I am excited to share a piece today from a friend of mine, Lauren. Lauren immediately caught my attention when I met her. Easily one of the most passionate and knowledgeable breech experts out there, she is doing some amazing work on her website (www.MyBreechBaby.org) making information about breech birth options more available to women everywhere.
She echos many of my own feelings regarding how sad it is that physicians are not even well trained in breech delivery these days. How tragic that a profession would choose to lose skills that will inevitably be necessary on occasion.
Read it. Check out MyBreechBaby.org. Share it.
Change can happen, but it needs to come from us.
At one time I was naïve enough to walk into a McDonald's and ask for a salad Niçoise and a lemon Perrier water. As you can imagine, none of it was available. Some of the employees shook their heads in shock, some laughed scornfully, and some told me I should just be happy with a double cheeseburger because, after all, I would have a lunch and that's what really mattered. What I learned is that the service at McDonald's is a lot like what you get from your obstetrician.
McDonald's is McDonald's. They only offer things one way. They are good at it. It's what makes them McDonald's. It is a great fiction in fast food that you can “have it your way.” There really is only one way. You get the same sandwich in Plano, TX as you do up the road from Boston University. The inflexibility and assembly-line efficiency are what make it comfortingly samey day in and day out, everywhere.
So yeah, it's silly to walk into a McDonald's and ask for a salad Niçoise, almost as silly as asking for a vaginal breech birth at a major medical center. Actually it's not silly at all, but you're likely to get the same reaction. A what?? It hasn't always been this way. At one time, many obstetricians knew what to do when a baby presented breech, besides rush to the OR. But along the way, insurance companies and hospitals were so excited to drop vaginal breech births and perform more cesareans that after only one (very flawed) study, not only can you not find a practitioner who supports vaginal breech, you're lucky to find one who has any significant experience or education in the matter at all. This is not OK. At one time, educational institutions were actually threatened loss of coverage by their insurance companies if they taught vaginal breech skills in med school. Considering women are literally dying from cesarean complications, even years down the road, and that vaginal breech birth “in select cases” is even encouraged by The American Congress of Obstetricians and Gynecologists, the lack of options for women with breech babies (or any other variation from ''normal') is disturbing and infuriating.
Today I would like to address this distressing McDonald's-ification of obstetric care. There is general inflexibility and inability to provide more complex care. This is not only infuriating, it's dangerous. In the case of breech babies, in spite of very high tech ultrasound, some breeches are a surprise. Without training or experience, a doctor cannot offer you any options or even any education to help you make a decision. Vaginal breech birth attended by people who are afraid of breech birth is incredibly risky. Allowing someone to cut a hole in your abdomen and extract a tiny human from your uterus is also risky. Women need to really understand their options, but to do that, they have to have options.
In any good restaurant, you can have things a number of different ways. In excellent restaurants, you can even say, “I'm vegetarian, I don't see anything that strikes me on the menu. Have the chef create something.” They want to serve you, they want to get you the best possible care and nourishment they can, and they care what you think when you leave. They still set the menu and the seating arrangements. Of course. You should not be able to just get whatever you want, wherever you are, without question---at a restaurant or a maternity unit. Doctors do know many things, they have more training than you, and hopefully they can advise you. But unfortunately, very often the menu is short, the explanatory details are slim, and the service is lacking. There are 3 things that have really dumbed down obstetric care to a fast food level:
- Impatience. When I enter a fast food joint and start looking at the menu, I stand back along the ketchup counter, as far from the registers as I can. I'm looking at the menu, contemplating which delicious horror I will consume, avoiding eye contact. Inevitably, “Can I help you?” (Because I do, in fact, prefer to shout my order from back here, yes.) What the poor teenage sap means, of course, is, “I don't want to stand here waiting for your order for ten minutes; hurry up and pay.” Sound familiar? We've got mass quantities of inductions. Failure to progress. Scheduled cesareans. Immediate artificial rupture of the bag of waters. Pitocin, pitocin, pitocin. All often symptoms of impatience. With breech babies, for example, many good doctors (and midwives) have observed that you can tell in labor (based on how it is progressing) if a woman will deliver safely. If it looks unfavorable, you move to a cesarean. The vast majority of breech mamas never get the chance. Same with vbac. It's 'cleaner' to just schedule. Get the messy stuff out of the way. The health inspector loves it.
On top of that, there is the almost complete lack of education that goes on in doctor's offices and hospitals. Do they really want us to go home and google it for ourselves? Shouldn't a large part of being a physician be about educating your patients? I want to know exactly what is going on, what it means, what my options are, and what the chances are. If you have a breech baby, they often don't mention it until 36 weeks when they say, “Baby's breech. If she doesn't turn we'll have to talk about cesarean.” Not helpful. Maybe they just don't have the time. Or they assume you don't care or wouldn't understand. Or, don't you trust them to make the decisions for you? It's like, if you want to ask for the nutrition information papers at McDonald's, you shouldn't be there.
