Doctor Resigns From Hospital Because She Won't Do Unneeded C-Sections

Apparently her patients are happy and the births she works on have good health outcomes. Nonetheless, the hospital pressured her to more than double her rate of c-sections. LAmom has the story.

This entry posted in Abortion & reproductive rights, Whatever. Bookmark the permalink. 

182 Responses to Doctor Resigns From Hospital Because She Won't Do Unneeded C-Sections

  1. Noodles: It is a matter of points of view. I cannot picture anything described as pleasurable, beautiful and peaceful, and picture extreme physical pain and discomfort in it.

    Well, but I didn’t say anything about “extreme” physical pain or discomfort. I have had pain with my births, some more than others, but I wouldn’t describe it as extreme, in part because it wasn’t just pain– was part and parcel of something very beautiful– the birth of my children. Something long-awaited and anticipated and much desired. I think extreme pain more often accompanies births in hospitals, not only because of interventions, but also because of the way women must be removed from their familiar surroundings, are surrounded by strangers and strange procedures, and are made to be afraid ahead of time. Managing the pain of birth is mostly a matter of a woman being able to relax and feel safe and that’s not how it is for most women entering hospitals. They may feel “safe” in that they are in the hospital, but very fearful about what is going to happen to them, again, in large part because of what they have heard from other women.

    But think about it: sports involves both discomfort, sometimes extreme pain, but also really exultant, good, happy, positive feelings, right? A personal best in running or lifting, say, training for and finally running a marathon, climbing a mountain — all of these involve discomfort and extreme pain at different points, but are nevertheless, in the end, often beautiful, pleasurable and peaceful. I mean, they don’t call the moment of birth a “mountaintop experience” for nothing! Yes, there might have been pain and discomfort, heck, frostbite, extreme cold, lots of fear along the way but when you get to the top, whoa, it was *so* worth it, the pain and discomfort are just not the most important thing. And the same can be true of birth.

    As to your grandmother’s experience, agreed– there are times when moms have to be transported. Here in the U.S. midwives who birth at home always transport for twins or multiple births, largely because, as you say, twins often need extra attention from doctors that midwives aren’t qualified to provide.

    Heart

  2. Piny, I responded to all of that in posts 96 and 102. Try to keep up.

    Heart

  3. 103
    Tuomas says:

    Cheryl:

    Tuomas, one reason there is faith in medicine in your country might be that your country IS so progressive overall and its policies and laws so much more egalitarian and even favorable to women. That isn’t so in the U.S. and especially under Bush’s reign of terror, where women are losing their rights over their bodies steadily and daily, very scary.

    Fwiw, I’m not so much about most alternative medicine, either? I don’t really understand midwifery or home or natural birth to be about alternative medicine. I am glad hospitals and doctors are around for broken limbs and big, bleeding gashes, and some diseases, and yes, for the times when a birthing woman really does need help. I am not opposed, iow, to doctors and hospitals. I just think that far and away, they are not woman-friendly or woman-centered, particularly, again, in the U.S.

    Hmm. It seems to me that we have basically agreed on the issue all along, but it did take some straightening out misconceptions on both sides. With this, I don’t think it’s necessary for me to argue with you anymore. But, of course scandinavian health-care isn’t perfectly egalitarian either (if there would be a discussion on that, I’d be sure to throw in some studies and personal experiences from women here, but, off-topic and I’m lazy). :)

  4. 104
    piny says:

    [ftr, you're complaining that I didn't read a post that couldn't possibly have been available to read while I was writing. Moving on:]

    >>And I see here that it *was* Mythago who was called a sheep, complete with bleating noises, just not by her own midwife. I do have to take Mythago at her word … I was being facetious and smart-alecky when I said “don’t lie,”? … but for the record, in all of my years around midwives and doulas, I have not seen anything like this, and that’s a lot of years, 33. Mythago also appears to be someone who can take good care of herself, I’m pretty sure she stands up for herself quite well, and in view of all the eye-rolling, possibly the midwife got pissed off and said some things she should not have.>>

    Whoops, you’re right. I should have acknowledged that you re-read and took back the accusation that she was lying.

    Sorry.

    Instead, you switched to saying that (a) Mythago’s experience cannot possibly have any relation to the experiences of women as a whole, (b) she brought it on herself, what with the refusal to uncritically accept rhetoric she saw as inflammatory, inaccurate, and bullying, and (c) well, she should be able to withstand all the pressure and guilt-tripping, anyway.

    Yeah, that’s much better.

  5. 105
    mythago says:

    but very fearful about what is going to happen to them, again, in large part because of what they have heard from other women.

    I don’t know what y’all talked about when you were pregnant, but among every single woman I’ve talked to facing her first birth, the questions were not “What horrible things did they do to you in the hospital?” but “How bad did it HURT?!”

    The only women I’ve ever had ask me fearful questions like “do they not let you drink water?” or “do you have to lie on your back?” were those who had been told these things by some “natural birth” person.

    Cheryl can re-engage and say that she’s never heard those things in all her years, and I’m sure she hasn’t, because she’d sail right by them and not notice their bias neatly matches hers.

    But perhaps it would be more helpful to women to stop the scare tactics (doctors will make your birth awful!) and making us doubt pretty much *everything* you say when you give out bad, outdated or unscientific advice. When a midwife tells me that hospitals will always be mean to you and make you give birth on your back, I’m that much less likely to listen to anything she has to say about C-sections.

  6. 106
    Lee says:

    Cheryl, just very quickly because my dial-up connection is threatening to die, but at what point do you believe an MD should be involved in a birth? Not at home vs. in hospital, or vaginal vs. C-section, but in prenatal and postpartum care? Because I agree the woman should have control over what she would prefer to happen, but I also think that it is too easy to go the other way and rely solely on the midwife for the stuff that modern medicine does so well. Are most midwives not adverse to referrals if things don’t seem to be going well, like pre-eclympsia (sp?).

  7. And I suppose, Mythago, that the biases of the women you’re citing to don’t match your own. In fact, I published a magazine for 13 years, a big focus of which was conception, pregnancy, labor and delivery, birth, home birth, post partum, and a lot of what I know comes from the work I did then, including with columnists and freelance writers as well as just women who wrote to me, many, many. I heard from all sides, from your side as well as my side and all the sides around and outside of and in between.

    And nothing I’ve posted here has been outdated, unscientific or bad advice. I think a *lot* of what you (and others) have posted here has been all or some of the above in addition to wrong and wrong headed. And you’ve neatly sidestepped all sorts of stuff that has soundly refuted pretty much everything you’ve had to say. So anyway.

    Lee, in Washington — and I think this is the standard of care in the United States pretty generally, though I couldn’t swear to that — midwives who attend home births work closely with OBs who have agreed to step in if there is a need. I relied on my midwife to refer me when she felt she needed to. You agree at the beginning that if there are undiagnosed twins, persistent breach (meaning external version doesn’t turn the baby successfully), transverse lie (the baby lies across the cervix, neither head nor bottom down) or other unusual presentations (like a foot or hand presenting), or problems like placenta previa (the placenta threatens to deliver before the baby) or placenta abrutio (the placenta detaches from the wall of the uterus before birth, and a few other things, you will be transported to the hospital and one of the doctors who backs up your midwife will attend your birth alongside your midwife.

    Midwives don’t typically attend women who are actually high risk, not talking now about “high risk” as the medical establishment understands it but by the lights of midwives. But in general, diabetes, heart disease, high blood pressure, and a few other chronic health conditions would mean midwives would likely not agree to attend a woman’s birth. So those are not usually going to be problems for midwife attended births.

    Midwives handle late stage labor issues a little differently. They might be inclined to watch pre-eclampsia closely and not to send the woman off to the hospital as quickly as a doctor would. Broken amniotic sack is not cause for immediate induction and/or c-section. Women whose waters have broken can stay home and wait until labor begins without being induced. But where there are signs of real difficulty, midwives refer. One real benefit of midwife-attended home birth is, the midwives really knows her patients well, the patient she’s only her own midwife with rare exceptions, and hence, the midwife quickly picks up on whatever might be going wrong. Also, most midwives deliver all of their patients’ kids, so they become familiar with a woman’s own idiosyncratic patterns, i.e., some women’s pregnancies are 42 weeks, some 40, some are 38, some are 36 and that is normal for that woman (whereas doctors insist that pregnancy should be 40 weeks view anything earlier as premature and medicate-able or an emergency or as “late” requiring induction. Argh.

    So, the short of it is, yes, midwives rely on doctors for back-up. :-)

    It’s frustrating to me. Years and years ago in my magazine I published an article about how home birth became legal. One way it became legal was, doctors courageously defied hospitals and the medical establishment, generally. I published the sweetest story, maybe I have it at home and can post it, about a male doctor who was captured by home birth when he attended a birth on a nearby farm. From that time on, he attended home births, defying hospital rules. Over time, all of his peers and colleagues turned against him, dogged him, did all they could to undermine him, and finally he left being a doctor and became a carpenter. But he still attended home births. And his work and others in the organization he was part of persisted and eventually home birth became legal in his state.

    Here I see that it’s as though none of that happened. Once again we’ve got a progressive, woman-centered doctor dogged and harrassed for helping women to birth in the way they choose. We’ve just lost so much. Very discouraging.

    Heart

  8. Ugh, sorry for this insane paragraph– I just don’t have the time to edit as I should. Here it is cleaned up.

    ***
    One real benefit of midwife-attended home birth is, the midwife really knows her patients well, the patient sees only her own midwife, with rare exceptions, and hence, the midwife quickly picks up on whatever might be going wrong. Also, most midwives deliver all of their patients’ kids, so they become familiar with a woman’s own idiosyncratic patterns, i.e., some women’s pregnancies are 42 weeks, some 40, some are 38, some are 36 and that is normal for that woman (whereas doctors insist that pregnancy should be 40 weeks view and view anything earlier as premature and medicate-able or as an emergency or as “late”? requiring induction. Argh.)

    ***

    Heart

  9. Here is the link about a mother jailed for murder for refusing a c-section:

    http://www.usatoday.com/news/nation/2004-03-17-mother-charged_x.htm

    So you jail women who refuse c-sections, fire doctors who don’t do them enough, teach medical students to do c-sections in all sorts of situations, including when there are good alternatives, and then tell women they can come to the hospital and have the birth experience they choose. Right.

    Heart

  10. 110
    noodles says:

    Cheryl: I would and did describe it as extreme pain and discomfort. I can’t see how it can be considered ordinary pain and discomfort. No comparison with any sport makes sense to me. Definitely not climbing, which is about effort, not pain (unless something goes bad).

