Holistic OB/gyn Residencies

[Jessicagraceyod]

I am really interested in pursuing an OB residency at a program that encourages natural childbirth, has a low ceserean rate, and values the fact that having a baby can be an empowering experience for women. I realize that deviation from the conveyer belt model of labor and delivery is the exception rather than the rule, but does anyone know of programs that lean more toward the holistic rather than technocratic model of birth?

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[snowinter]

Hi Jessica,

I doubt there will be programs that discourage C-sections. But, your thought is interesting-- you sound just like one of my best friends; she recently had her baby at home --she was frustrated with her ob doctors-- and she has many of the philosophies that you seem to have. I've spoken to her a lot now that ive decided to puruse obgyn.. trying to see how what patietns like her want in their obgyn.

I think the problem in today's climate is -- that even if we try to discourage c-secitons-- there are times when it is indicated.. but that obgyn is not an EXACT science (nor are any of the other fields) ... so an ultrasound may say your baby is too big and you need a c-section -- and he is born -- and the baby is not. however, if teh baby were to be big -- as teh ultrasound predicted --- and baby dies or gets injury from shoulder dystocia-- you can bet that obgyn will get sued. So, now the physician must work 3 patietns at all times: 1. mother 2. baby 3. potential law suit.

I'm interested in hearing more of your thoughts on this issue --since you'll have to face the same issues as an obgyn physican.

also, it is a neat question-- maybe their are some programs have addressed thsi issue as well -- my guess would be california?

snowinter!

 

[kem]

Hi-

I would look into University of New Mexico. I remember when I interviewed there I got the impression that they were more holistic than other programs. Everyone was very nice there, too.

Good luck!
-kem

 

[snowinter]

also, if you do a search for holistic obgyn residencies-- you get a few matches:

wisconsin:
http://www.aurorahealthcare.org/aboutus/meded/programs/obgyn/narayan.asp

oregon:
check out dr. Collins
http://www.ohsu.edu/obgyn/generalist/general.html

long island:
http://wehealny.org/services/lichobgyn/index.asp

 

[Jessicagraceyod]

Thanks for everyone's help. Snowinter in response to your comments I'm really not seeking a program that actively discourages C-sections when medically appropriate. However, when one in four babies in the U.S. must be extracted by a surgical procedure rather than natural vaginal birth then this reflects more than medical necessity (-- perhaps physician impatience, increased use of epidurals, increased inductions leading to the need for c-section intervention). The World Health Organizations recommends aiming to keep the C-section rate below 15%, and I think this is an attainable goal without risking the health of mom or baby.

My interest in holistic birth also came from having a number of friends who have had really positive experiences with home births, midwives, doulas. This sort of launched me into reading all sorts of books on the subject....I think a lot of these books are MUST READS for anyone going into OB/gyn...I'll list them if anyone has interest....

1. "Birth as an American Rite of Passage" by Robbie Davis-Floyd (written by an anthropologist who deconstructs the rituals that inculcate women into the technocratic model of birth...a little dated by still a valuable read).

2. "Obstetrical Myth vs. Research Reality" by Henci Goer (summarizes journal articles revealing how obstetrics is not always the empirical science it claims to be).

3. Birthing From Within" by Pam England. Unlike "What to expect when you're expecting," this birth preparation book helps women examine their underlying attitudes toward pain and prepares them for the emotional and spiritual challenges of labor.

4. "Ina May's Guide to Childbirth" and "Spiritual Midwifery" by Ina May Gaskin. This midwife is a bit of a hippy who lives in a Tennessee commune called The Farm but her stats on birth speak for themselves...she has like a 4% c-section rate, .01 % forceps deliveries, no maternal and minimal neonatal mortality.

5. "Baby Catcher: Chronicles of a Modern Midwife". This is an AWESOME book of stories - thoughtful, funny....it'll make you want to have a home birth!!

6. "Having Faith" by Sandra Steingraber. Written by an ecologist who examines the environmental sources of breast milk and amniotic fluid contamination. Beautifully written.

 

[deeq]

You should check out Baystate Medical Center in Springfield, Massachusetts. It's Tufts community hospital campus. The interns work very closely with midwives their first year on L&D.

 

[fang]

Thanks for everyone's help. Snowinter in response to your comments I'm really not seeking a program that actively discourages C-sections when medically appropriate. However, when one in four babies in the U.S. must be extracted by a surgical procedure rather than natural vaginal birth then this reflects more than medical necessity (-- perhaps physician impatience, increased use of epidurals, increased inductions leading to the need for c-section intervention). The World Health Organizations recommends aiming to keep the C-section rate below 15%, and I think this is an attainable goal without risking the health of mom or baby.

