questions……

it may be time to find yourself a different care provider!!!!


And it is never too late in your pregnancy to do so!!!

What we (and it isn’t just us women) tend to forget in the presence of    medical persons is that WE ARE THE CUSTOMER!!!! This is true of facilities, too.

This does not mean that we have the right to be rude and/or arrogant. But it does mean that we have the right to feel comfortable, to have the respect of the medical person, and to be given the time to address the topics that are important to us.

You are sharing probably the most important, and intimate, time/event   of your life. You have every right to feel good about whom you are sharing this with. Baby professionals should feel honored that you have chosen them for this time. I know I do in my capacity!

And after all…… are the one paying this person’s salary!!!

Without you…they will not be in business!!!