    You picked an interesting analogy there, it so exemplifies how our respective views of childbirth differ. Both in terms of physical pain involved – and we’re never going to agree on that! the more you talk about it the more idyllic and unrealistic it sounds to me – and most of all in terms of the idea of childbirth as achievement.

    Say I didn’t manage to climb a peak I’d set out to climb, it would be natural for me to feel it was a failure, and that I could have done something this way instead of that way. I wouldn’t need to beat myself over it, but I could still think, damn, well I’ll train harder/plan better/wait for better weather conditions next time. OTOH, climbing is not a means to another end; it is the end, in itself. The whole thing is about the experience. It lasts hours, days. The journey is itself the goal. Not just getting to the top. Otherwise no one would climb and we’d all just take helicopters.

    Wheareas for a pregnant woman who may even start out wanting a home birth and then either has to or chooses to go to hospital (c-section or not), I believe it would be truly horrible for her to feel that she has “failed” in not having a natural birth (as in the example someone above was making). I cannot see it as a kind of achievement. I personally don’t share that kind of focus on the act of childbirth itself because I honestly do not think it is that important in itself. I see it simply as a means to an end. To me the point is not the delivery as ‘experience’, but the wellbeing of the woman and of the child. So I really don’t think it makes any difference whatsoever how it happens and where, c-section, vaginal birth, hospital, home, whatever, who cares as long as the kid and the woman are fine and suffer as least as possible?

    If I can plan it, if I feel and know that drugs and doctors are going to ease my peace of mind, then you bet I want drugs and doctors, and no amount of eulogising on the beauty of home birth is gonna cut it. I don’t care if someone else thinks I’m giving up on some peak that I should climb, it’s my decision to take, not theirs, and pregnant women could really do with less “this is the right way to do it” advice from all sides. It can all get a bit too much.

    Some will feel more at ease at home, some will feel more at ease in hospitals. Some will want epidurals and drugs, some will want to do without. Some will want a vaginal birth unless absolutely impossible, some will want a c-section at all costs. What should matter, I believe, is that each woman is properly informed in realistic terms so that they can take the decision that makes them feel at ease on their own terms, not some supposed ideal, and that everything goes fine (a lot of which is of course like anything in life beyond the control of both doctors, midwives, partners etc. and the woman herself).

    As to your grandmother’s experience, agreed”“ there are times when moms have to be transported. Here in the U.S. midwives who birth at home always transport for twins or multiple births, largely because, as you say, twins often need extra attention from doctors that midwives aren’t qualified to provide.

    Yeah, but that wasn’t my point really. That works the same in Europe too, today, it’s a big step ahead from my grandma’s times – that was the point. The progress and increased availability of medical care even in (formerly) poorer rural areas. That medical care has allowed more children to survive and more women to go through childbirth with less risks and less pain. I don’t believe that can be denied.

    Can I just ask two quick questions, you don’t have to reply but I’m genuinely curious:
    - When you talk of home births, do you mean completely drug-free?
    - Do you think women who opt for c-sections because they want to avoid stretching and tearing and the consequences on their sex life are also just being scared by horror stories (like you said of the ones who opt for c-sections to avoid the pain)?

  11. 111
    mythago says:

    .And nothing I’ve posted here has been outdated, unscientific or bad advice. I think a *lot* of what you (and others) have posted here has been all or some of the above in addition to wrong and wrong headed. And you’ve neatly sidestepped all sorts of stuff that has soundly refuted pretty much everything you’ve had to say

    It must be nice to live in a world where “I say so” is a refutation of all other facts and everyone else’s contrary experience. It is precisely attitudes like yours that led me to back away from the ‘alternative birth’ movement.

    My ‘biases’ are towards actual facts instead of scare tactics, and focusing on what is really best for the woman–not on presenting an idealized birth experience and insisting it’s one size fits all. Not to mention candy-coating any discomfort or pain in childbirth and palming it off on ‘fear’ and ‘doctors,’ as though any woman who doesn’t have a Venus of Willendorf experience has nobody but herself and her choice of birthing assistant to blame for it.

    And I am always amazed that some advocates of alternative birth really dis themselves: they don’t see, or don’t care to see, the absolutely profound effect they have had on the medical establishment. Do you think that hospitals had birthing centers 40 years ago? That women were encouraged to walk during birth, to have their partners present, or to keep their children in their room instead of in a nursery? That episiotomies are no longer considered safer than tearing? All that happened because women challenged doctors and made them listen.

    But I guess it’s harder to scare women with horror stories about what the bad doctors will do to you if you admit that, yeah, we taught those doctors a few things and made them do things better.

  12. 112
    noodles says:

    Years and years ago in my magazine I published an article about how home birth became legal. One way it became legal was, doctors courageously defied hospitals and the medical establishment, generally.

    Now I’m going to sound dumb but I gotta ask: what do you mean “make legal”? It was illegal? Seriously? Illegal for women to have births at home (which sounds insane) or for doctors to attend (even more insane)?

    I’d never heard of anything like that. How did it work?

  13. I not only SEE the “absolutely profound effect” advocates of alternative birth had on the medical establishment, Mythago, I *participated* in creating those effects, in all the ways you list and several more. And I am proud of that and talk about it all the time. But what I know *because* of my participation is that we can *lose* what we’ve gained, what we’ve won. And what I also know is that not enough has changed. And that there are people who don’t care about change, who would turn back the clock if they could and who are actively trying to do that. And what I also know — firsthand, not scare tactics, I have lived this and I have witnessed it with my friends, daughters-in-law in the births of my grandchildren, and others — is that women are STILL mistreated and violated during their births, that they are STILL not having the birth experiences they would like to have. We have barely scratched the surface of that part of this discussion, and I don’t have time to get into it. But in all sorts of ways, doctors do indeed intervene in ways which *cause* pain for women or *worsen* their pain. Nobody wants to talk about that. There is this idea that doctors have spared you, or other women, all of this pain, or that c-sections spare women pain or problems with their bodies, when in fact, that is just not true, for so many reasons.

    Noodles, my mountain example was not about “achievement,” it was about the way pain and discomfort can coexist with pleasure and peace and wonderful experiences, about the way people who are working towards something, looking forward to it, often take a philosophical perspective towards the pain that might be involved. You may not think mountain climbers experience pain– I think that they do. And discomfort as well. And I also think that just as the journey is integral to the experience of getting to the top of the mountain, the same is true, for many women, as to pregnancy and birth. There are some women who love being pregnant but hate being moms. Or who love giving birth but hate being pregnant. Or who hate giving birth and being pregnant but love motherhood. So some women have babies as much for the journey of the pregnancy as for having the child at the end of it all. And there’s tons I could say about that. Well, there’s so, so much here that is important, so just know that for everything I write, I’m leaving out reams of stuff that I don’t have time to write. I mean, I am a gardener, and I experience plenty of pain gardening– I get sore muscles, I brush up against nettles, I scratch my hands and arms and legs, I get sunburned, I get exhausted, but when I’m done, I’m sure not thinking about all of that, I’m enjoying my garden. I do really think that pain and discomfort are part and parcel of many of the things people do which they very much value, find beautiful, peaceful and so on.

    Despite the villainizing of advocates for natural and home birth which is ongoing in this thread — and I think it really sucks and should stop — advocates for home and natural birth do not, ime, suggest that if it doesn’t happen, that equals “failure.” A woman whose heart is dead set on a certain experience who doesn’t have that experience may feel as though she has failed, but that isn’t because of some trip home or natural birthing mothers have laid on her, that’s because she has suffered a disappointment and wishes things had gone better. Home and natural birthing people IME faithfully warn women that things don’t always go as planned, that it isn’t the end of the world if they don’t, they urge women to create Plans A, B and C so that they *don’t* get their hearts set on something that might not be possible, and in my experience, they offer tons of wise and seasoned encouragement that *includes* the ongoing reminder that we can never predict how these things will go, and that no birthing mom is ever a failure.

    I don’t agree that medical care has allowed more women to go through birth without pain. I just don’t. I think medical care has improved infant mortality and maternal mortality in some ways, for some women and their kids, but has also caused lots of damage to women and their kids as well. Some of what appears to be improvements in infant and maternal mortality has to do do with the availability of birth control and abortion and with the fact that women actually *can* decide whether or not to become pregnant now, and how and when. In your grandmother’s day women and babies became sick or died more often in part because women didn’t have that choice– there was no birth control or ineffective birth control, the babies just came, whether the mom was healthy or not, no matter what the circumstances were, in the dead of winter when babies were born into the cold and couldn’t be kept warm enough, all sorts of things.

    You think I have idealized birth, but you know what, I have given birth 11 times. I have attended friends’ a number of friends’ home births as well. I know very well what giving birth is all about. I asked this before and you didn’t answer, but how many births have you attended? Have you ever given birth yourself?

    I think you have accepted the medicalized version of birth, this idea that birth is like a sickness to “treat” and a medical emergency to be survived and endured rather than a natural process — sorry, but pregnancy and birth *are* a natural, physiological processes, they are not illnesses, women’s bodies are made for them — and if that is your view, then of *course* you are going to think highly of all sorts of interventions. But those interventions *cost* women. C-sections result in lengthy and painful post-partum periods requiring lots of bed rest. A c-section is major surgery with all of the risks of major surgery as follows (and more) (and this is *information* , though Mythago, you probably will call it “scare tactics”):

    ***

    Risks for the Baby

    Premature birth. If the due date was not accurately calculated, the baby could be delivered too early.

    Breathing problems. Babies born by cesarean are more likely to develop breathing problems such as transient tachypnea (abnormally fast breathing during the first few days after birth).

    Low Apgar scores. Babies born by cesarean sometimes have low Apgar scores. The low score can be an effect of the anesthesia and cesarean birth, or the baby may have been in distress to begin with. Or perhaps the baby was not stimulated as he or she would have been by vaginal birth.

    Fetal injury. Although rare, the surgeon can accidentally nick the baby while making the uterine incision.

    Risks for the Mother

    Infection. The uterus or nearby pelvic organs, such as the bladder or kidneys, can become infected.

    Increased blood loss. Blood loss on the average is about twice as much with cesarean birth as with vaginal birth. However, blood transfusions are rarely needed during a cesarean.

    Decreased bowel function. The bowel sometimes slows down for several days after surgery, resulting in distention, bloating and discomfort.

    Respiratory complications. General anesthesia can sometimes lead to pneumonia.

    Longer hospital stay and recovery time. Three to five days in the hospital is the common length of stay, whereas it is less than one to three days for a vaginal birth.

    Reactions to anesthesia. The mother’s health could be endangered by unexpected responses (such as blood pressure that drops quickly) to anesthesia or other medications during the surgery.

    Risk of additional surgeries. For example, hysterectomy, bladder repair, etc.