I've haven't been with any ob-gyn's who WANT to do C-sections-- they just want to protect both the mom and the baby. I support the idea of dropping the c-section rate, but the way to do it is to examine the indications for C-sections and inductions (which can fail). That won't be as easy as you might think-- imagine saying this to a patient: "Your baby's heart rate is dropping occasionally in a way that might make us think he isn't happy with labor. (think occasional late decels). Usually we'd be considering a c-section at this point just to be on the safe side, but we're trying to better understand when women actually need c-sections and when they don't so we can drop the c-section rate in this country. We'll leave it up to you, but we'd like to delay c-section and see if your baby will be ok after a vaginal delivery."

Or, how about when you walk in the room and there's a 16 year-old girl who is screaming every time she has a contraction, and is only about 3 cm dilated. Are you going to say "we could give you an epidural right now to really cut down your pain, but it prolongs labor by about an hour and isn't natural, so we're going to show you how to breathe through it instead." (I'm all for breathing techniques, but not AFTER someone is in that much pain!)

I'm pointing this out b/c it seems like many of the proponents of "natural" childbirth don't seem to acknowledge the uncertianty and risk in all of this... to many of them, it's lazy or impatient intervention-happy doctors who are making women have tons of c-sections and epidurals that they don't need. A natural, at-home, empowering birth is great if everything goes well. If it doesn't, my argument is that you WANT some "unnatural intervention". Yes, we really need to better find out when to do c-sections and inductions and when to wait, but it's not as simple as just adopting a plan of less intervention with no data to back it up.

 

[DrBuzzLightYear]

I'm pointing this out b/c it seems like many of the proponents of "natural" childbirth don't seem to acknowledge the uncertianty and risk in all of this... to many of them, it's lazy or impatient intervention-happy doctors who are making women have tons of c-sections and epidurals that they don't need. A natural, at-home, empowering birth is great if everything goes well. If it doesn't, my argument is that you WANT some "unnatural intervention". Yes, we really need to better find out when to do c-sections and inductions and when to wait, but it's not as simple as just adopting a plan of less intervention with no data to back it up.

i want these "natural birth" people to see a crash-n-splash c-section when theres no time for anesthesia. after you hear screaming like that, any woman would want to make damn sure she had an epidural in place early in labor.

 

[snowinter]

Fang,

I agree with all your points -- and very well put too!

I wonder though -- to what extent is this whole anti-obgyn naturalist movement a result of establishing a poor rapport with our patients? I'm still a student -- but i've developed the same tendancies that I see in many residents (in every field) -- rush rush rush. Patient wants to complain? no time for that

How much of this battle was created b/c young ladies felt out of control over their bodies -- the doctor came in and said -- no i wont listen to your alternative breathing method. no time for that., etc. And because obgyn (like many other fields) is not an EXACT science.. when things didn't work out exactly as said by their obgyns -- the lack of trust in the relationship has now just spiraled out of control.

If you look at the "naturalist population" advocating all this-- they are usually young, healthy, and educated ( at least a college degree).

and would it be stretching it too much to say that our malpractice state is to some extent also a reflection of poor rapport with our patients? Not that the rulings haven't been excessive in the past. I'm not saying all of these things are our fault (as the obgyns) .. I'm just wondering to create a solution -- if the answer isn't really just to take heart all the concepts they are emphasizing in today's medical schools more (communication, eye contact, patient's right to choose, etc) as opposed to the more paternalist values taught 10-20 years ago.

On the other hand, I admit that I get tired & frustrated & impatient as much as the next person -- so I know this solution isn't easy.

snow

I've haven't been with any ob-gyn's who WANT to do C-sections-- they just want to protect both the mom and the baby. I support the idea of dropping the c-section rate, but the way to do it is to examine the indications for C-sections and inductions (which can fail). That won't be as easy as you might think-- imagine saying this to a patient: "Your baby's heart rate is dropping occasionally in a way that might make us think he isn't happy with labor. (think occasional late decels). Usually we'd be considering a c-section at this point just to be on the safe side, but we're trying to better understand when women actually need c-sections and when they don't so we can drop the c-section rate in this country. We'll leave it up to you, but we'd like to delay c-section and see if your baby will be ok after a vaginal delivery."

Or, how about when you walk in the room and there's a 16 year-old girl who is screaming every time she has a contraction, and is only about 3 cm dilated. Are you going to say "we could give you an epidural right now to really cut down your pain, but it prolongs labor by about an hour and isn't natural, so we're going to show you how to breathe through it instead." (I'm all for breathing techniques, but not AFTER someone is in that much pain!)

