Born in the USA (5 page)

A professor of obstetrics at an Ivy League university medical school posted a copy of a “Reciprocal Natural Childbirth Index” (supposedly as a joke) on his office wall (see
table 1
). This table heaps contempt on women whose ideas and preferences for giving birth inconvenience the doctor. Many obstetricians find the table hilariously funny. Isn't it frightening that the ultimate weapon obstetricians use to punish overly “independent”
women is to cut into their bodies, using a surgical procedure (cesarean section) only obstetricians can perform, which completely deprives the women of control over their own bodies?

Another story of contempt: Early in my career, I heard several women in a local hospital where I was working complaining that a certain obstetrician treated them in an aggressive and mean way. I dismissed their complaints, until one day, by accident, I saw the doctor with a patient when he didn't know I was there, and I was shocked to see him shouting at her and calling her deprecating names. Over time, through informal chats with him, I learned that he had a very low opinion of women, seeing them as inferior and irrational, and I came to understand that he truly hated women. This confused me. Why would he choose to go into obstetrics and gynecology? Then I got it. He had found the perfect way to punish women. Sound ridiculous? Ask the women who have suffered through unnecessarily rough pelvic exams. Over the years, I have run across other obstetricians who hate women and this horrible hypothesis has been confirmed, although my impression is that most obstetricians have a gentle manner with the women under their care.

At the other end of the continuum are obstetricians who cherish women. These are the obstetricians who practice obstetrics for many years. They don't mind long waits with women in labor or being on call 24/7, and still experience wonder with every birth. However, given the strain of the job, it is not unusual for obstetricians in the United States to take the first opportunity to drop obstetrics and limit their practice to gynecology—perhaps handing obstetrics cases off to a younger partner.

With few exceptions, obstetricians are not evil people. They are hardworking and want the best for their patients. But years of isolation in the obstetric world leaves them believing the obstetric establishment point of view—that they should control maternity services. Obstetricians internalize this as the official truth. They don't sit down and decide, “I'm going to speak for the obstetric establishment.” They unconsciously internalize a set of assumptions, and one of the most potent assumptions is that pregnancy and birth are medical events and so maternity care should be seen in obstetricians' terms, not women's terms. Individual obstetricians are human beings, no more, no less. They have all the imperfections and neuroses everyone else has. But when individuals get together in groups, strange things can happen. There is a process of natural selection that allows a certain type of obstetrician to rise to a position of authority in organized obstetrics. Whether driven by a need for power, admiration of peers, or feelings of self-importance,
the people at the top in organized obstetrics in the United States have gotten there by convincing others that they are best able to protect and promote the obstetric monopoly.

Given the constricted, adversarial nature of a doctor's world, it's not surprising that, despite good intentions, it's difficult for physicians to maintain real compassion for patients. Some obstetricians achieve it but, in my experience, they are in the minority, and it is difficult for women to identify these obstetricians through the smokescreen of hype and falsehoods that envelops the field. The world of doctors and hospitals functions satisfactorily, in general, for cases of serious illness and major injury. In these cases, a medical approach focused on diagnosis and treatment is appropriate, as is spending time in a hospital with other sick and injured people where care routines focus less on emotional and social needs than on heroic treatment of physical ailments. But the way things are done in the medical realm is totally inappropriate for normal life events such as birth and death.

Generally speaking, most of us would prefer not to have a surgeon taking charge during a normal life event. And obstetricians are surgeons, a fact you forget at your peril. To slice a woman's body open, the surgeon must maintain a dispassionate distance from the woman, which, when achieved, makes it difficult to feel compassion. It makes no sense for a gynecological surgeon to assist during normal pregnancy and birth—unless doctors' tasks are to be divvied up by dividing the human body into territories. Some countries, such as the Netherlands, are considering a new system that would make gynecology and obstetrics two separate specialties. Gynecologists would provide reproductive health care to women who are not pregnant. Obstetricians would provide care to pregnant and birthing women with medical complications. And birthing women with no complications would be cared for by midwives (as they are currently in these countries), whether they are giving birth at home or in a hospital.

It's interesting to note that the word
obstetrician
comes from the Latin for standing in front of (the female genitals), and that is what a gynecological surgeon does: stands in front of a woman, between her legs. This requires that the woman be on her back. It is no coincidence that in the United States, where gynecological surgeons are also obstetricians and bring their surgical mindset and methods when they attend normal births, women are put in the worst of all positions for giving birth—“lithotomy” or “on the back.” The doctor is close to the woman's genitals and far away from her head and heart—symbolic of the focus of obstetrics.