    You can get blood clots in the legs, pelvic organs or lungs.

    Your bowel or bladder can be injured.

    http://www.pregnancy-info.net/c-section_complications.html

    Medications to relieve pain during labor often don’t. Often, they are given late in the labor process when most of the hard work has already been done by the mother. Sometimes they have to be withheld because they slow down labor too much (usually because they were given too early, meaning a longer overall labor). Usually, I’d say, not enough medication is given to actually eliminate the pain of labor and birth. The mother still feels plenty. And I could say *so* much more, but I just don’t have time.

    Noodles: – When you talk of home births, do you mean completely drug-free?

    Yes. Midwives can’t prescribe drugs, though they do bring methergen in case of hemorrhage after birth (stops it immediately) and they bring topical anesthetic in case there is tearing (which there rarely is; midwives are skilled at helping women to deliver without tearing.)

    Noodles: – Do you think women who opt for c-sections because they want to avoid stretching and tearing and the consequences on their sex life are also just being scared by horror stories (like you said of the ones who opt for c-sections to avoid the pain)?

    Yes. Because (1) there is no need for a woman to tear while birthing, as I’ve already said– just takes an attentive midwife; it is induction of labor and the way it intensifies contractions which is more likely to cause tearing; (2) I don’t get what you mean by “stretching.” Women stretch to give birth and then they return to their pre-stretched condition. Women who do not return to their pre-stretched condition usually don’t because they tore (having to do with induction or attendants not attending properly or thoughtfully or carefully) or because their babies were birthed way too quickly (goes along with tearing) which is most often a function,*again* of having been induced. Tearing and stretching are *not* usually part of births attended by skilled midwives and so there is no reason to be concerned about consequences on the sex life. (And beyond that, for what it’s worth, not all women have heterosexual sex or the kind of sex that being “stretched out” would problematize.)

    Heart

  14. Now I’m going to sound dumb but I gotta ask: what do you mean “make legal”?? It was illegal? Seriously? Illegal for women to have births at home (which sounds insane) or for doctors to attend (even more insane)?

    I’d never heard of anything like that. How did it work?

    Yes, it was straight up illegal for women to birth except in hospitals. And even after it was made legal, it remained unavailable to most women because insurance companies wouldn’t cover the cost of the births unless they occurred in the hospital.

    Heart

  15. 115
    mythago says:

    There is this idea that doctors have spared you, or other women, all of this pain

    If you can tell me where I said such a thing, I’ll give you a dollar.

    I don’t think doctors are gods. I don’t think midwives are goddesses, either. Sorry.

  16. 116
    Barbara says:

    noodles, it’s still illegal in some states for some health professionals to attend births at home.

    As for everyone getting what they want, well, it’s nice to think that there is a happy medium — to have the possibility of required intervention if needed in a setting that halfway feels like home, with supportive attendants. Very few in a hospital setting feel compelled to do that for you. They are just too focused on their own needs, schedules, and so on. When did I finally realize this? Maybe it was when the l&d nurse was only coming in to see me in order to yell at me for screwing up the fetal monitor or maybe it was when the doctor refused to let me squat anymore while pushing, for his own convenience, or maybe it was when I realized that I had been mutilated by forceps and episiotomy that I probably never would have needed if I hadn’t been pressured into an induction. But, hey, I’ve got the most delicate c-section scar you can imagine (even my new OB commented on what good work it was).

    As for the risk of sexual dysfunction — first, the pelvic floor gets weakened through pregnancy itself, and a c-section doesn’t change that, and can cause its own host of related issues (prolapse, weakened uterus). Second, if I am an example, the damage was clearly caused by the intervention of episiotomy and nothing else. Most natural tears heal well and don’t cause scarring, unlike mine. Third, I hope you don’t assume that vaginal expansion during the birthing process inevitably causes reduced sexual function. It doesn’t.

    Your view that how one gives birth should be unimportant is your view. I respect it, but I don’t share it for myself. I do care. I think Cheryl is overstating the benefit of a home birth, but women shouldn’t have to give birth at home in order for their their needs to be met, their wishes respected, and their feelings validated.

  17. 117
    mythago says:

    but women shouldn’t have to give birth at home in order for their their needs to be met, their wishes respected, and their feelings validated

    I couldn’t agree more.

    I will, however, tell you that part of the doctors’ malpractice fears is that they will be punished for agreeing with the patient.

    “But she didn’t want a C-section.”

    “You’re the DOCTOR. You’re the expert. She was a laboring woman in pain who didn’t have your medical knowledge. How could you go along with her decision instead of doing what you knew to be the medically-appropriate thing?

  18. 118
    noodles says:

    I think you have accepted the medicalized version of birth, this idea that birth is like a sickness to “treat”? and a medical emergency to be survived and endured rather than a natural process … sorry, but pregnancy and birth *are* a natural, physiological processes, they are not illnesses, women’s bodies are made for them … and if that is your view, then of *course* you are going to think highly of all sorts of interventions.

    Now that is a straw man, Cheryl. “If that is your view” – no it isn’t. I didn’t say or imply that.

    Like I said, I am not interested in advocating any “right” way for anybody. I’m for freedom of choice on everything. I respect all individual choices – that doesn’t mean I have to embrace them personally for *myself*, to respect them when *others* take them. Precisely because women’s bodies are made for them. Not for doctors, not for midwives, not for natural birth advocates, either. Each woman’s informed choice is her own and she has a right not to be pressured or scared or judged, either way, from any side. I guess we all agree there.

    What I have trouble with is preaching, which seems to be what you’re doing here. It comes across very strongly that way, Cheryl.

    Just because I don’t personally share *your* notion of giving birth as some beautiful pleasant experience where pain is negligible, you have to tell me I have been brainwashed into “accepting the medicalised version of birth”. That’s a bit of a Tom Cruise thing to say, you know, him and his powerful antidepressant vitamins…

    (NB: absolutely no childbirth-depression comparisons intended, nor between natural childbirth advocates and Scientologists, not even close. Just between that black/white binary kind of reasoning. Like, to someone vehemently committed to convincing others that drugs are bad, all you need to do to become a supporter of the most business-driven and prescription-happy form of psychiatry is to dare suggest that perhaps sometimes pills are useful if you’re suicidal. God forbid!! Have this orange juice instead, woman!)

    Now, I am glad you had your children without any help from chemistry or surgery and that you were happy with it. I did not say you were a fool for doing that. How could I? I am not you, I cannot and do not feel any desire to tell you what you should do. I also did not say that no one should do what you did. I am only speaking my own mind on my own choices, what I consider good for me, and might not be good for someone else, because I do not believe there is a universal “best” here.

    For myself, I do appreciate the options of avoiding or reducing pain, as well as risks and complications.

    I do not appreciate people considering my own capacity to choose for myself impaired because of making a different choice than they did.

    The pain is what can be reduced by drugs. Pain itself doesn’t make childbirth an illness, no. But natural childbirth pain doesn’t make that pain any less painful.

    Between “childbirth is an illness” (which I did not say or imply even remotely and obviously do not believe) and “childbirth is a pleasant peaceful experience whose pain is secondary and comparable to that you experience in gardening”, there’s a whole range of things that are actually within reality. My idea of reality at least. Everything is relative.

    What isn’t relative but fact is that women who have access to modern health care are having less trouble with pregnancy and childbirth than women who didn’t, in the past, or still don’t, today. Globally. Less children die as a result of better health care. Less malnourished children are born when mothers have access to modern health care. No one needs to be an apologist of the kind of problems you criticise in the way a particular medical system may work, to acknowledge that.

  19. 119
    noodles says:

    Your view that how one gives birth should be unimportant is your view. I respect it, but I don’t share it for myself. I do care. I think Cheryl is overstating the benefit of a home birth, but women shouldn’t have to give birth at home in order for their their needs to be met, their wishes respected, and their feelings validated.

    Barbara, I absolutely agree, you summed up my point in a nutshell.

    And yes, that was my view only, of course, I appreciate you respecting it!
    (anyway that “the how is not important” was above all in relation to the wellbeing of mother and child. In itself, it is of course important to make the choice one feels comfortable with, but in the end it really doesn’t *define* you as a mother and it doesn’t matter as much as baby and mother being healthy).

    I am sorry to hear you had that kind of nasty experiences. I can even barely picture that kind of thing.

    I hope you don’t assume that vaginal expansion during the birthing process inevitably causes reduced sexual function. It doesn’t.

    No, but I know women who had trouble getting back into shape, so to speak, especially after multiple births. It never went back to the way it was before.

  20. 120
    noodles says:

    Cheryl, thanks for the replies to the two questions – and on the illegal thing too, I really had no idea it used to be like that.
    On the sex thing again – well… I imagined you’d consider that concern unnecessary and paranoid. But it’s not necessarily true that for women who do not “return to their pre-stretched condition” it has to be because of particular complications or effects of hospital intervention that skilled midwives can avoid. For one thing, the baby can simply be big and take longer to deliver. There is no 100% returning to pre-birth conditions anyway, is it?

    And beyond that, for what it’s worth, not all women have heterosexual sex or the kind of sex that being “stretched out”? would problematize.

    Well yes, but knowing that is no use to women who do have that concern in the first place. Even heterosexual women do not only have vaginal sex, still, you know, it’s nice to know it’s there and hasn’t turned into the Channel Tunnel to steal a certain Julie’s words.

  21. 121
    Lee says:

    Cheryl, thanks for answering my question. Since both of my pregnancies were considered high-risk, I had a high degree of medical monitoring and never really considered home births. I asked because the media usually only covers the awful outcomes. One of my former neighbors had 4 kids, all at home, and her mother, who was a nurse-practitioner, was also her midwife. However, within hours of the birth, she always went to the hospital to get the baby and herself checked out and make sure the postpartum stuff all went OK. On the other hand, my friend’s sister-in-law had a midwife who I think must have been unlicensed or something, because despite some clear warning signs that things were not going well, she never saw a doctor and the baby died within a week of birth. (I think this one was written up in the Chicago Tribune.)

  22. 122
    Barbara says:

    noodles, unfortunately, I don’t think my experience was atypical. Even as of two or three years ago, something like 70% of first-time mothers were still being subjected to episiotomies in many parts of the country. That’s why ACOG and others keep publishing studies, because the failure to change this practice is truly inexplicable.

    I have no doubt even a “normal” birth has complications. But so does a c-section, and the studies are pretty much consistent that the complications of the latter outstrip the incidence of complications for the former.