I'm pointing this out b/c it seems like many of the proponents of "natural" childbirth don't seem to acknowledge the uncertianty and risk in all of this... to many of them, it's lazy or impatient intervention-happy doctors who are making women have tons of c-sections and epidurals that they don't need. A natural, at-home, empowering birth is great if everything goes well. If it doesn't, my argument is that you WANT some "unnatural intervention". Yes, we really need to better find out when to do c-sections and inductions and when to wait, but it's not as simple as just adopting a plan of less intervention with no data to back it up.

 

[burlypie]

I'm doing OB research at San Francisco General this summer, and most of their low-moderate risk patients are cared for by Certified Nurse Midwives. If you can find another program that's midwife-friendly, the rest of the department will likely be more receptive to a more "natural" approach to birth.

just a thought

 

[fang]

I wonder though -- to what extent is this whole anti-obgyn naturalist movement a result of establishing a poor rapport with our patients? How much of this battle was created b/c young ladies felt out of control over their bodies...

Yeah, I this this is exactly the reason that the notion of a more naturalistic childbirth has become more popular. It's unfortunate that people equate medically competent with emotionally distant though-- it seems like we should be able to have both competence and a better relationship with patients. Now we have some competing options that patients can choose from, but is it really an informed choice if you're not aware of all the things that can go terribly wrong during a delivery? To me, an at-home midwife delivery birth would sound wonderful if I could somehow guarantee that I wouldn't have any complications...

There are some good resources on our L&D suite here so that pt's don't feel like they're on a "conveyor-belt"... pt's can get on-call doumas, the nurses are great and stay the whole time, many times the husband or friends are involved. We're moving in the right direction, but other people (not the physician) are filling in to spend more personal time with the patient.

 

[starayamoskva]

Yeah, I this this is exactly the reason that the notion of a more naturalistic childbirth has become more popular. It's unfortunate that people equate medically competent with emotionally distant though-- it seems like we should be able to have both competence and a better relationship with patients. Now we have some competing options that patients can choose from, but is it really an informed choice if you're not aware of all the things that can go terribly wrong during a delivery? To me, an at-home midwife delivery birth would sound wonderful if I could somehow guarantee that I wouldn't have any complications...

There are some good resources on our L&D suite here so that pt's don't feel like they're on a "conveyor-belt"... pt's can get on-call doumas, the nurses are great and stay the whole time, many times the husband or friends are involved. We're moving in the right direction, but other people (not the physician) are filling in to spend more personal time with the patient.

You should also consider that the majority of obgyn residencies as most residencies in a University hospital setting, serve a very high risk patient population. There patients are not the 25-30 healthy women that Obgyns in the community see that are likely to have no complications.

You should also consider that since the advent of cesarean delivery we have removed a strong evolutionary control. Before cesarean section babies with large heads/shoulders were selected against. The other consideration is the rampant obesity in our population with type II diabetes and the macrosomia that accompanies it.

 

[burlypie]

Now we have some competing options that patients can choose from, but is it really an informed choice if you're not aware of all the things that can go terribly wrong during a delivery? To me, an at-home midwife delivery birth would sound wonderful if I could somehow guarantee that I wouldn't have any complications...
.

I should have been more clear -- I meant that CNM's do L&D IN THE HOSPITAL. These are not home births, and the OBGYNS are right there for consults and problems. Some places are pretty welcoming to midwives in the hospital (because they do a fabulous job with prenatal clinic and lower risk deliveries) but other places aren't. My original point was that a program that is midwife-friendly might be more likely to be welcoming to "holistic" physician practice.

 

[Gut Shot]

4. "Ina May's Guide to Childbirth" and "Spiritual Midwifery" by Ina May Gaskin. This midwife is a bit of a hippy who lives in a Tennessee commune called The Farm but her stats on birth speak for themselves...she has like a 4% c-section rate, .01 % forceps deliveries, no maternal and minimal neonatal mortality.

With all due respect to Ina May, I somehow doubt that she's taking a lot of high risk cases. I'm sure I could net a 4% c-section rate if I could cherry pick, and I'm in friggin' pathology!

Amidst all the glowing reviews of her Guide to Childbirth on Amazon, I found the following:

I'm in my 34th week of pregnancy and wanted to read up on what to expect when I give birth. This book was reccomended to me, but I couldn't stand this book. Ina May pounding the messages of "hospitals are evil", "Doctors are idiots" and "Men who aren't your husband are all clueless" was too much. Since the book had been reccomended to me, I was trying to make my way through it (After skipping half of the "empowering" birthing stories in the first half of the book) but when I got to the message of "ALL prenatal screening and tests are unecessary and postentially harmful" I had enough. I'm returning this book to get something, anything better.