- Ineptitude. I have literally never had my order correct at the Wendy's in our town. Not once. Last week I had a 4 minute discussion at the counter about how I didn't want cheese on my snack wrap even though the cashier assured me that cheese never came on them. I will leave you to imagine if the snack wrap I got had cheese--along with whether or not the bear poops in the woods. I have noticed this exact same phenomenon is often observed when a woman says she doesn't want an epidural! Going to go natural, huh? No problem, it's your choice...The anesthesiologist is here for your epidural. It's your last chance, I would go for it. Doctors really only know how to do two kinds of birth. 1. You sit there hooked up to tubes and wires and they tell you when to push your baby out onto the table and 2. Surgery.
Though there are certainly exceptional doctors working within the establishment, the general truth is that the choices in childbirth are abysmal. Almost no one does twin or breech births. Few doctors can perform ECV or have much useful knowledge of fetal positioning. They can't (or won't) help turn a posterior. Since they make liberal use of sonogram, their ability to palpate the abdomen has gone out the window. Many have never even witnessed a planned un-medicated, un-induced and un-augmented birth, much less an active birth. The vast majority only feel confident delivering a baby with you on your back on a table, and they get very antsy or angry if you want to deliver on your feet or knees or side. Most do not prepare you for or help establish breastfeeding and they don't offer anything useful in the way of nutritional advice. It's crazy that these more extensively trained, much more highly paid guardians of health and safety offer so little in the way of health and safety. It's fast food obstetrics. No restaurant can provide you with every possible option, of course. But obstetric care has gotten so low that your choices boil down to: processed chicken or beef patty and how soon do you want diabetes with that?
- Impersonal Care. Ever seen them make those burgers? The only difference here is that it's lubricating gel instead of ketchup. Line up the vulvas, squirt 'em, check the beepy machine, and the bun comes out of the oven. You're lucky if anyone calls you by name, and very lucky if they don't do so with a tone that makes you wonder if they've confused you with a child about to get a tetanus booster. Oh sweetie, you can't have a breech baby naturally. They all get stuck and die. Or you end up with a cesarean anyway and have a brain damaged baby. You don't want that, do you? On top of that, it's all about those blasted machines. Oh snap! the automatic frier is down. The microwave keeps beeping. You're about to have a contraction! OK, the contraction is over. Hey! It's over! What's wrong with you? Stop whimpering! (True story.) There are some wonderful, sensitive, and genuinely kind people working births in hospitals. But if you get such a birth team on your birth day, it's really something to write home about. Like getting fresh french fries at 3pm.
Calling obstetric care impersonal is really actually me trying to be professional. It's hard not to be incensed when whole staffs of people--who are being paid the big bucks to help you during one of the most difficult/intense/important days of your life--can be downright mean. Usually just condescending and insensitive, but sometimes, mean. Micky D's employees are just annoyed at you, but there's plenty of that going round in maternity as well. Another woman with a birth plan...sigh.
There are exceptions. Maybe even many. And like many things, it's really the system that is at fault. The whole medico-legal, insurance and profit-driven system breeds impatience, ineptitude, and impersonal service. It's not that these people-serving professionals are horrid people. It's that the system they are trained, surrounded with and paid by almost requires them to be this way. That does not excuse it. These are our bodies, our babies, and our lives. This is not a small deal. It is not just one day.
And it's getting worse. Systems are slow to change, and though bright individuals do make a difference, it's going to take a full scale ground-up revolution to exact real change. And it has to be driven by money. Case in point: doctors tell me that hospitals don't offer breech births because women don't demand them. I have to believe there are many, many things they do or don't do because we as consumers aren't making a big enough fuss about it. Even McDonald's changes in response to heavy consumer complaints.
Well, it's time to make a fuss. Tell your friends. Start advocating for yourself and everyone else who will give birth. Do it by refusing to pay for care that is less than excellent. Those of us who bring money/insurance to the table will be helping the women who don't have this bargaining chip. The first woman may not exact change, but if enough people say they are switching care providers--because of a certain center's cesarean rate, for example--change will come.
The hitch is that women have to care first. And before that they have to know why they should care. That won't come from the doctors. Those who know just how much better the care at most hospitals could be must share their knowledge with others—gently. Each one of us must learn about birth, prepare ourselves, make the best decisions we can, and then demand the best care available. We must be willing to take our business elsewhere. Otherwise, we collectively condemn ourselves to impatient, inept, and impersonal care in birth. I, for one, am not lovin' it.