Wednesday, February 4, 2009

Doctor-Persuaded Cesareans

Another follow-up to my recent blog entry about so-called "elective cesareans" and how women are scared, convinced, bullied and even de facto-forced into cesareans they don't want or need.

Here's a blog entry from a midwife who is currently in med school to become an OB-GYN, and the attitude towards Vaginal Birth After Cesarean (VBAC) and planned cesareans she has encountered.

Here is a little excerpt:

Women are absolutely bullied into repeat cesareans. When I was training as a midwife at a freestanding birth center, we had women transfer to our care late in pregnancy all the time because their doctors were forcing them into a repeat (or primary!) cesarean without medical indication. In fact, we had one mother who said the doctor told her she had to go see a psychiatrist because she was literally crazy for requesting a trial of labor....

One of the ob/gyns at our school (and our main women’s health professor) told our ob/gyn interest club that he thought that his offering of elective cesarean to his patients was completely ethical...But, in reality, his practice does not simply involve maternal request for cesarean. The two women in my class who were his pregnant patients said that he offered them a non medically indicated cesarean at every single visit.

He even went on to explain at that meeting that he tried to convince his patients by extolling benefits of cesarean section, including “your mom can arrange to be there”. He told us that he preferred it because “twenty minutes, the baby is at the mom’s breast, and I get to go home, instead of waiting for twenty hours of labor.” He disparagingly said, “I am not a labor sitter. I am not a glorified midwife"....

Magnify That For Fat Women

Now take this attitude about "doctor-persuaded cesareans" and multiply it times TEN (at least) and you get the kind of pressure many fat women encounter from their doctors during pregnancy.

Sometimes it's really that egregious and obvious, but often it's more subtle and plays upon the fears they have carefully built up for us about how our weight and size might harm our babies.

"Well, dear, obese women have a higher risk of 'xxxx', so better do an early induction now (before the baby gets too big!...or before your blood pressure goes up!....or before your placenta degrades!). But you know, if we just schedule a cesarean, you don't have to go through all that messy labor pain, you can pick your baby's birthday, your mom can be there for the birth, and you'll have your baby in your arms in half an hour."

Or, "Chances are really high that you'll end with a cesarean anyhow; better and safer to do it in a planned and controlled fashion than as an emergency procedure. If there was a real emergency, it would take too long to get through all that extra adipose tissue and your baby might die. You don't want your baby to die, do you?"

(The last argument is used all the time.....and very successfully I might convince women of size out of trying for a VBAC and into scheduling a repeat cesarean. I've seen it work many many times.)

This is not to say that 'all doctors are bad.' Of course not. There are many wonderful doctors out there, and of course there are bad midwives out there too. It's not one's title or credential that makes you size-friendly or birth-friendly. BUT there is a set of cultural attitudes and beliefs about interventions that tends to cause more cesareans and complications with doctors than with midwives in general.

Some birth attendants truly mean well when they schedule fat women for early inductions and cesareans, thinking that they are providing the best possible chance at a "safe" birth for them, despite little evidence actually supporting that idea.

The problem is that they rarely question that belief, in research or in practice. It just becomes "standard of care" for obese women, without any careful examing of whether it actually does improve outcome or not.

There is just simply a culturally-warped attitude in favor of birth interventions and "the machine that goes PING!" in medical training these days. Add in the additional bias about the 'dangers of obesity' and it means that fat women are being pushed into inductions and cesareans at RECORD rates today.

Fat women can birth vaginally. But often, they are simply not given a real opportunity to do so.


Anonymous said...

Thanks for the link love. You are completely right about excessive interventions being even more of a problem for overweight and obese women. And, there is not evidence supporting that these interventions make their birth outcomes better.

Jill Arnold said...

I think you hit the nail on the head. Add to it discrimination (or bias. or fear. or whatever we call it...) against suspected large babies and you get the formula for Instant Cesarean.

My midwife and I were talking once about palpating a woman with a lot of adipose tissue on her belly. It can be done. =)

Ashley said...

Oddly enough, most of the women I know who have natural births are significantly into the "obese" category.

Noelle said...

I am a counter-voice here, but I am a person who *wanted* a C-section the 2nd time, but was bullied into a VBAC by staff of Kaiser Permanente. With a C-section, I got to stay in the hospital at least 5 days and recuperate. (Given the lack of help at home, this mattered.) With the VBAC I had to be out in 24 hours (it was during that time when the insurance companies could get you out that quickly).

I was induced in the afternoon and was there overnight and the hospital midwives would not call the doctor. They waited till she got there at 6 AM, said "C-section," I breathed a sigh of relief, then they browbeat me into trying "one more time" for a VBAC (which also meant I couldn't get my tubes tied immediately, another thing I wanted done).

I specifically blame the insurance company for wanting to promote the cheapest birth experience for them. What is key is mom's having a reasonable *choice* for giving birth.

Well-Rounded Mama said...

Noelle, counter opinions, politely expressed, are welcome too. Thank you for sharing your viewpoint.

How long ago was this birth? For a while, doctors got on board with VBAC to the point where some hospitals actually REQUIRED them, including of women who weren't good candidates for VBAC or who weren't watched properly. They also began inducing VBACs a lot, just like they do all their other births.

Turns out that they created a number of uterine ruptures that way, who then sued and won lots of money. That's one reason why docs are so shy of VBACs these days.

The risks of VBACs have not changed over the years, but the way docs handled them did. In the beginning they were very cautious, never used artificial drugs to induce/augment, and were ready to intervene if there were any problems. Then they got careless, forced women into VBACs at times, induced VBACs like crazy (which greatly increases the risk for rupture), and didn't respond quickly enough to some emergencies.

The OBs are insurance companies (Kaiser in particular) are at fault for that, but the pendulum has swung FAR too much in the other direction now. Both extremes were ridiculous.

I agree with you. Women should have a reasonable CHOICE about VBAC or not. As long as they understand the risks/benefits of both choices thoroughly, I have no problem with either choice. But scaring, forcing, or bullying women into the doc's preferred choice? No way.

Anonymous said...

I'm pretty vocal about wanting women to have informed consent, and get rather heated when I hear of women who were not informed about the risks of procedures. But at the same time, there are plenty of women who very proudly announce that they are happy for their scheduled c/s or induction because it puts the doctor in control, or because then they don't have to worry about when they'll go into labor. While part of me feels (hopes) that with better information, women would let go of the convenience in favor of their health, I'm thinking it's safe to say that here in America plenty of people do willingly sacrifice their health for convenience. I don't think it's quite as simple as just blaming it all on the doctors. Not that it's all on women either, but there are many issues that need to be addressed on many levels. Doctors need reform, but we also need to fix childbirth classes, sex ed, and changing womens' attitudes about birth in general.

The Rebound Girl said...

So glad I kept reading this blog. I am just getting down blogging about how my OB has said c-section is mandatory because I've had a myomectomy. Well I wrote a letter of rejection on that decision and will happily move on if they force the issue.