Tuesday, September 28, 2010

Nice Is Not Enough: Questions for Interviewing a Maternity Care Provider

Many women want to choose their pregnancy care provider carefully, but aren't sure what questions to ask when interviewing doctors or midwives. 

Here are some general questions from http://www.birthsense.org/ to ask any provider you are considering during your pregnancy and birth.

I don't want to reproduce the entire post, so be sure to go to her site and read the whole thing because the author wrote about the "wrong" answer and the "right" answer to each question, and that's really much more informative than just looking at the questions themselves.
  1. What is your philosophy of pregnancy and birth?
  2. How do you define “normal birth”?
  3. Can you give me an example how you typically manage a normal birth?
  4. How would you feel if I disagreed with you about a procedure you recommended during labor or birth?
  5. How long will you “allow me” to wait if I go overdue?
  6. What position(s) will you allow me to use when giving birth?
  7. How do you feel about IVs and continuous fetal monitoring?
  8. How do you feel about a woman eating and drinking in labor?
  9. What do you recommend a woman do during labor?
  10. What are your thoughts on pain relief in labor?
  11. How do you feel about cesarean birth?
Some childbirth educators would substitute different questions here and there from this list (for example, I probably wouldn't use the first question) but it's a reasonable basic list to start with.   Adapt as necessary for your own personal situation and concerns.

Again, be sure to read the original article ("In Search of Dr. Right: 11 Questions to Ask") so you can see what are good caregiver responses to these questions and which ones should raise a red flag to you.

There are other additional questions I would ask if you are a woman of size, but more on that below and in future posts.  If anything, women of size need to be even more vigilant in asking questions of potential care providers because size bias is so prevalent in maternity care. But for now, the above questions are a reasonable start to the process.

Nice Is Not Enough

The author also cautioned against letting a doctor's bedside charm and personality supercede your own commonsense about interventions.  A doctor can be really charming, caring, and nice and still have a 50+% c-section rate and a 40+% episiotomy rate, which will do far more harm than good in the long run.

Just because they are "nice" doesn't mean you are going to get safe care from them that doesn't put you at risk for more complications. 

This same midwife told the story of the following doctor on her blog (note that the "Dr. Wonderful" in this scenario is not the same as the truly birth-friendly "Dr. Wonderful" discussed on some birth blogs):
What is the definition of a “good doctor”? I once knew a physician whom everyone believed was a “good doctor”. Let’s call him Dr. Wonderful. He had a very high cesarean rate, a high episiotomy rate, a high forceps/vacuum rate, and yet his patients adored him. Why?
He made each woman who came to him feel special. He was handsome and charming, and would treat each woman as if she were the only patient in the world that mattered to him. This is not necessarily a bad thing–I believe each patient should feel special and important to her provider. However, when this perception of being special clouds a woman’s judgment, it is time to have a reality check.
Dr. Wonderful would visit his patient after whatever unnecessary procedure he did, sit by the bedside, take her hand, and very regretfully tell her how sorry he was that she needed ___________ (insert the procedure of your choice), but if he had not done it, ___________ would have happened (insert catastrophe of your choice). So he very reluctantly had heroically intervened to save her life, or the life of her baby. The woman would be trembling with gratitude toward this marvelous physician by the time he left the room. None of his patients could ever believe that any of these procedures were unnecessary.
This bait-and-switch tactic is very common among some doctors (and even some midwives).  They know how to manipulate patients into going along with what they think is best and/or what is most convenient, even when the actual research doesn't support these interventions as best practice. 

Most women think that if their doctor recommends a procedure to them, it must be necessary, and who are they to question the doctor's judgment? But most don't realize how much interventions vary from caregiver to caregiver. Nor are most given adequate information about the pros and cons of most procedures.
The point is not that all interventions are "bad" or must be avoided, but that the benefits and risks of proposed interventions should be discussed thoroughly and true patient autonomy respected, not manipulated. 

If you are sure you want a hospital birth but you'd like to try and find a provider who is more friendly to natural childbirth and patient autonomy than most, this midwife summarizes one strategy for scoping out the possibilities:
I suggest that women who are planning hospital birth call their local [Labor and Delivery] unit, and ask to speak to a nurse who enjoys helping women who want unmedicated birth. Then ask that nurse for names of doctors [or midwives] that she thinks are most likely to support you in your goals.
Last, and perhaps most important, don’t be fooled by a charming bedside manner. Make sure there is substance behind it.
Amen to that.  "Nice" is great, but some doctors use it as a way to convince women into all kinds of risky interventions as a way to lower the risk for being sued. 

In particular, many women of size are just so grateful just to find a doctor who doesn't yell at them about their weight that they fail to ask further questions about the provider's rates of interventions that increase the risk for cesarean (a high induction rate, inducing for suspected big baby, etc.). 

