Lamenting the System

By Jill Arnold | May 10, 2011


In the May 2011 Green Journal, OB-GYN Annette Fineberg wrote a commentary titled “An Obstetrician’s Lament.” She begins with a few stories of pregnant women in her life who were making decisions about their pregnancies and births. Two women were pregnant with twins and the other was preparing for a breech birth after an “easy first birth” and all believed or discovered that they had no options in the hospital but a cesarean.

Fineberg has observed what she believes to be a trend at the level of the press of touting the benefits of giving birth at home and feels that obstetricians contribute to this trend. In her words, “our lack of experience as obstetricians colored by our fear of liability is narrowing women’s choices, and sometimes motivating them to ignore fetal and maternal safety in an effort not to be coerced into unnecessary interventions” and “many obstetricians do not have the willingness, time, or skills to provide maternal choices.”

While she highlights the decrease in maternal mortality in the last century as a strongpoint of modern obstetrics, Fineberg also notes that in spite of the U.S. spending more per capita on health care than any other country in the world, infant and maternal mortality rates are higher in the U.S. than in all of western Europe, with the world’s third highest cesarean rate to boot. She cites a recent study which found that “nearly half of all primigravidas attempting vaginal delivery are induced, and half of cesarean deliveries for dystocia are done before 6 cm of dilation, presumably before active labor.”

Fineberg calls obstetrics an art and a privilege and implores her colleagues to seek out mentoring if they lack basic skills such as forceps and breech extractions. She advocates for offering “real choices” to patients and being willing to admit what is truly evidence based versus what is merely tradition and culture. While she feels that collaborating with midwives is a positive, she encouraged other obstetricians to stop the trend of becoming simply cesarean-performing machines in part by “hav[ing] conversations with [their] patients that are not one sided and allow for true informed consent.”

A few quotes from the article:

“A colleague of mine in another state watched the residents she was supervising emotionally bully a young woman and her mother into a cesarean delivery.”

“We can all agree that VBAC, twins, and breech should not be managed at home, yet we frequently demand complete control of the situation and eliminate some appropriate choices in the hospital.”

“Most midwives know from experience that Friedman’s curve is too strict.”

“The Term Breech Study closed the door on vaginal breech delivery even for the lowest-risk women in most obstetricians’ minds…”

“We need to recognize and own those aspects of obstetric management that are driving our skyrocketing cesarean delivery rate but having no positive effect on maternal or infant morbidity and mortality.”

“Many of the obstetric disasters we have all seen and which color our perspective (which David Grimes has called “numerators in search of denominators”) are at least in some part iatrogenic if examined deeply enough.”

I sent the article to a group of OB-GYN friends last week and asked if they would be willing to write up a response to the article, whether critical or complimentary, formal or informal. Their work will be featured daily this week.

Respectful contributions to the discussion are welcome on subsequent posts.


Lament, in Stereo by Lauren A. Plante, MD, MPH

A Comeback for VBAC? by Poppy Daniels, MD

Another Obstetrician's Lament by Gustavo San Roman, MD

An Obstetrician's Hope by David Hayes, MD