    I could go on and on why the typical birth experience is harder on women physically than it needs to be, but with respect to damage to the vagina there are two things that are key: failure to do Kegel exercises and otherwise prepare the perineum for the experience, and the insistence in many settings that the pushing phase should be conducted with a level of exertion that is normally reserved for olympic events (i.e., forced, fast paced breathing accompanied by active rather than “instinctive” pushing, the latter being exacerbated by epidurals and forced lithotomy positioning that requires the woman to work against gravity).

  23. 123
    Doktor says:

    Arrgghhhh… where to start?

    “First of all, induced labors are really, really painful labors, far more painful than labors which come on in their own good time.”?

    This is not correct. Studies have shown that women who are induced are no more likely to request an epidural than women who enter the hospital with spontaneous labor.

    “Second of all, induced labors often go on and on and on and on interminably, because how much medicine to be given to any individual woman is always a crap shoot, so the doctors give not so much and the labor goes on and on, and the woman gets exhausted, and then either she is begging for a c-section because of weariness and pain or she is bumping up against hospital rules about duration of labor.”?

    This is not correct. You need to understand that there are two types of induction. The first type of induction is one where there is a medical need such as hypertension or preeclampsia. In these inductions, it is imperative for the doctor to proceed with the induction regardless of the state of the cervix. This is when prolongation of the pregnancy outweighs the risk of c-section from a failed induction.

    The second type of induction is the “elective induction”. Studies have shown that in a private hospital (not a teaching hospital) that women who are electively induced have a lower c-section rate than if they in turn labor spontaneously. Also, labor is 30% shorter in duration.

    “When the reality is, you know what? Birth can, does and most often will occur peacefully and beautifully and pleasurably as a continuation of the process which began right where the birth takes place: in a woman’s own bed, in her own room, in her own home.”?

    The key word is “most often”. For every story that you can quote about a horrific hospital delivery….. I can tell you as story of women brought into the hospital after laboring for three days at home with a midwife and the baby dies in the NICU due to sepsis. Or a midwife who allows a patient to push for six hours straight and then brings the patient the hospital where the doctor on call has to perform an emergency c-section for fetal distress. And then there are the cases of placenta abruption or cord prolapse which are brought in by ambulance only to find the infant stillbirth on arrival.

    “The c-section rate went up way before the so-called “malpractice crisis.”? That too is a bogus explanation.”?

    There is a direct correlation between the c-section rate in United States and the number of malpractice suits.

    For example, last night a doctor was involved in a difficult delivery and the family was insistent on a vaginal delivery. This was a normal, natural non-induced labor. The baby was in a persistent occiput transverse position. The doctor offered a c-section and the patient\family refused. After three hours of pushing, the baby was low enough that the doctor could rotate the head using forceps and then finish the delivery with a vacuum extractor. The baby weighed 9 lbs. 6 oz. The family was very happy.

    Now, if this baby develops any type of seizure activity, developmental delay or any other type of problems that might be related to the delivery, for the next 18 years, there will be a line of attorneys drooling at the opportunity to sue this physician.
    “She (the doctor) was wrong to allow the patient to push for over two hours”
    “She should have known the baby was too big”
    “The doctor should never do a combined forceps/vacuum extractor delivery”?
    …. and on and on and on……

    “The majority of studies report that in the rare event of a uterine rupture, if the labor was carefully monitored, the birth attendant was trained to attend VBAC births, and if the medical response was rapid, mothers and babies do well. The focus should be on improving the quality of care for women who want a VBAC, not on discouraging them because of negative outcomes publicized in high profile medical malpractice law suits.”?
    This is very easy for someone to say if they are not the ones that are being sued. In my state, the largest insurer of physicians has recently stated that if the doctor is sued for a VBAC delivery it will not be covered. The other insurance company covering physicians state that for them to defend a bad VBAC delivery the following must have occurred.
    1. There had to have been in-house anesthesia dedicated to the patient for the duration of her labor. This means an anesthesiologist would have to be on the unit, with no other duties, other than being available one patient.
    2. There had to have been an in-house OR team dedicated to the patient for the duration of her labor.
    3. There had to have been a dedicated OR suite setup and dedicated to the patient for the duration of her labor.
    4. There had to have been an obstetrician in-house and immediately available to the patient for the duration of her labor.
    Then if all of these things occurred and there was a bad outcome, the insurance company would defend the doctor. I used to love doing VBAC’s and never had a bad outcome although I did observe bad outcomes of other physicians. It finally came down to the fact that the risk was too much for me to accept. Every time I did a VBAC delivery, I was putting at risk everything that I owned and had saved for the future of my family. VBAC’s became a thing of the past when they became the 3rd most common reason for a malpractice lawsuit. As physicians, most of us believe the patient should be able to accept whichever risks they feel appropriate. This is America and people have the right to make own decisions. The problem comes in the doctor gets sued because the patient made the wrong decision.
    “The hospital threatened to watch her number of *collarbone fractures*, a common event in vaginal deliveries, that almost always requires no treatment, and that people don’t sue over.”?
    This is wrong. A fractured clavicle is not a common event (4 per 1000 deliveries in a teaching hospital).
    “The real problem is that parents with injured and sick infants have no safety net to fall back on to obtain expensive care, UNLESS they can prove that the doctor or hospital is at fault.”?
    This is a very true statement because all malpractice is about the money. A recent study in West Virginia asked the question, “If you ever were to become wealthy, how would it occur?” The answers were 1. Through inheritance 2. Win the lottery 3. Win a malpractice case.

    “?Low birth weights are a huge concern and associated with high infant mortality. But *higher* birth weights are a GOOD thing, which is what makes that hospital’s letter so incredible. The goal with pregnant women is always to ensure that they birth when their babies are big enough.”?
    Higher birth rates are a good thing if you’re comparing a 4 pound baby with a 7 pound baby. It is not a good thing if you’re comparing a 7 pound baby with a 9 pound baby. A 9 pound baby is not healthier than a 7 pound baby… it is just a more difficult delivery for the mother and baby with an increased risk of trauma to the mother’s birth canal and trauma to the baby.
    “I have two friends who have birthed soldier dystocia babies at home with midwives … one weighing nearly 12 pounds … and there was no problem.”?
    Defending this statement is like saying my four-year-old child once ran across a busy street and made it safety to the other side so therefore it is safe for all four-year old children to cross a busy street. Anecdotal stories mean nothing.
    “Midwives are trained to deliver babies with shoulder dystocia whereas MD’s usually are NOT.”?
    Give me a break! This statement is just is just silly.

  24. Nah, you give me a break, Doc. Anecdotal stories mean nothing to YOU. But they mean everything to women because as against patriarchal medicine, and those trained under male supremacy, and those whose biggest concern is being sued, those are the stories that matter to US. Those “anecdotal stories” represent *our lives*, they are the stories patriarchal medicine *does not publish* and does not *value*.

    And I think what you’ve posted there is damn silly– MOST of it. And wrong. And for every “study” you cite to I could do you one better. And I could refute, at length, everything you’ve said up there. I might if I decide it’s worth it to me; for now, you’ve represented patriarchal medicine well, as you’ve been trained to do. Which doesn’t mean that anything you have had to say is true, or especially, that any of it reflects women’s reality.

    Heart

  25. 125
    alsis39 says:

    Not to pick on Doktor too much, but not everyone agrees with him/her that it’s fear of malpractice that’s most likely to prevent obstetricians from providing women the full spectrum of choices they deserve when birthing :

    http://www.citizen.org/pressroom/release.cfm?ID=1805

    *
    A University of California-San Francisco (UCSF) study of New York doctors found that the main reason doctors cease providing obstetrics care is advancing age.UCSF researchers studied the effect of liability premiums on doctors’ behavior, the only such study trying to show such causation that we know of. The study, of New York state physicians during the mid-1980s insurance crisis, found no association between malpractice premiums and doctors’ decisions to quit.[5] The study did find that the decrease in doctors practicing obstetrics was associated with the length of time since receiving a medical license in New York. This relationship “very likely represents the phenomenon of physicians retiring from practice or curtailing obstetrics as they age.”?[6]

    *
    Obstetricians frequently cut back their practice as they advance in years.As doctors become more financially secure, and as the child-bearing years of their patient population pass, many obstetricians give up the demands of delivering babies in favor of concentrating on the gynecological needs of their patients. For example, in 2000, 18.7 percent of Georgia’s OB/GYNs were between 40 and 44 years old, but only 11.1 percent of OB/GYNs were 50-54 years old ““ a decrease of about 40 percent.[7]

    *
    A North Carolina survey found that the main reasons doctors decreased their obstetrics patients were unrelated to fear of lawsuits.The authors note that while some providers whose obstetrical patient volume had decreased cited fear of lawsuits as a factor, “…[T]his was not the overwhelming reason for stopping or planning to stop deliveries.The strain and inconvenience of the practice and problems with burnout also were issues.”?[8]

  26. 126
    Doktor says:

    Since more women are in medical school than men and at this point about 30% of all Ob’s are women….. who will you scapegoat when you don’t have the “patriarchal medicine” to go after…. the matriarchal medicne?

  27. 127
    mythago says:

    alsis, that doesn’t really address the C-sections out of a fear of malpractice issue.

    Oh, dear, Doktor, you really had me supporting you up until that last post. And I’m a lawyer.

    Which doesn’t mean that anything you have had to say is true, or especially, that any of it reflects women’s reality.

    I might say the same to you, Cheryl. If anecdotes are truth, then it’s ludicrous of you to say that those supporting your point of view are clearly true but any women whose experience is different is merely brainwashed by the patriarchal medical establishment.

  28. 128
    mousehounde says:

    Actually I think it is fear of malpractice suits that make doctors choose C-sections.
    In South Florida:
    The fear that drives them to perform c-sections on four out of 10 mothers is delivering a baby with brain damage. Obstetricians once believed that sparing babies the trauma of passing through the birth canal would drastically cut the rate of cerebral palsy and mental retardation. More recent studies have proven that brain disorders are rarely related to childbirth, and that the surge in cesarean deliveries has not diminished the incidence of cerebral palsy.