Another point to understand about surgeons is that they believe in surgery—“if in doubt, cut it out.” There are many examples of surgeons choosing to “cut it out” when the scientific evidence says that's not a good idea. One recent example is surgery for the pain and stiffness caused by arthritis in the knee resulting from old age, in which the smooth surfaces of the knee joint become roughened. Incisions are made in the knee, an instrument is inserted into the knee joint and the rough areas are shaved off and flushed out. Sounds like a good idea. But a study proved otherwise. Half the patients in the study had the surgery and the other half had a sham procedure (patients were sedated and surgeons pretended to operate). Subsequent tests revealed that the operation did not help knee function and most of those who got the sham surgery reported feeling just as good as those who had the real operation. This surgery is done on at least 225,000 middle-aged and elderly Americans each year at a cost of more than a billion dollars to Medicare, the Department of Veterans Affairs, and private insurance companies.
⁴

That obstetricians are surgeons who believe in surgery is further illustrated by a study that asked women health practitioners and laywomen if they would choose to have a surgical birth (cesarean section) rather than a vaginal birth if there was no medical indication of a need for cesarean. Four percent of midwives said they would; 5 percent of laywomen said they would; and 46 percent of women doctors said they would.
⁵
That women doctors would choose cesarean section for themselves, without any medical indication, shows the extent to which they believe in surgery and in the obstetric hype about how safe elective cesarean section is, even though scientific evidence shows clearly that vaginal birth is safer for the woman and the baby except in certain emergency situations.

Interestingly, while the rate of cesarean section performed in the United States has nearly doubled since 1980,
⁶
the trend among other medical specialists is toward doing less surgery. It is becoming common to hear other types of surgeons quote a very different saying—“A good surgeon knows when to operate and a better surgeon knows when not to operate”—and express concern, if not contempt, for the surgical excesses of obstetricians.

While obstetricians tend to lose compassion for their patients over the course of their education and practice, their desire to protect their tribe (and with it their own self-interest) tends to grow stronger. One of the most convincing demonstrations of the power of tribal loyalty in obstetrics is Mafialike “omertà”: tribal members are taught never to speak about the tribe or any of its members in public in a negative way. Never. We may talk to one
another about the terrible way a certain tribal member practices obstetrics, but only in private.

In every tribe—from the U.S. Marine Corps to a local fraternal lodge—the tribe and its leaders take care of their own people first; everything else is secondary. In return, each member of the tribe has an absolute duty to support the tribe and follow its rules. Loyalty, of course, can be a good thing, but like many good things, it can also be misused or misplaced. When loyalty is misplaced, as often happens in obstetrics, we have cronyism, which can lead to behaviors that are detrimental and even dangerous to patients and the community. For many obstetricians, cronyism is a way of life and they call it loyalty.

In Oakland, California, in 2001, a woman and her baby died after Cytotec was used to induce her labor. Preparing to report on the case for the local affiliate of a national television network, a journalist contacted a number of local obstetricians. Some of them told the journalist “off the record” that they do not use Cytotec for induction themselves because of the known risks, but not a single obstetrician was willing to go on camera. Omertà. This response from local doctors was typical, as any journalist will tell you.

The same is true in a court of law. When an obstetrician is charged with malpractice, it is extremely unlikely that another local doctor will be willing to testify against him. Lawyers must go outside the community to find a doctor willing to testify. Why? Because an obstetrician knows that if he testifies in court against another obstetrician, he will be shunned (and worse) by the tribe. And when someone has spent so many years becoming a doctor, that price is simply too high. As we will see in
chapter 7
, the organized medical establishment has found a number of ways to prevent doctors from assisting lawyers in malpractice cases.

Hospitals have their own brand of omertà. Hospitals have perinatal “peer review” committees that investigate obstetric cases in which something has gone wrong, but these committees are made up of other tribal members in that hospital and always meet behind closed doors. Even if a case goes to court, it is virtually impossible to find out what was said, because hospital peer review findings are inadmissible as evidence. As further protection, most hospitals have people on staff whose job it is to convince patients who might have cause to sue that a doctor has not made a mistake. I have also noticed that these “patient liaison” people, like some nurses and other non-physician hospital staff, are often so eager to be liked by tribal members that their loyalty can go to extremes. They seem to seek an “affiliate” membership of sorts, perhaps hoping that a bit of the glory will rub off on them,
or hoping to convince themselves and others that they are made of the same stuff as tribal members.

I saw the hospital omertà in action at a regional level when I was invited to speak at a large obstetric meeting attended by doctors from a number of private hospitals in the area. In my presentation, I showed a slide of the cesarean section rates for each hospital, and some rates were shockingly high—up to 60 percent of all births. The next day there was an uproar in the local obstetric community, not about the shameful number of unnecessary surgeries or the disparity between their cesarean rates and what scientific evidence shows is acceptable, but about the fact that someone had given me, an outsider, those hospital data. The critical question: Who broke the hospital omertà? In that area, hospitals are required to report cesarean section rates to the local health department. However, in typical allegiance to the tribe (rather than to the public they are paid to serve), the public health officials had promised the hospitals that they would not leak the rates to the public. The hospitals believed that the health department had betrayed them. They were outraged. But, as it happened, the public health department was not the source of my data.