In a grander sense I find this whole debate fascinating. I doubt anyone could argue that historically childbirth has been a massive source of morbidity and mortality. More women have died giving birth than men have died in all wars, combined. However, over the past 100 years it has suddenly become a much safer event in industrialized nations. The maternal mortality rate in the US in 1900 was around 1:100 births, and by 2000 it was 1:10,000. Hmmm, was this the result of the rise of midwifery?

And so it goes, with the advent of modern surgery, diagnostics and antibiotics, there is a natural backlash against these entities during childbirth. Fortunately for women in first world nations, they now have the luxury of opting for a home birth without a substantial chance of dying.

I would be curious to know the attitudes of women in developing nations to modern obstetrics. It was estimated in 2000 (by the WHO and some other organizations) that 513,000 women in these countries die each year due to childbirth. Furthermore, for each death there are an estimated 30 additional women who suffer some significant debilitation from the process. That works out to 15 million a year, or 300 million total (about a quarter of fertile women in the developing world).

Given all this, I would like to poll the women in sub-Saharan Africa as to whether they would prefer to give birth in modern obstetrics ward or on Ina May's farm.

 

[fang]

You should also consider that the majority of obgyn residencies as most residencies in a University hospital setting, serve a very high risk patient population. There patients are not the 25-30 healthy women that Obgyns in the community see that are likely to have no complications. .

So, you think that because the risk of obstetric complications in the general population is less than that in an academic hospital we should all have babies at home? That makes no sense... the risk of tearing, fetal intolerance of labor, arrested labor, etc aren't insignificant, even in a relatively healthy general population.

You should also consider that since the advent of cesarean delivery we have removed a strong evolutionary control. Before cesarean section babies with large heads/shoulders were selected against. The other consideration is the rampant obesity in our population with type II diabetes and the macrosomia that accompanies it.

You're not suggesting that kids who have big heads/shoulders or macrosomic kids should not be "saved" by doing a c-section?? I think everyone agrees about controlling HA1C during pregancy to avoid macrosomia, but what if it's already there?

 

[fang]

I should have been more clear -- I meant that CNM's do L&D IN THE HOSPITAL. These are not home births, and the OBGYNS are right there for consults and problems. Some places are pretty welcoming to midwives in the hospital (because they do a fabulous job with prenatal clinic and lower risk deliveries) but other places aren't. My original point was that a program that is midwife-friendly might be more likely to be welcoming to "holistic" physician practice.

Yeah, that's definitely better-- there are midwives in the hospital where I am. One drawback though is that when something goes wrong with a midwife pt, the docs are not familiar with them and there is a huge learning curve. When something happens with one of their own patients, they have the background already and have seen the problem develop, which is a big advantage IMO.

 

[fang]

However, over the past 100 years it has suddenly become a much safer event in industrialized nations. The maternal mortality rate in the US in 1900 was around 1:100 births, and by 2000 it was 1:10,000. It was estimated in 2000 (by the WHO and some other organizations) that 513,000 women in these countries die each year due to childbirth. Furthermore, for each death there are an estimated 30 additional women who suffer some significant debilitation from the process. That works out to 15 million a year, or 300 million total (about a quarter of fertile women in the developing world).

Thanks for looking up the numbers.

 

[DrBuzzLightYear]

You should also consider that since the advent of cesarean delivery we have removed a strong evolutionary control.

yeah, you're right, we've been fools to get in the way of evolution. i should be able to breed with any woman i can force myself upon and beat to death anyone who pisses me off, that way we wont be getting in the way of evolution, survival of the fittest.

 

[girlpope4]

Hi, I want to encourage all of you other like-minded future physicians out there who have been writing about holistic birth. I am working on a database of physicians, programs, and hospitals that are less invasive, more holistic, and what they call "mother-friendly," for a women's health group at my school (Medical School for International Health) and would be happy to share with all of you. I was a student of Robbie Davis Floyd's and she and a few other women in the childbirth activist community are helping me locate these programs so that we can continue the movement within the allopathic field.
If you want to make sure you recieve the database, please send me your email: [email protected]
Best of luck to all of you!

 

[BBCatcherVA]

I've recently completed reading the book "Pushed: The Painful Truth About Childbirth and Modern Maternity Care" by Jennifer Block. A friend gave this book to me as a gift. I expected to read it and get angry because of what I presumed to be ob/gyn bashing. Instead, I thought it was well researched and presented facts in a not too philosophically preachy light. Towards the end of the book, I think the author waxes a little too poetic about midwifery and home births. All in all though, I would highly recommend this. It is also well referenced (long list of references in the back) and I intend to use these references to examine the evidence first hand. Good luck to all!