    Obstetricians know of the studies, yet they also know how easily jurors can be swayed by testimony from “medical experts” who’ll say that if the doctor had only done a c-section, the baby would have been fine.
    From the ACOG

    # According to the Delta Democrat Times, 324 Mississippi physicians stopped delivering babies in the last decade. Only 10% of family physicians deliver babies.
    # In the ACOG practice change survey, 86.2% of responding Nevada ob-gyns indicated that they have changed their practices, with 27.59% dropping obstetrics.
    # As of October 2002, according to Clark County, Nevada OB-GYN Society, only 80 private practice physicians, 14 HMO physicians, and 12 residents are doing deliveries, totaling 106 doctors. With an estimated 23,000 deliveries expected in Nevada in 2003, each physician will have to deliver 216 babies.
    # According to the Star-Ledger, “An obstetrician with a good history — maybe just one dismissed lawsuit — can expect to pay about $45,000 for $1 million in coverage. Rates rise if the physician faces several lawsuits, regardless of whether the physician has been found liable in those cases.”
    # The president of the New Jersey Hospital Association says that rising medical liability premiums are a “wake-up call” that the state may lose doctors. Hospital premiums have risen 250% over the last three years, and 65% of facilities report that they are losing physicians due to liability insurance costs.
    # In the ACOG practice change survey, 67% of responding New York ob-gyns indicated that they have changed their practices, with 19.28% dropping obstetrics.
    # In 2000, there was a total of $633 million in medical liability payouts in New York State, far and away the highest in the country, and 80% more than the state with the second highest total.
    # One-quarter of respondents to an informal ACOG poll of Pennsylvania ob-gyns say they have stopped or are planning to stop the practice of obstetrics. 80% of medical students who come to the state for a world-class education choose to practice elsewhere, according to the Pennsylvania State Medical Society.
    # On April 24, 2002, Methodist Hospital in South Philadelphia announced that it would stop delivering babies due to the rising costs of medical liability insurance. The labor and delivery ward closed on June 30, leaving that area of the city without a maternity ward. Methodist Hospital has been delivering babies since its founding in 1892.

    So, when there is a shortage of doctors to sue, will midwives become the next targets? Because nothing bad ever just happens, there has to be someone to take the blame and pay the bills.

    Midwives earn on average $41,500 to $52,000 annually, topping out at $65,000, according to the University of Missouri Career Center–less than half of the $133,450 earned by obstetricians, according to the Bureau of Labor Statistics. The insurance plan endorsed by the American College of Nurse-Midwives costs from $7,000 to $32,000 per year, depending on experience, education and location. New York, and Florida are two of the priciest states to practice.

    The doctors and hospitals go out of business because they can’t afford the insurance. Next it will be midwives who can’t afford to practice.

    Doctors are not evil people out to cause women pain. They are just folks trying to work within a system that makes it hard or impossible for them to do their jobs in as good a fashion as they would like. Midwives are not saintly creatures who magically make child birth pain free and safe.

    The problem isn’t the medical community, it is the folks who sue right and left with some strange idea that it’s free money they deserve because something bad happened. Sometimes bad things just happen. Sometimes it is no ones fault.

  29. 129
    mythago says:

    Obstetricians know of the studies, yet they also know how easily jurors can be swayed by testimony from “medical experts”? who’ll say that if the doctor had only done a c-section, the baby would have been fine.

    Interesting use of quotes, given that those ‘medical experts’ have to be, um, medical experts. Not that doctors themselves would hire their own medical experts to contradict that, either.

    The medical malpractice crisis isn’t anything like doctors believe it is–but they’re paranoid, and they’re convinced they’d get sued, and it only takes one time in court to convince them that it’s better to cut Mom open than pay her millions of dollars later.

    By the way, the line about how frivolous lawsuits are lottery tickets driving up insurance rates is crap. Insurance companies are very happy you believe it, but as a plaintiff’s lawyer, I get pretty fucking tired of telling some people that they should accept reasonable settlements–because they’ve heard all these stories about “an injury is a lottery ticket” and they want to know where their million bucks went.

  30. 130
    alsis39 says:

    The problem isn’t the medical community, it is the folks who sue right and left with some strange idea that it’s free money they deserve because something bad happened. Sometimes bad things just happen. Sometimes it is no ones fault.

    Actually, if you believe P.C., the problem is neither of these things. It’s the insurance companies:

    http://www.citizen.org/congress/civjus/medmal/articles.cfm?ID=8101

    “Suing right and left,” isn’t actually all that common. Hikes in malpractice rates have more to do with insurers passing on costs to doctors to make up for tanked investments in the aftermath of the internet bubble bursting– And less to do with some supposed gigantic upsurge in patients suing by the truckload.

    It’s interesting that this impression you give, Mythago, thrives all over the U.S., amongst citizens of many political stripes. As with the brouhaha about the supposed imminent bankruptcy of Social Security, “Welfare Queens,” and so on, it points out the degree to which the center political discourse regarding social issues has continued to shift more and more to the right, toward favoritism to corporations and against that of the individual.

    I was unable to find any direct corolation between the prevalence of Caesarians and fear of malpractice at P.C. (Though I didn’t have unlimited time to search, either.) But I don’t think it’s out of the question that Caesarians, like other medical procedures, may simply be serving as a convenient excuse for insurers to jerk around both doctors and patients. If you’re curious, here is one of the press releases that P.C. issued regarding Caesarians:

    http://www.citizen.org/publications/release.cfm?ID=6930

  31. 131
    alsis39 says:

    My comments should have been adressed to mousehounde, not Mythago. My apologies. :o

  32. Me, Cheryl: Which doesn’t mean that anything you have had to say is true, or especially, that any of it reflects women’s reality.

    Mythago: I might say the same to you, Cheryl. If anecdotes are truth, then it’s ludicrous of you to say that those supporting your point of view are clearly true but any women whose experience is different is merely brainwashed by the patriarchal medical establishment.

    Uh, Mythago, who said anecdotes are “truth”? Not me. And you know, it seems like frequently argue with me over points I never made and things I never said. And I wish you would stop doing that.

    The good Doktor said that anecdotal stories “mean nothing.” In response, I didn’t say that anecdotal stories are “truth” — mine, yours, his anybody’s. I said that anecdotal stories mean *everything* to the women whose lives are the stories. They do not “mean nothing.” Women’s stories are women’s stories; they matter. They are a picture of our realities. And yes, our stories differ.

    I went on to say that he represented patriarchal medicine well, which diddn’t mean that what he had to say was true or reflected women’s reality. Which had nothing to do with whether or not anecdotal stories are “true.”

    The truth is, I could demolish that post Doktor wrote there, honestly. And I still might. But it’s the 3rd of July and everybody comes to my house on the 4th; hence, I have to decide if it’s worth my time. And one thing that discourages me *is* your habit, Mythago, of responding to my posts as though I said things I never said. I don’t have the energy to straighten it all out time and time again.

    Heart

  33. 133
    Robert says:

    And one thing that discourages me *is* your habit, Mythago, of responding to my posts as though I said things I never said.

    Boy howdy, I’ll sign up for that club. You can be President if I can be Treasurer. (Always go for the money, momma said.)

  34. 134
    mousehounde says:

    alsis39 said:

    It’s interesting that this impression you give, [mousehounde], thrives all over the U.S., amongst citizens of many political stripes.

    alsis39, thank you very much for the links. I would have bet money that it was high awards in malpractice suits that were driving up insurance costs. I appreciate you taking the time to point those cites out to me.

    I was unable to find any direct correlation between the prevalence of Caesarians and fear of malpractice at P.C. (Though I didn’t have unlimited time to search, either.)

    I went poking around and found : this

    Data from the Physician Insurers Association of America indicates that in 2003 almost as many lawsuit claims were closed out (through settlement or jury verdict) against ob-gyns as against internists–992 and 1100. But ob-gyns comprise a much smaller segment (about 5 percent) of the total physician population than internists (about 17 percent.)

    The American College of Obstetrics and Gynecology says 75 percent of its members have been sued at least once. In 2003, the organization surveyed a portion of its membership and found that, as a result of lawsuits or the fear of lawsuits and high medical liability insurance costs, 22 percent of respondents reduced the number of high-risk obstetric patients they accepted, 15 percent stopped doing vaginal deliveries for pregnancies subsequent to a Caesarian section and 14 percent stopped practicing obstetrics altogether, but kept their gynecology patients.

    —–

    In an effort to avoid being sued, obstetricians are increasingly delivering babies by Caesarian section, if fetal monitoring shows the slightest abnormality. But the increased C-section rate in the United States–now at 26 percent of all live births, according to the National Center for Health Statistics–has not reduced neo-natal mortality or the occurrence of cerebral palsy, a birth outcome that has prompted many of the lawsuits.

    So, it seems like regardless of whether malpractice suit awards are raising cost of insurance [seeing as how they account for only 2% of overall health costs] the costs are rising. And the fear of being sued does cause an increase in c sections. One site I found said that while insurance costs across the board had risen 15%. For OBGYNs and internists the costs had risen 22 – 33% respectively.

    In Dade County Florida the cost of malpractice insurance for OBGYNs can be as high as $277,000 per year, with the average being $195,000. It won’t be long and everyone who wants to have a baby will have to travel to Oklahoma, with average malpractice insurance costs of $17,000, because that’s where all the doctors will be. :D

    I have learned a whole bunch of stuff I never knew on this thread. Thank you for posting it, Ampersand.

  35. 135
    mousehounde says:

    Bean said:

    In the end, does it really matter whether it’s Dr’s insane need for control and/or paranoia, or hospital administrator’s need for more patients (read: money), or insurance companies fucked up practices that’s causing the c-section rate to skyrocket?

    Ummm, yes? Because if you don’t know why something is happening, you can’t fix it.

  36. 136
    alsis39 says:

    :o No prob, mousehounde. You know the old joke/proverb: “I’m only smart now because I’ve been stupid before.” :D

    I have learned a whole bunch of stuff I never knew on this thread. Thank you for posting it, Ampersand.

    Me, too.

  37. 137
    Doktor says:

    To mousehounde

    “More recent studies have proven that brain disorders are rarely related to childbirth, and that the surge in cesarean deliveries has not diminished the incidence of cerebral palsy.”

    That is true but it doesn’t stop a suit from being brought or sway a jury. In my experience, a malpractice case in more about emotion than fact and when they bring a child with CP into the court room and play a scripted video about “The Day in the Life of _____”, the facts become overwhelmed by the emotion of the moment. Does anyone really believe that the normal person of the street can be made to understand the complexities of acid-base balance, fetal monitoring and the role of cytokines in intra uterine infection in 5-7 days to the point that they can decide a case? Is a state worker at the DMV or a retired aircraft mechanic really constitute a jury of my peers?

    “Next it will be midwives who can’t afford to practice.”

    Sadly, this has already happened in OKC where the one free standing midwife clinic closed after 1 lawsuit raised the malpractice rates to the point they couln’t work.

    “It won’t be long and everyone who wants to have a baby will have to travel to Oklahoma, with average malpractice insurance costs of $17,000,”

    I wish this were true but as a practicing doc in Oklahoma City, I can tell you that for Ob’s the cost of malpractice is around $85,000 this year. $17,000 may be true if you average in the family practice docs.

