How to train your obstetrician – part 1

surgeon_penguinDear esteemed obstetric colleagues,

Before you write in and complain, please let me tell you that not only has this post been approved by some of my favourite obstetricians, it was actually commissioned and titled by one of them.  It is dedicated with love to all obstetricians, but particularly those who seek to take a woman-centred approach and have removed the words ‘allow’, ‘patient’ and ‘trial of labour’ from their vocabulary, except perhaps for when they attend conferences and find themselves otherwise unable to communicate with their peers 😉


It is a truth universally acknowledged, that an obstetrician in possession of a scalpel must be in want of a holistic midwife to teach them woman-centred ways.
However little known the feelings or views of such an obstetrician may be on his or her first entering practice, this truth is so well fixed in the minds of the surrounding midwives, that s/he is considered as the rightful recipient of some – if not many – of their woman-centred values, primum non nocere viewpoint and ways of seeing birth as a normal, everyday event.


The power of the paradigm

Unless this is your first visit to this website – in which case, welcome – you’re probably aware that I often talk and write about the existence of two different paradigms (or sets of ideas) that exist in relation to maternity care. They’re often called ‘the obstetric approach’ and ‘the midwifery model’. Although I try never to mention them by these names without immediately adding the caveat that the names of these approaches relate to belief systems, not to people or professional groups. Because there are plenty of obstetricians who take a midwifery model approach, just as there are a good many midwives who are more closely aligned to the obstetric viewpoint. If you’re not already familiar with the differences between these models, this brief article explains them a bit further.

medium_360181859Many women value and want the ‘midwifery model approach’. It’s more inclusive of their knowledge and experience and sees pregnancy as a personal and usually healthy journey.  The midwifery model approach is also supported by tons of evidence that it brings many benefits for women and babies. It places the woman firmly at the centre of her care and acknowledges her as the key decision-maker. The approach doesn’t reject technology and intervention where this is appropriate and the woman is happy to have it, but it is often respectful of non-Western approaches, ideas and therapies as well.

There are variations between different countries and areas, of course. And many midwives, doctors and others are already respectful and supportive of an evidence-based, woman-centred approach. They see enormous value in a model where midwives are the primary caregivers for women, with obstetricians being invited (if a woman wants this) to consult in situations which are not quite so normal or straightforward. There exists mutual respect between the two groups. Obstetricians are respectful of midwives’ knowledge, of their ability to determine when things are fine and normal and when a bit of help (of whatever kind) might be needed. Midwives in such settings are equally respectful of the obstetrician’s experience in dealing with less straightforward situations and of their surgical and medical skills which are sometimes the best pathway to a good outcome.

Yet in other areas women and midwives struggle to get their obstetric and other medical colleagues to see the value in this kind of approach. So this article offers a few suggestions from my own experience of how we – as midwives, birth workers, women and families who are trying to facilitate a greater uptake of this evidence-based, woman-centred model – can help facilitate the journey of those who have come from an obstetric paradigm background and who want to be more woman-centred (even though they may not know it yet 😉 )

Because I have quite a lot to say on this topic, I’m dividing this piece into two parts.  In this first part, I am going to suggest that the first step is about understanding why people think, believe and do what they do, and then in the second part of this article I will look at how and why people come to reconsider and change their approach, and what we can do if we want to help facilitate reflection and change.


Understanding where medical-model focused people are coming from … and how they got there.

I medium_55767480don’t mean to suggest that everyone has been on the same journey. Far from it. So this needs to be individualised, but there are some key elements of our culture in general and of medical (and sometimes midwifery) education in particular which predispose people to taking a medicalised, technocratic approach to birth.

If you’re reading this as someone who has been part of ‘the birth world’ for quite some time, it is easy to lose track of how birth is viewed and portrayed outside of such networks. Turn on daytime TV for even just a few minutes (but only if you think you can handle it – I did just that the other day when I was unwell – big mistake!) and you’ll encounter all sorts of fear-based views about birth. These views are often in complete opposition to what we know from the evidence. So many people are affected by the mainstream Western cultural viewpoint – and the idea that birth is risky – before they even go into medical or midwifery education. It is, then, unsurprising that this notion carries on as a core element of many people’s belief systems.

