Offensive attack on the professionalism of obstetricians

The article below appeared in the Sydney Morning Herald today (Sunday 22/5/11 on page 16). It represents an offensive attack against my profession and its claims warrant a response.

Statements that obstetricians are performing too many episiotomies and caesarean section are opinion statements without any evidence behind them. As far as my practice is concerned, I will only perform an episiotomy or caesarean when I believe that there is a genuine necessity to do so, and as far as possible I will involve the woman in that decision making process. The same applies to all forms of pregnancy intervention. As a profession, we choose to be obstetricians because we genuinely care about pregnant women and their babies. We undergo 6 years of specialty training, we undertake an onerous and at times difficult job because we want to provide the best possible care to the women we look after.

I have been a specialist obstetrician (& gynaecologist) for 15 years now and I can honestly say I have never been aware of any culture of “cover up” or “self interest”. The obstetrics/gynaecology profession was I would suggest even more appalled by the actions of the recenlty convicted doctor from the south coast of NSW than the general public was, and to suggest that we would in any way condone such criminal behaviour is offensive.

I see my role as an obstetrician is listen to my patients and to try and provide them with the care they seek, within a framework of safety for mother and baby and to provide them with sound, rational advice based on the best evidence currently available. There is no single formula or approach to pregnancy and childbirth.

The other aspect to this issue which is not raised, is the expectations of women and families in regard to pregnancy and childbirth. I have seen significant changes in these areas during last 15 years. In my opinion the majority of women do not want a long and exhausting labour, they want control over their pain managment options, including epidural and they want to know that if things are not going well in labour that there will be someone who will take responsibility for discussing things with them and giving them appropriate advice and options. The natural approach is great when it goes well and it should be encouraged and supported, but it is not what every woman wants and it does not always go well. There seems to me to be a small section of the midwifery profession who refuse to acknowledge these realities, and the tone of the article below suggests that A/Prof Reiger is part of that vocal minority.

In my opinion the notion of “professional hubris” and “tribal arrogance” could not be further from the truth. Obstetricians recognise that safe, high quality, personalised pregnancy care requires a team approach. A team which needs to include midwives, obsetricians, paediatricians, anaesthetics amongst others. Personally I value enormously the contributions of all the health professionals I work alongside in providing obstetric care, but I especially value and take heed of the opinions of the outstanding midwives I have the privilege of working with. It distresses me greatly to see articles such as this, propagating the us and them (midwives vs doctors) approach, because after all, we are working to achieve the same goals – healthy outcomes for mothers and babies. Together, we have made Australia one of the safest places in the world to have a baby and that is a fact that we should all take pride in.

Obstetricians accused of tribal arrogance

Jill Stark

May 22, 2011

WOMEN are having unnecessary caesareans and cases of genital mutilation and medical errors have gone unreported owing to a culture of tribal loyalty among obstetricians, a health sociologist says.

La Trobe University’s Kerreen Reiger said doctors were treating childbirth as an illness, leaving many women powerless in the delivery room, sometimes with harmful results – claims strongly rejected by obstetricians.

”Obstetricians are doing unnecessary episiotomies [vaginal cuts during labour] and far too many caesareans,” Associate Professor Reiger said. ”It’s a long-standing culture of professional hubris, a particular style of arrogance which says, ‘Don’t question me, I’m the expert. Don’t bring a private midwife with you because I don’t want her there.”’

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Professor Reiger examined public inquiries in Australia, Ireland and Britain and concluded concerns about alleged misconduct of obstetricians and gynaecologists were often not pursued owing to a culture of ”cover-up and self-interest”.

In a paper published last week in the journal Health Care for Women International, she cited cases such as the NSW south coast doctor convicted of maliciously inflicting grievous bodily harm on a patient whose genitals he removed without consent, saying that a lack of collective responsibility contributed to the problem.

Another case in Toowoomba involved an obstetrician accused of refusing to stop a painful vaginal examination while a woman was in labour, which midwives and consumer groups deemed an assault.

The doctor was cleared of misconduct but Professor Reiger said the cases reflected an obstetrics culture of arrogance, poor leadership and a lack of collaboration.

”Those examples are the tip of the iceberg,” Professor Reiger said.

”If you look at the case of the woman in Toowoomba who was saying, ‘No, stop, I don’t want a vaginal exam now,’ and she’s in labour and the obstetrician just shoves his hand in, in any other condition we’d talk about that as sexual assault when a woman says no.

”I’ve had other encounters lately of women who’ve had episiotomies, cutting to get the baby out, when they didn’t need to and the women didn’t want to and weren’t asked to give consent.

”It’s a recurrent pattern and the profession mostly doesn’t want to ask critical questions about its practice.”

Australian Medical Association president Andrew Pesce, an obstetrician who works collaboratively with five midwives, rejected the claims.

”Good obstetricians always listen to women, always include them in decision making and that would be considered good practice,” Dr Pesce said.

”I’m sure there are some obstetricians who don’t do that as much as they should, but there are a lot of women who come into my rooms telling me about their birth stories from when they were in a midwives clinic where they were allowed to wait far longer without pain relief, without intervention that they actually asked for because somebody arrogantly thought that nature was best and they just had to wait for nature to take its course.”

He said obstetricians had been responsible for decreasing mortality rates from about 20 babies for every 1000 pregnancies in the 1970s to about nine for every 1000 today. The death rate for mothers in childbirth had also fallen.

”Some people might call it treating pregnancy as a disease, other people say it’s being very alert for potential problems and being pro-active in the management of them.”

Professor Reiger said Australia’s caesarean rate of about 31 per cent of all births was too high, partly because obstetricians had lost skills.

”The delivery of breech babies is a case in point,” she said.

She called for more collaborative models of care led by midwives.

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