    ——–

    I understand the value of anecdotal experiences for the individual but do you really want a doctor to practice medicine based on ancedotal stories?
    Do want a doc to say ” I have delivered babies vaginally that weighed close to 12 pounds without any problems”
    or
    “The risk of birth trauma to a baby who weighs over 10 pounds is 25% if it is born vaginally?”
    Now if this were Las Vegas… I would love to have 3 to 1 odds in my favor but in obstetrics, injurying 1 big baby out of 4… is unacceptable, IMHO.

  38. 138
    mythago says:

    And you know, it seems like frequently argue with me over points I never made and things I never said.

    Eerie! I was thinking the same thing about your posts.

    And yes, our stories differ.

    That’s *not* what you originally said. When you talk about “women’s stories” and “women’s reality” as oppoosed to “patriarchal medicine,” you sure as hell aren’t saying our stories differ: you’re saying there’s a single reality for women (all women).

    You also keep talking about how you won’t engage (but then you do) and how you don’t have the energy to argue (right after you post a response). If it’s not worth your time, then walk away. Insisting you could win the argument easily if you chose, but you simply don’t have time or energy just at the moment, convinces no one.

    So, it seems like regardless of whether malpractice suit awards are raising cost of insurance [seeing as how they account for only 2% of overall health costs] the costs are rising. And the fear of being sued does cause an increase in c sections.

    Exactly. I wish doctors would take a hard look at their insurers and how those rates are set.

  39. 139
    mythago says:

    doh! bad tag. [Fixed! --Amp]

  40. 140
    Doktor says:

    Medicine is a weird profession….. I ponder this today after after delivering a drop-in patient who tested + for cocaine.
    It is the only job I can think of that you are forced to work against your will, for free but then can be sued if anything goes wrong.

    Musings from the front line on the 4th of July…….

  41. 141
    Barbara says:

    Gee Doktor, at least you are honest enough to admit that you let lawyers dictate your medical practice.

    And as for induced labor being more painful, maybe you can talk to the l&d nurse who told me that yes, indeedy, in her experience women going through induced labors tend to have shorter but harder labors. On average. Mine was 27 hours anyway. Of course she didn’t go to MEDICAL SCHOOL which, I guess means her experience counts for naught.

    And if you don’t like working for free find something else to do. People respect doctors for a reason and it isn’t because they make boatloads of money.

  42. 142
    Barbara says:

    More seriously, even if it is understandable, a doctor who is motivated by factors that are extraneous to medical evidence is not earning his or her patient’s trust, and it won’t take long for patients to understand this. Doctors should think long and hard before they succumb to this particular temptation.

  43. 143
    Robert says:

    Gee Doktor, at least you are honest enough to admit that you let lawyers dictate your medical practice.

    In the same way that you let lawyers dictate how you drive your car.

    I’m not sure how encouraging doctors to ignore rational incentives is going to be productive for anyone in the long run.

  44. 144
    Barbara says:

    Robert, the analogy isn’t even close. And the incentives here are rational only if you consider the scientific evidence in opposition to a knee-jerk insistence on doing c-sections to be irrelevant. Or, as I suggested above, if you consider good individually determined patient care to be a subsidiary goal of the medical profession. Either way, it gives patients one less reason to trust their doctors and doctors should realize that it matters what incentives they consider important and listen to, and if it isn’t those incentives that flow out of the best interests of their patients, they don’t deserve the trust they crave and sometimes try to demand from their patients.

    But then, I’m someone who is pretty sure I was bullied into an induced labor so that my obstetrician could get away for a holiday weekend without having me hanging me over his head.

    Imagine a doctor saying, “well, I have big plans for the 4th of July weekend so you are going to have to buck it up and be induced.” Or, in this context, “I’m afraid that you will be one of the 1/1000 (or whatever) patients who has a bad outcome and sue me and it will look a lot better in court for me to insist that you have a c-section even though I know that all the evidence shows a much higher rate of complications for a c-section than a vaginal birth. Sorry, but it works best for me if all the risk is on your head instead of mine.”

    I don’t mean to flog a dead horse, but if doctors want to play those games they had best be prepared for some fairly nasty consequences.

  45. 145
    Lee says:

    Re: induced labor. Both of mine were induced (for hypertension). My first labor was 7 hours from start of drip to cutting the cord, my second was 4.5 hours. However, my cousin was induced at 42 weeks with both of hers, and both of hers were >36 hours. Like everything else to do with labor, I think induction is highly individualistic.

  46. 146
    Robert says:

    And the incentives here are rational only if you consider the scientific evidence in opposition to a knee-jerk insistence on doing c-sections to be irrelevant.

    Barbara, incentives are rational if the payoff or penalty actually exists. Being afraid that subterranean demons are going to consume you if you venture into a cave is an example of a non-rational incentive (unless you are in a horror movie).

    Being afraid that a lawsuit is going to take your house or quintuple your malpractice insurance premium if you don’t perform a C-section is rational if those lawsuits are a realistic prospect. The fact that some people, not sitting on a jury, think those lawsuits are based on bad science is not material to the rationality of the incentive.

    Your position seems to be essentially that if doctors want to have their patients’ trust, they must ignore the economic reality of lawsuits against them. I do not believe it is productive (or realistic) to expect people to ignore enormous economic incentives.

  47. 147
    Barbara says:

    No, my position is that doctors are being, and are willing to be, manipulated by insurance companies and are way to eager to dump a lot of externalities on their patients — you know, those people whose welfare they are supposed to assure — based on soggy economic rationales that don’t hold up under scrutiny. That, and not being willing to take the forefront in addressing the only “real” insurance crisis that exists in America: lack of access to needed care for the very sick and disabled among us.

    The fact that many OBs cling to clearly discredited l&d practices does not help their cause in my book.

  48. 148
    Robert says:

    OK, Barbara. What do you want doctors to do? In concrete terms, not abstracts like “put the interests of the patient first”.

  49. 149
    Lee says:

    Yes, but, Barbara, in many states you can’t practice medicine (even if you have a valid license) unless you also have malpractice insurance. If I were a doctor and my insurance company told me that my performing a particular procedure would lead to a spectactular rate increase, I would have to choose between raising my rates – which would lead to a loss of patients because their health insurance companies wouldn’t cover my full fee; performing the procedure anyway and maybe not being able to pay my staff or my mortgage; joining a group practice (if I had a solo practice); or leaving the profession altogether. My son’s pediatricians closed up their practice with only 6 weeks notice because their malpractice insurance had gotten too high – and the practice had only been sued twice in 10 years.

    I agree that there are still plenty of old-school and/or patriarchal OBs out there, but there also many doctors who are using tremendous amounts of time and energy to fight the insurance companies for everyone’s benefit. We just don’t hear about it unless they go out on strike or do something really spectacular that gains media attention.

  50. 150
    Barbara says:

    1. Not lie to their patients about why they propose to undertake a course of treatment. Like my doctor did to me.

    2. Not push women into induction, c-sections or other interventions that are not supported by evidence (or in inappropriate circumstances).

    3. Think 120 times before they conclude that malpractice is an adequate excuse for not assessing the circumstances of an individual patient and advocating a course of action that is known, on average, to be riskier than its alternatives.

    4. Advocate for better obstetric care (like 24/7 anesthesia) that would actually make all deliveries safer.

    5. Consider reviewing the experience of Virginia and Florida no-fault birth injury compensation funds to see if, indeed, there is a better way to address ALL birth injuries so that parents and children in distress are not required to prove that their obstetrician was at fault before they are eligible for care.

    6. Explore more effective disciplinary processes when a doctor’s malpractice history reaches a certain level — like Massachusetts currently does.

    7. In short, understand that there is a critical and unmet need for care by children who suffer from congenital/birth injuries, and not expect their patients to bear all of the costs of these injuries, whether in the form of inferior care (like coerced c-sections) and whether fault based or not, but especially not if they are fault based.

  51. 151
    alsis39 says:

    Adding on to Barbara’s list:

    8. Push for state-enforced caps on malpractice premiums, rather than caps on damages caused by a scant handful of negligent doctors.

  52. 152
    Barbara says:

    Lee, very often malpractice rates are driven by the insurers experience as a whole. Sometimes this is mandated by state law, which effectively prohibits individual underwriting. Individualized underwriting would allow differentiation that rewards good risks. But there are two real issues here that would go a long way to reducing the so-called malpractice insurance crisis, and that would, incidentally, make medicine better and fairer for everyone:

    1. More effective oversight of health care providers by competent and reasonably funded state boards.

    2. Universal access to health care for sick people regardless whether their doctor was at fault.

    Organized medicine has opposed any form of these changes with tooth and nail, so yeah, my sympathy is pretty limited. For doctors, it seems as if it’s all take and no give when it comes to “reforming” malpractice. Much better that patients just suffer their ill health in silence regardless of need or fault.

  53. 153
    Doktor says:

    It is so hard to regulate bad docs. As head of a QA committee, I can tell you that when we try to regulate or remove incompetent doctors several things happen….

    1. They bring in their own lawyers and usually use the ploy, “these doctors (the ones on the committee) are in direct competition with my client and therefore can’t be considered as unbiased.” Then they find some other squirrel doc as their “expert witness”, so the incompetent doc gets to continue practice.

    2. The incompetent doc resigns from the hospital just before their privileges get yanked so they don’t have to report it to the next hospital they apply at.

    3. The incompetent doc just disappears and goes to some other state.

    We try to police our own practice but everyone has got “rights” and some lawyer to defend them……..

  54. 154
    Kim (basement variety!) says:

    Doktor,

    While I appreciate the contribution you’re making to the thread from a professional perspective, I do have to say that you come off as a bit easy on the amount of needless c-sections than might be comfortable. It took me a great deal of courage to really confront my own doctor on whether or not there was a genuine need for me to have a c-section, and what her stance is on the VBAC issue and amount of c-sections occurring. I was, however, pleasantly surprised in that she didn’t seem to write off my concerns as meaningless, which is sort of how you have appeared (to me) in a few of your posts. I got particularly frustrated with the comment you made about the idea of medicine being part of a patriarchal system.

    Here was a synopsis of her response to me:

    (nutshell)I tend to feel as a physician that my hands are tied due litigation concerns that the overall practice has, with regards to VBAC’s. I don’t, however, agree with the use of c-section as a catch-all response to women who have had c-sections before. Their are many cases, such as breach birth or lowered heart rate, where the chances of repeat are slim and a woman can likely have a perfectly healthy VBAC. In those cases, I talk to the woman about her options and my opinion that she could likely have a successful VBAC, if she chose to investigate what options were available to her more thoroughly. (/nutshell)

    She then went on to explain to me why she considered me a ‘triple’ risk:
    1) General physical structure, with a familial pattern of non-progressing long-time labor (grandmother labored for 80 hours with my mother and 72 with my uncle) and my mother labored for 30 hours with my brother and then had a c-section for him, and consequently a c-section for me.
    2) Previous c-section myself after an unproductive labor (was induced and had HORRIBLE back labor for 15 hours, btw).
    3) Have anterior placenta this pregnancy which has a heightened chance of getting in the way during labor if I were to attempt a vbac.