The educational journeys of midwives, doulas and childbirth educators often include significant opportunity to unpack one’s own pre-existing cultural biases. And to reflect on situations experienced in practice as well as consider a wide variety of ideas and approaches. However, with the caveat that some innovative and exceptional courses are beginning to be offered by some medical schools, this is not generally the case in medical education.

And let’s not forget that our culture promotes the notions of doing over being, action over reflection and pharmacological pain relief over psychophysiological care and support…

The process of medical education itself may also have a significant part to play in informing the belief systems and priorities of practitioners.  I don’t really need to write much about this – although it is a huge issue – because Robbie Davis-Floyd wrote a really interesting paper called ‘Obstetric Training as a Rite of Passage‘.  She analysed the words and experiences of obstetricians, showing how the very nature of medical education has an effect on the way in which they thought about and saw the world. If you’re interested in this question and not already familiar with this work, I thoroughly recommend you go off and read that paper in full. It can really help to illustrate why people who go through different kinds of educational processes end up with different kinds of belief systems.

‘In the first two years of medical school, pressures of threat and uncertainty mount. A competitive emphasis on grades and tests, the unpredictability of pop quizzes, the overwhelming bulk of the work at hand, and the increasing isolation of the initiates – all combine to narrow the initiates’ range of cognitive functioning. In this process medical students do not become less intelligent; rather, the span of their intellectual capacities and concerns becomes constrained. A kind of tunnel vision develops: the cognitive overload which first- and second-year medical students experience forces them to focus only on what is immediately in front of them. Progressively less capable of reflexivity (Babcock 1980) and the conceptual distance from the socialization process which would accompany it, students gradually lose sight of the idealistic goals they may have had on entering medical school. If the rite of passage is successful, the new goals medical students eventually develop will be structured in accordance with the technological and scientific values of the dominant medical system. The emotional impact of this cognitive retrogression is aptly summarized by a former resident:

Most of us went into medical school with pretty humanitarian ideals. I know I did. But the whole process of medical education makes you inhuman….I’ve seen people devastated when they didn’t know an answer…. The whole thing can get you pretty warped. I think that’s where the feelings begin that somebody owes you something, ’cause you really, you know, you’ve blocked out a good part of your life. People lost boyfriends and girlfriends, fiancees and marriages. There were a couple of attempted suicides….So you forget about the rest of life. And so by the time you get to residency, you end up not caring about anything beyond the latest techniques you can master and how sophisticated the tests are that you can perform.’

Then, we need to look at the expectations that people have of doctors (and other professionals) these days, which are often – perhaps partly because of the erroneous ideas perpetuated by modern culture and the mass media – unrealistic.  There are no guarantees, and yet that is exactly what some people want and expect doctors to provide.  People who specialise in the abnormal are only ever really going to see that, and so it becomes harder and harder to remember that normal really does exist. Which explains why some people have such a hard time trusting women’s bodies, taking a woman-centred approach or feeling able to wait.  In addition, some people don’t want to make their own health-care decisions (although of course many do) and the weight of expectation (and let’s not forget litigation) that some professionals feel can create immense pressure to perform. Along with an almost unbearable sense of responsibility. Add in the pressure placed upon people by the systems of care, budgets and other frameworks within which many are working, and I think it becomes easier to understand why some people end up taking an approach that seemingly ignores the individual and prioritises routine intervention.

There is little doubt in my mind that the best way to address much of this is to do so at a systemic level.  Just being nicer to each other is a lovely idea, but it isn’t going to address the political, economic and socio-cultural impact of decades of medical model dominance. But while we await (or perhaps plan?) a system-level revolution, there are a few things that we can do in our relationships with those colleagues whose clients wish they would be a bit more open to their needs and to the ability of their bodies to birth without needing to be strapped to a monitor and held to the clock.   In my next post, I share seven tips from my own and others’ experience of working with obstetricians who were actually Midwives in Disguise but just didn’t know it when they met us 😉


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midwife with pinard by Joshua Berman and surgery by ReSurge International via photopin cc and cc