I've been there, done that myself and gotten burned, so learn from my mistakes.

Don't fall for "nice" over substance.  Nice is a good start, but you still have to ask further questions.

Ask for Specific Intervention Rates

It's really important to ask a provider's intervention rates, especially his/her intervention rates for first-time moms.  What's the induction rate, cesarean rate, episiotomy rate? 

"I only do them when necessary" is not an acceptable answer; for some docs, interventions like these are "necessary" 50% of the time, and that rate presents far more risk than benefit. 

For example, episiotomy rates should be extremely low; if it's not, the provider is not practicing evidence-based medicine, which has clearly shown routine episiotomy to be more harmful than helpful. 

Many doctors say they "only do episiotomies when necessary" --- but if they find it "necessary" 40% of the time, there is something wrong with their definition of "necessary."  Actual numbers are important for evaluating a provider.

Primary cesarean rates (cesareans in first-time moms or mothers who have never had a cesarean before) is another benchmark by which you can judge providers.  Women who have not had cesareans before should not have a very high rate of cesareans during labor; if they do, it suggests that the doctor has a low threshold for surgery or encourages a lot of interventions that lead to more cesareans.

(Of course, if a provider regularly provides care to many high-risk women, the cesarean rate is going to be higher than a provider who mostly sees only low-risk women.....but generally speaking a high cesarean rate is a red flag.) 

It's also helpful to ask the question above about how the care provider feels about cesareans. 

If they have a high cesarean rate but are defensive about that, they'll likely say something that minimizes the impact of cesareans and ridicules the mother for caring. 

Watch for comments like, "The real priority is a healthy baby" or "A healthy baby is more important than the delivery method".....as if that justifies any intervention the doctor uses, as if the mother's outcome is of no importance, and as if the mother questioning things means she doesn't really care about her baby over herself.

Of course the priority is a healthy baby, but a healthy mother is also a priority, and one recovering from unnecessary surgery is not a healthy mother. Nor should a woman be ridiculed for caring about avoiding a cesarean or an episiotomy whenever possible. 

A provider that avoids the question of intervention rates by blaming the mother, brushing off her concern, or making her feel selfish for caring is a giant red flag.

Beware care providers that "don't know" their cesarean rate, "only do one when necessary," or who subtly deride anyone who asks questions about cesarean or episiotomy rates. 

Also ask when/why the provider would want to induce labor. 

If they routinely induce labor if the baby is thought to be  "big," that's another tremendous red flag.  Research shows that inducing early for a "big baby" actually increases the cesarean rate, not decreases it, but despite the evidence, many providers still induce early for a big baby anyway.  [This is one major factor driving the high rate of cesareans in women of size.]

If you interview a provider and they would induce early for a big baby, this is a huge red flag.

Many providers also routinely induce labor at 40 or 41 weeks (sometimes earlier!), and research is mixed on the pros and cons of this practice

Particularly for women of size (whose pregnancies tend to last longer), inducing labor early or right around term "just in case" probably leads to more cesarean risk and a whole host of other potential complications.  Find a provider who is more willing to wait and not rush things as long as mother and baby are doing well.


You can have the "nicest" doctor or midwife in the world, and he or she can coax you straight down the path to a cesarean or episiotomy you don't need by engaging in unnecessarily high rates of interventions with dubious benefits.

Being nice is just not enough.  You have to ask careful questions when interviewing a care provider, you have to ask for specific intervention rates, and it's very important to watch for the classic red "alarm" flags.

*What questions were most helpful to you when you were interviewing providers?  What questions do you wish you had asked?  What advice do you have for other pregnant women looking for maternity care providers?


Cassandra said...

I did research first and if I ever felt like I knew more than the provider, or simply questioned something said beyond needing further explanation, trust went out the window and I moved on. I can deal with someone who doesn't have a great demeanor as long as I believe they know what they're talking about. Even had to do this with a birth center midwife who overall shared the same views of birth as I did. I just couldn't trust her to know what to do, even if she actually did. Doubt was enough to make me see someone else.

Tami said...

I had a doctor exactly like the "Dr. Wonderful" the midwife described. Everyone loved him. Everyone thought he would never do something unnecessary, he only did things because he was saving the mother or the baby. He charmed many a woman into the OR unnecessarily. sigh... I also hate when women say "Well, you need to choose a doctor you can trust." Most of us DID trust our doctors! That's why we feel so betrayed! That's where the outrage comes from, when you realize the doctor you thought was helping you, making decisions in your best interest, the one who "went to medical school and thus knows more about you than you do", actually didn't have your best interest at heart, didn't care about your health, was more interested in getting home for dinner or out to a golf game (or wherever), or was trying to punish you for having an opinion.