 

[Global Disrobal]

Greater suggestion BBCatcherVA. She just recently spoke at Georgetown as an invitee of the local midwifery group. Excellent speaker, great writer, good book, but as an OB/GYN I do hold alot of reservations... but definitely worth while to read this and get in touch with the aprehensions the patients rightfully have when they enter L&D. Its helped me with my counseling on admission alot.

 

[OphthoBean]

Just wanted to add that there is also a very informative website addressing some of the issues raised in her book as well. http://pushedbirth.com

I found Block's information coupled with my last birth experience and experiences during my training was so helpful in aiding my decision-making process for my current pregnancy. I have opted for a midwife attended homebirth for this pregnancy so that I can have the natural birth experience I want (provided of course that I remain low risk).

I would have gone with an OB had I been able to locate one in my geographical area that supports natural birth (and it would be covered by insurance and the hospital portion waived since I am on staff) but the lack of providers here left me no choice but to pay cash out of pocket for my excellent midwife care and pending out of hospital birth.

It would be awesome if even a small number of you still in training remained open minded and supportive of natural birth for low risk women once out in community practice. During my med school and intern rotations on the OB service I don't recall even being exposed to a single intervention-free birth. I think it is great if the current crop of trainees is getting more education in a hands-off/natural birth process. There is a sore need for OBs with the mindset that pregnancy and birth are not pathological disease states.

 

[Global Disrobal]

Good luck with your pregnancy! Hope it stays low low low risk

As for your comment about natural childbirth, we have a midwifery service that is part of our faculty as well as birthing center nearby which transfers their patients over (intrapartum) when faced with need for intervention. I must say, we do "throw" our interns into the "natural births" as often as we can to give them the experience. Personally, I learned my leopold's, delivery techniques, cervical exams from a good group of former midwives (in other countries) whom are nurses in our L&D and I can say the experience was invaluable.

 

[LadyGrey]

I'm doing OB research at San Francisco General this summer, and most of their low-moderate risk patients are cared for by Certified Nurse Midwives. If you can find another program that's midwife-friendly, the rest of the department will likely be more receptive to a more "natural" approach to birth.

just a thought

Sounds reasonable, but not true in my experience. The hospital where I did my OB core had midwives, and yet I can't imagine doctors and residents being any more pro-intervention than these folks. High C-section rate, epidurals for everyone, lots of inductions, and amniotomies and episiotomies as a matter of course. If anything, the doctors influenced the midwifes toward a more medicalized view of birth rather than the midwives influencing the doctors.

 

[ashbrant]

Sounds reasonable, but not true in my experience. The hospital where I did my OB core had midwives, and yet I can't imagine doctors and residents being any more pro-intervention than these folks. High C-section rate, epidurals for everyone, lots of inductions, and amniotomies and episiotomies as a matter of course. If anything, the doctors influenced the midwifes toward a more medicalized view of birth rather than the midwives influencing the doctors.

These midwives are commonly referred to as "medwives" within natural birth communities. It makes sense that anyone who is trained to attend birth within the medical system is going to have a medical approach to birth.

I'm glad I found this thread. I think it's a problem that medical students and residents see very few natural and uncomplicated births during training. I'm planning on supplementing my medical education by working with home birth or birth center midwives when I have breaks from school. Luckily I live in an area where there is a stong midwifery movement.

 

[medeli]

Yeah, that's definitely better-- there are midwives in the hospital where I am. One drawback though is that when something goes wrong with a midwife pt, the docs are not familiar with them and there is a huge learning curve. When something happens with one of their own patients, they have the background already and have seen the problem develop, which is a big advantage IMO.

It sounds like the doctors should have better rapport with the midwives so that both of them know the patients well enough...

 

[medeli]

but it's not as simple as just adopting a plan of less intervention with no data to back it up.

Hi, Fang

There is data to back up less intervention birthing. Heaps of data! Check out this study... it's just the tip of the iceberg..

 

[cadingcading]

I am really interested in pursuing an OB residency at a program that encourages natural childbirth, has a low ceserean rate, and values the fact that having a baby can be an empowering experience for women. I realize that deviation from the conveyer belt model of labor and delivery is the exception rather than the rule, but does anyone know of programs that lean more toward the holistic rather than technocratic model of birth?

Go where the midwives are. Otherwise, perhaps look at a specialty such as family medicine with an OB component. I live in NYC and both NYU and Mt. Sinai Roosevelt are known for having midwives and being more "holistic".

 

[JoBreeze]

Anyone else automatically associate use of the word "holistic" with low intelligence?