    She stated that the triple risk made her comfortable and confident that a second c-section is the right choice for me.

    Knowing that she doesn’t just accept without question the notion that c-sections are just swell, no matter what, I felt a lot better in the diagnosis that chances are I’d end up back on the operating table anyways if I gave it a second go.

    I think there is not only room, but absolute need for questioning with regards to the use of c-section in the manner that we do in the US by both doctors and patients.

  55. 155
    Barbara says:

    Doktor, I am not talking about QA committees and so on. These play a role, certainly, and they can certainly be misused (though having defended a few doctors in these types of settings I can tell you that they are also misused by the complainants, not just the defendants). I am talking about an agency that has resources and authority to investigate medical professionals and to mandate solutions, to escape litigation and accusations of conflicts of interest. In Massachusetts, when a doctor settles or goes to verdict on three malpractice cases, the Board of Registration in Medicine investigates not just those cases but the doctor’s entire practice, and makes recommendations (or not — sometimes things do happen as a result of random bad luck).

    With regard to moving from state to state — this is something I know a lot about. Again, professional societies (of all stripes, not just physicians) are so jealous of their turf that they resist any kind of centralized credentialing and disciplinary reporting that would help to build an accurate and complete picture of the doctor’s practice patterns and make it more difficult for bad doctors to evade detection.

    What you are describing is also a pattern of non-compliance with the HCQIA — which mandates the reporting as an “adverse action” of any physician that resigns in lieu of a full blown disciplinary hearing. It’s no secret that hospitals don’t like reporting. However, hospitals (and other participants) were handed antitrust immunity in a trade off to make information more available to other credentialing bodies. They asked for and received the protection, and now seem to consider the whole process optional, depending on what’s most convenient for them. Meanwhile, other institutions can’t get information that they are entitled to think would be available.

    Professional societies and health care providers also resist making any quality or peer review data public, or even available to credentialing bodies who don’t plan to disseminate it publicly, again stifling the dissemination of information that would allow other hospitals and potential patients to steer clear of bad doctors. Now, I am divided on whether or not a doctor’s malpractice history should be easily accessible to the public. The “raw score” is so simplistic that it is nearly impossible to interpret it correctly without a lot more knowledge. However, I do not accept that such information should be withheld simply to protect professionals, which is essentially how the system works now.

    Saying that “it’s hard to deal with bad doctors” is just not enough. There’s a context of professional privilege that keeps those difficulties firmly in place as a form of professional self-protection that is simply unavailable to any other professional group.

  56. 156
    Lee says:

    Barbara, while I agree with your points, I do have to take issue with your use of “so-called” when referring to the malpractice insurance crisis. This is a very real issue in Maryland, where the state legislature was forced to examine some ugly budgetary issues in the last session (Maryland’s legislature is only in session for 90 days, so it’s kinda crunched legislatively) in order to make sure that almost a third of the doctors in the state would be able to continue to practice. It’s a very real issue in New Jersey, where there is a huge shortage of the “high risk” specialists. It’s becoming an issue in Florida. Based on Doktor’s posts, Oklahoma is not far behind. Doctors do need to pound on their professional organizations about universal health care and malpractice insurance, but most of the doctors I know already work 50-60 hours a week, so where would the time come from to do this? IMO, there is a huge disconnect between the AMA and its members on these and other issues.

  57. 157
    Barbara says:

    Hey, I’ve lived in or near Maryland for more than 20 years — I have a pretty good grasp on what’s happening there and the “solution” was to raise health insurance costs via taxes (retrospective taxes at that) in order to placate a highly organized professional lobby. Do you really accept that 1/3 of doctors practicing in Maryland would simply “leave” in a short period of time? Somehow, I just don’t see the JHU and UM faculty practice doctors pulling up stakes and moving away or closing their doors. Or the well-heeled physician practices that operate in Bethesda/Chevy Chase. The truth is, Maryland is particularly vulnerable to hard core lobbying by health care groups because, especially in Baltimore, the provision of health care services makes up a huge percentage of the economic activity that occurs in the state, which has had a difficult time attracting different kinds of business. Partly because of the high cost of health insurance. Which is itself the result of the clout that hospitals in particular have over the pricing of hospital services. A really vicious cycle exists in Maryland. And if you live here then you no doubt saw the WaPo article on the unbelievably inept system of professional discipline that exists in each of the three jurisdictions that make up Metro D.C., including Maryland.

    You see, Lee, somehow, even though they work 50-60 hours a week Maryland doctors and their lobbyists found time to lobby for relief for themselves alone but just can never seem to find the time to advocate for a long-term fix that would help others. And you know what, nearly anybody who lives in Maryland lives close enough to Delaware, Virginia, D.C., Pennsylvania, West Virginia or New Jersey to find a doctor. And I would be grateful if my husband ONLY worked 50-60 hourse per week. The truth is, lots of people work that hard.

    I’m sorry to be snarky, but time and priorities are always up for grabs, it’s never easy to make progress, and, frankly, it’s only a crisis if you have a laser focus on what the doctors are telling you.

  58. 158
    Barbara says:

    Lee, here is a link to an article that discusses the proportion of the crisis:

    http://www.washingtonpost.com/ac2/wp-dyn/A15752-2003Sep15?language=printer

    Choice quotes:

    “A study released last week about Maryland, where medical groups have warned about a “crisis” caused by rising malpractice premiums, reached similar conclusions. Researchers from Public Citizen Health Research Group analyzed government data and found that the number of malpractice claims filed per physician declined significantly between 1996 and 2002, as did the amount paid by insurers to cover claims. And while some groups have warned about an “exodus” of physicians, the number of doctors in the state actually increased between 1996 and 2002, according to the advocacy group.”

    “‘What the latest GAO report shows is that the threat about access to health care is largely overblown,’ said Maryann Napoli, deputy director of the New York-based Center for Medical Consumers. “It’s interesting that [organized medicine] always zeroes in on pregnant women every time there’s a so-called crisis.”

  59. 159
    Barbara says:

    And another link about the distribution of doctors by state:

    http://www.citizen.org/documents/FCT-Why_Doctors_Practice_Where_04-05-04.pdf

    Maryland is one of the states with the highest number of physicians per capita, and ranks second after Alaska in the average income earned by a doctor.

    It’s a big subject, but the scarcity of doctors in the U.S. only really exists in rural communities, and the reason for the scarcity can only be very tangentially related to malpractice premiums. For the same reasons that rural areas in general have experienced depopulation, they have experienced shortages of doctors and dentists, who have the luxury of locating almost anywhere. My in-laws live in a rural area, and I have seen this phenomenon first hand.

    The scarcity of primary care physicians, if it exists, is the result of payment and education policies that reward specialists and those who train them.

  60. 160
    Lee says:

    Barbara, thank you for those links. I hadn’t seen those articles. Most of the doctors I know on a personal level practice in Michigan, which is a whole different ball of wax.

  61. 161
    Lee says:

    But it also makes me wonder, if the number of malpractice claims is going down and the amount of claims is going down, and the number of doctors is urban areas is increasing, why malpractice insurance premiums are increasing so rapidly.

  62. 162
    Barbara says:

    Lee, it’s called a bear market. Insurers, especially p&l insurers (and life insurers too) price their policies with the expectation that they will earn returns from investing “unearned” premiums, and the market has been very difficult over the last five years. In addition, there is also something called the insurance underwriting cycle that is usually about 7 years in duration — it’s difficult to predict underwriting experience with precision and there tends to be under/over pricing trends that are then adjusted for over time. Making up an underpricing trend during a bear market when market returns are lower than average results in a spike in prices that is much higher than would normally be expected by claims experience.

    You don’t see this in health or auto insurance, where the rate of unearned premiums is actually much lower — basically, they have a much lower profit margin because their payouts are continuous.

  63. 163
    Lee says:

    Barbara, thank you for that lucid explanation. Usually explanations of insurance policy start looking like time travel theory! :)

  64. 164
    mythago says:

    Doktor, my state bar journal has pages every month of disciplinary actions taken against lawyers by the State Bar. If even lawyers can’t so easily escape discipline by their own professional board, why are you doctors having so much trouble?

    Lee, this is a flatly partisan link, but here are reasons other than malpractice suits that doctors are getting screwed by their insurers.

  65. 165
    mythago says:

    hm, link didn’t show:

    Summary of NBER report

  66. 166
    Lee says:

    Mythago, thanks for that link. Is it still true that the top 5 earning firms in the U.S. are insurance companies?

  67. 167
    Barbara says:

    mythago, the snarky answer is that lawyers are so used to arguing and pointing fingers that it’s in their blood and the fact that the other guy is also a lawyer is just another detail. But the real answer is that there are two types of disciplinary problems. The first is incompetence and the second is misconduct (lying, cheating and stealing). In the case of physicians or lawyers, out and out fraud or stealing or sexual abuse or whatever is somewhat easier to deal with, overall, but the real problem with physician discipline is policing professional incompetence, and this requires one set of professionals to make judgments about the practices of another, and doctors just don’t want to do it. Plus, there is a real culture of self-protection — clearly played out in the extent to which known drug abusing doctors are permitted to continue practicing for years in many communities, because “it would be tragic for someone’s investment in their career to go down the tubes.” This is what I mean when I say that professional disciplinary action is primarily for the protection of the professional, and not his patients. Until this changes, there will be no way to improve the situation.

  68. 168
    Lee says:

    Bean, if you are referring to me, I don’t think it’s entirely the insurance companies’ fault that there are more C-sections, and I don’t think unnecessary C-sections are a good thing. I was trying to point out that it isn’t just due to doctors and hospitals being paternalistic or misogynist, that even very good and thoughtful doctors have to pay attention to what the health insurers and the malpractice insurers are saying, because it impacts their jobs. I also think that many doctors and hospitals are trying to practice medicine the best way they can, and that many patients would benefit tremendously by being informed consumers and being willing to talk to their health practitioners about what is happening. I have indeed stood up to my doctor and to my health insurance company when necessary. Sometimes I won, sometimes I lost. If I was coming off as complaining about evil insurance companies, it was probably because I was responding to what I thought were unnecessarily fierce attempts to pin it all on an evil doctor or an evil hospital.

  69. 169
    mythago says:

    There are a few people in here who seem to want to believe that the fault entirely lays on insurance companies, never the doctors.

    If you’re referring to me, this is crap.

