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  • Writer's pictureDr Sean Holland

In defence of obstetricians

Recently there have been a couple of newspaper articles that have painted the obstetric profession in a rather unflattering light. So unflattering in fact that I feel it necessary to offer up some defence of my specialty.

The first article was in Brisbane's Courier Mail reporting on allegations that obstetric clinicians have been "barging in" to birth suite rooms at the Mater Hospital Brisbane uninvited and with seemingly aggressive and unwelcomed demands for intervention - "Doctors slammed for 'sticky beaking' into births". To the Courier Mail's credit, this was followed up with a balanced counterpoint including salient interviews with Dr Gino Pecoraro (former AMAQ president and practicing obstetrician) - "Fears labour ward culture is fuelling suicides and baby deaths".

The second was an article in The Review section of The Weekend Australian newspaper, "Fighting for the feminine", a printed extract from feminist writer Antonella Gambotto-Burke's latest work, "Apple: Sex, Drugs, Motherhood and the Recovery of the Feminine". To say that it is disturbing reading barely scratches the surface. Indeed, at one point the author seemingly blames climate change on the harm committed by obstetricians involvement in childbirth! At a minimum, the extracted pages present a grab bag of misinformation and popular negative tropes associated with obstetric involvement in maternity care.

The above articles are hardly isolated examples of reports and publications critical of the role obstetricians play in the birth process. As I'm sure most women will attest, it is all too easy to be exposed to warnings and fear-mongering about the 'evils' of obstetric practice as soon as you announce your pregnancy and delve into the social media driven world of Instagram, Facebook et. al. Such on-line commentary is at its least unhelpful but at its worst harmful in the way that it can fundamentally undermine a woman's preparedness to engage with obstetricians if and when events arise that potentially place her pregnancy at risk.

Social media aside, the academic and pseudo-academic (read blogosphere and personal websites... yes the irony is not missed) literature is replete with articles, particularly from academic midwives (many of whom are somewhat removed from clinical practice) critical of obstetricians for excessively intervening in the birth process. These writers are no doubt well meaning, however, as a clinician I can't help but feel that they are often guilty of cherry picking data to suit their narrative rather than adjusting their narrative to suit the data.

In this regard, the tension seems to be between the primacy of the birth experience vs. medically perceived safety of the woman and unborn child. The fundamental question being, "when push comes to shove, which of these important aspects of childbirth, experience or safety, should be leading the continuum of care?" As an obstetrician, while I want all of my patients to have a positive experience, I try to ensure that they are prepared to cope with the possibility that safety may require a fundamental departure from their anticipated birth plan.

In some ways, we as obstetricians are victims of our own success. As demonstrated in the following graph (US data), perinatal mortality (a combination of stillbirth and immediate post delivery newborn loss) has steadily fallen over the past 80 years:

Similarly, maternal mortality has dramatically improved:

The above graphics illustrate the tremendous advances in healthcare that have been achieved in modern advanced societies. In terms of pregnancy related outcomes, these advances are due to an array of factors including improved diet, access to healthcare, improvements in education, and, importantly, improvements and advances in the investigation, monitoring and management of complications as and when they arise in pregnancy - in other words, the growth of evidence based obstetric practice. To name but a handful of advances:

  • High definition ultrasonography, including cutting edge in-utero surgery;

  • Advances in screening for congenital and genetic abnormalities, including potentially fatal congenital concerns that can now potentially be addressed with a combination of high level obstetric and neonatal medical/surgical intervention (think complex cardiac abnormalities as an example);

  • Improvements and advances in our understanding and management of complex maternal disease processes such as pre-eclampsia and gestational diabetes;

  • Improvements in our knowledge and recognition of risk factors for end of pregnancy complications;

  • Improvements and advances in obstetric techniques to address both predictable and unexpected complications of delivery.

On the back of this explosion in evidence based practice there has been decided shift towards involvement of obstetric clinicians in the management of many pregnancies, either during the antenatal period or at the time of delivery - as an example, 25% of first time mothers end up having an instrumental delivery and over 15% have unplanned caesarean sections (according to the most recent Australian data).

We are now living in an age where pregnancy and childbirth are safer than they have ever been at any other point in human history. So safe in fact that there has developed somewhat of a backlash against the involvement of medical practitioners in the "natural process" of childbirth. This backlash, in my opinion, is driven by a multitude of factors:

  • professional conflicts between midwives and obstetricians, particularly in the public sector where the line between obstetrician as senior clinician and midwifery independence too often becomes blurred;

  • under resourced public systems trying to provide care to more pregnant women than they genuinely have capacity for. This creates a system that is constantly under strain and only serves to amplify tensions between medical and non medical approaches to care;

  • dishonest (or perhaps just ignorant) leaders in public healthcare who promise women and their families that all models of care are equal and supported when the reality is that efficient utilisation of scarce healthcare resources should be demanding an improvement in the system that serves the many without compromising that system to provide "gold class" care to the few;

  • equally, a fundamental reluctance of those self same leaders to point out the genuine clinical risk that all too often accompanies non-hospital led care, instead dismissing such concerns as "not statistically significant".....a phrase that fails to acknowledge the concept of clinically significant findings - those that may not reach a predetermined p-value but for which data undeniably demonstrates a difference in outcomes;

  • ignorance of history creating the fertile ground upon which experience trump's safety; and

  • a fundamental misunderstanding of exactly what it is that an obstetrician seeks to do.

I have to some extent already addressed the historical improvements in maternal and infant outcomes. This has been transformative for millions of families. Equally, I think it has falsely reassured many into believing that childbirth is a wholly safe endeavor, almost without risk. And to be clear, for the majority of women they can expect their pregnancy to be largely uneventful, other than the life changing arrival of a baby that is. But, for a significant minority (40+% of first time mother's as per Australia's data), that safe outcome is only achieved with the assistance of a trained obstetric physician.

So what does an obstetrician do?

For an obstetrician, our philosophy is built on the foundations of medical practice and that Hypocratic ideal "first do no harm". Our training is first and foremost in the identification and management of risk to ensure a safe pregnancy outcome for both the mother and the unborn child. We spend years (average 16+years (including medical school)) just to gain specialty qualifications and the right to call ourselves an obstetrician. This training instils a fundamental knowledge of the human body, the physiology of pregnancy and, importantly, the potential issues that can arise and how best to respond to them. The skill of the good obstetrician, and what distinguishes them from the mediocre, is in how they approach any identified risk in concert with the woman to ensure that she remains an integral part of the decision making process rather than simply having things done to her. Generally speaking, this is more easily achieved in private practice as our patients spend time meeting with us throughout their pregnancies and are given the opportunity to become comfortable with their obstetrician and educated and informed as to how and when potential obstetric procedures may be required. Public medicine is less ideal in this regard as often times the treating obstetric team have never met the woman and, regrettably, too often the woman has not been afforded adequate antenatal education due to a combination of inadequate public health resources and, in some cases, misguided principle non medical clinicians who philosophically seem incapable of addressing the potential need for obstetric intervention.

Philosophically and practically then, what is a good obstetrician? A good obstetrician is the following:

  • A caring clinician;

  • A knowledgeable clinician;

  • A skilled accoucheur;

  • A skilled surgeon;

  • A good communicator.

An obstetrician is not someone that prowls the corridors of their delivery suite waiting for the opportunity to ruin an otherwise perfect birth experience. A good obstetrician is not someone who over-reacts to potential risks and intervenes out of fear or laziness or both. Childbirth in the first-world is now safer than it has ever been in human history. This is the result of numerous advances in healthcare and well-being including improvements in diet, social demographics, new-born and preterm care and, critically, improvements in the identification, recognition and management options of the complications that can arise in any pregnancy.

This last advance is the achievement of obstetrics as a specialty and should be valued, not traduced.

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