    The state of malpractice premiums has more to do with insurance companies than doctors. The decision to do prophylactic C-sections has more to do with doctors than insurance companies.

    mythago, the snarky answer is that lawyers are so used to arguing and pointing fingers that it’s in their blood and the fact that the other guy is also a lawyer is just another detail.

    But Doktor attributes these doctors escaping discipline in part to their clever lawyers (apparently, medical boards investigating misconduct only hire stupid lawyers). You’d think that lawyers themselves would be even more likely to get a hired gun to get them out of trouble.

    You’re entirely right that it has more to do with the culture. Lawyers are protective of the profession, but we’re more than happy to attack one another. Doctors, not so much.

  70. 170
    alsis39 says:

    bean, why is it automatically “passing the buck” to introduce another factor into the equation ? If an institution is a possible factor in a bad situation, how does it profit the discussion to not point out this possible factor ? I don’t consider that “passing the buck.” I consider it introducing a factor that was previously not visible.

  71. 171
    Barbara says:

    Alsis39, many states have tried to mandate malpractice premium price controls and the net effect is that malpractice insurers leave the state. This happened in West Virginia. It’s happened for other types of insurance as well (esp. automobile and homeowners). Over time, if a line of business really can’t be sustained profitably, there’s nothing that can make an insurer continue to take a loss in it or write new policies. The problem in health care is that we have neither free nor regulated markets. A totally free market would be insane, but imperfect regulation doesn’t introduce enough sanity to solve the problems. But for doctors to ask for regulatory relief in the pricing of malpractice premiums and to ignore the devastating financial impact that lack of access to affordable medical care has for their patients and oppose solutions on that score — Well, I’m sure by now you know where my sympathies lie. There’s an insurance crisis alright, but it has nothing to do with malpractice.

  72. 172
    alsis39 says:

    bean, I never said that doctors shouldn’t be blamed. In fact, I posted what I did in response to Doktor’s trying to blame malpractice-happy jurors, et al for his dilemna. Furthermore, the insurance industry is largely headed by men, just as the medical industry is. It’s not as if one is more patriarchal than the other.

    Barbara, maybe the solution is for the state to step in and run the insurance business. Not that I expect this to happen anytime soon, but the uneasy hybrid model you describe doesn’t seem to be doing anyone any good– except the CEOs and the bad doctors, of course. :(

  73. 174
    Doktor says:

    The GAO report reminds of the old line “there are liars, damned liars, and statisticians.

    The Post article stated, “In Pennsylvania and West Virginia, for example, two of 19 states designated by the AMA as being in a “full-blown liability crisis,” the number of doctors per capita has actually increased in the past six years, according to the GAO.

    In Pennsylvania, despite reports of physician departures, the number of physicians per capita in the state has increased slightly during the past 6 years.

    The truth is…….

    Between 2002 and 2003, 24 OB/GYNs left the state due to malpractice concerns; however, the state’s population of women age 18 to 40 fell by 18,000 during the same time period.”

    So, Ob docs did leave the state but the Ob population decreased as well so that the net result was anlooked like an increase in Ob docs per capita.

    That is a little different flavor than the original story.
    Numbers can be used to support either side of any argument according to my old stats professor.

  74. 175
    Barbara says:

    Maybe they left “due to malpractice concerns” in the sense that the practice of obstetrics was already becoming marginal given the population drop. In any event, there was no verification of their reasons for leaving. In West Virginia, the medical society couldn’t really say how many were leaving for malpractice concerns. Pennsylvania has one of the oldest average age populations in the country (it’s where I grew up). I would never say that it makes me happy that a good doctor would leave practice for any extraneous reason, but the point is, the departure of a small number of physicians is not a public health threat, and as the GAO report also pointed out, many of these communities have always had difficulty recruiting and retaining physicians due to a variety of factors. It also pointed out the steps that hospitals, in particular, were taking to ameliorate the situation for doctors.

    Other studies have shown that doctors who “leave obstetrics” often do so as their patients age and they no longer want to maintain an OB lifestyle. This happened with my first obstetrician. He stopped delivering babies around the time of my first pg.

    And the most recent study, of course, shows that malpractice payouts have remained flat even as premiums have escalated. I tried to explain above why that could happen in the absence of “skyrocketing” malpractice verdicts.

    I have a doctor client who told me how unnerving it was to be sued (she’s an oncologist), and how betrayed she felt when her patient alleged that she had been mistreated. She lives in a state with one of those “pre-adjudication” panels that actually works — it’s so rare for someone to win a malpractice case if the panel declares in the doctor’s favor that it usually decides the case. The doctor’s care was considered appropriate, so that was the end of it. But her reaction shows that, at some level, doctors just don’t like being questioned — everything about their training puts them in command of those around them and they find it upsetting and disorienting to be challenged. I honestly believe that this fuels the belief that malpractice is a crisis as much as any financial issue does.

  75. 176
    H. Sandland says:

    Well–it certainly has been interesting that my battle with the hospital has generated so much discussion–I guess some good came out of it.

    Just to put a rest to some concerns: I would have LOVED for the entire peer review process to be reviewed by an outside source—because they would find nothing. the concerns stated in the letter were the only concerns—higher birth weights, longer gestation and lower C. Section rates and one or two more clavicle fractures a year.

    I DID ask about the birth weights and reviewed ALL my records. There was no higher incidence of macrosomia and everybody was delivered by 41 weeks–there were none over 42 weeks.

    there were no brachial plexus injuries. There were no encephalopathy.
    i did not walk around criticizing everybody–I was in solo and just did my own thing–live and let live philosophy. I knew I wouldn’t last long if I was openly critical. Actually most of the OB were very nice and we would chat quite often. this process was started by a couple of OB who had enough clout to “get ‘er done”

    I demanded an independent review and got it–the reviewer finding no fault with my care. I asked for an apology letter and got one but it was very carefully worded “……so sorry that you found this process so stressful….you have always been and continue to remain in good standing….”

    I did not leave to hide form anything. I did not have any lawyers sitting beside me because I knew that the peer review process is protected by WAY bigger governmental machines than I can handle.

    My malpractice rate was 40K a year in a crisis state–because my record was clean-and I don’t have nay suits pending.

    Life goes on—only with 14 year old girls on their second child down here in Mississippi—so I have new frontiers to try and conquer–.. I am getting very involved in programs at the school to foster a sense of self-worth.

    One girl at a time.

  76. 177
    Lee says:

    Wow, H. Sandland. Those girls in Mississippi are lucky to have you.

  77. 178
    mythago says:

    But her reaction shows that, at some level, doctors just don’t like being questioned … everything about their training puts them in command of those around them and they find it upsetting and disorienting to be challenged. I honestly believe that this fuels the belief that malpractice is a crisis as much as any financial issue does.

    Bingo.

    I recall reading an article, quoting a professor at a medical school who didn’t believe there was a ‘malpractice crisis.’ His students simply refused to believe it, even in the face of statistics showing they were getting screwed by their insurers. Having a patient sue feels like a betrayal and an attempt to say “You are a bad doctor.”

  78. 179
    H. Sandland says:

    oh yes–I DID say to the reporter at the time that I TRULY did NOT believe that doctors are saying “ooo–more bucks for me if I section her” OR “geez-I had a tee time of 5 pm—let’s get this over with”

    I really DON’t think the rise in C Section is financially driven–I DO think there is a difference in one’s approach to labor.

    MANY times I hear “I had a C. Section with my first because I was on the drip all day and I didn’t dilate” THIS DRIVES ME CRAZY!!!
    #1. I can never let on to the patient what I think about that because in truth I really wasn’t there and don’t want to open taht can of worms
    2. the indication was failed induction—not CPD as is coded

    If a patient opts for induction at 41 weeks–becasue ACOG says I have to OFFER and induction then priming the cervix is “a good thing” I prefer the use of a Foley catheter placed in the cervix –a quick strip on the monitor and let the patient go home. Many times she comes in during the night in good labor and I don’t need to use any Pitocin. I also encourage ambulation–which was NOT being done when I first got to Wilmington.

    I also offer breast pump or encourage nipple stimulation instead of pitocin.

    I don’t put too much weight in the push for 2 hurs rule–never did!

    If there is progress and the mother is not tired –she can push longer. If she has an epidural, I don’t “make her push at 10 cm”–let her sleep and the uterus do the lioness’ share of the work–she can spend 3 hurs pushing ineffectively or 2 hours sleeping and one hour pushing effectively–all the same to me.

    I am also VERY comfortable with forceps if it looks like intervention is needed. Even “natural” childbirth can lead to EXHAUSTED mothers who can easily be delivered with forceps. I give them the choice– but if the head is low I certainly tell them my preference. I think it helps to tell them I had a forceps with my first after 5 hours of pushing.

    I have seen 4th year residents who haven’t go the first CLUE how to put on forceps—needless tosay they will not be comfortable with this option when they are out in private practice—so it’s either push it out–and they won’t let them go past 2 hours or C. Section.

    During my17 years I have delivered at least 150 breeches and have had no problems with any of them—I wasn’t cited for any breech deliveries. I have certainly had to c. Section some of them but over 90% deliver vaginally. It is very sad to me that the ACOG has mandated C. Section. Again you have residents who are in awe at a vaginal breech delivery–they’ve never seen one–make no wonder they are scared of them.

    Overall I wonder about the exposure to different ways of thinking. If youget a whole town all trained in that town–everybody will be walking the same path. That’s OK as long as you don’t mind some people walking a different way down the same path–we’re all going to the same place. Some are more tolerant than others and some will be downright against anything outside uniformity.

  79. 180
    Barbara says:

    To respond to a previous poster’s comments about women dying in childbirth, just FYI, depending on which study you look at, women who have a cesarean have a 2-6 times higher risk of dying during childbirth compared to women birthing vaginally.

    In many cases, the problems that arise during labor are actually CAUSED by the medical interventions. Add to that that OBs are not trained (and mostly don’t bother seeking out on their own) in ways to get babies born vaginally.

    Midwives are the gatekeepers of normal birth and always have been. You get equal or better outcomes with much less interventions.

    -Barbara

  80. 181
    mythago says:

    Midwives are the gatekeepers of normal birth and always have been

    Just as private schools always have better outcomes than public schools, and for the same reason.

    Nice dig at women who required medical intervention in their, oh, I guess you would call them “abnormal” births, though.

  81. 182
    Barbara says:

    Okay, just fyi, the post just previous to Mythago’s by someone named Barbara was a different person from previous posts that were mine — I don’t add my name at the end of the post. I thought the post was okay up to the last paragraph. I have never used a midwife, my position is that women shouldn’t have to use a midwife to have a birth experience that is accompanied by only as much intervention as is genuinely useful.