How to choose your provider, step 1: ignore skill level

The osteopathic medical student who writes Mom’s Tinfoil Hat is obsessed with the process of birth and thinks that you should be, too. In dispensing advice on choosing an OB provider, she doesn’t even mention the most important characteristic, the skill level and professional reputation of the provider. Instead she concentrates on the atmospherics.

Step 1 for choosing a provider:

Episiotomy: Do you employ them? Routinely? Under what circumstances?

It is up to you, but this would be my main litmus test.

The main litmus test?

Let’s step back a minute and consider why you choose any obstetric provider. As I have written many times in the past, anyone can deliver a baby if there are not going to be complications. All you have to do is hold out your hands and make sure the baby doesn’t hit the floor. Dads, policemen and taxi drivers do it on a regular basis.

The reason to choose a professional provider is because childbirth is inherently dangerous and many complications do not announce themselves until they occur during the process of birth. You choose a provider to prevent, diagnose and manage complications, limiting the possibility of severe injury or death of the baby or mother. So the last thing that you should care about is whether the provider promises not to cut an episiotomy. The chief priority ought to be the baby’s and mother’s lives, not the mother’s perineum.

What other factors might you use to judge a provider. The blog author suggests among others:

During labor, can I eat and/or drink? Can I have access to a tub for labor, or a shower, or walking, or a birth ball, or my own clothing, or (fill in the blank)? Can I bring a doula to my labor? How many support people can I have, and what are the visitation rules in general? Can my support person spend the night with me in labor and after the baby is born? Do you require an I.V.?

What do all these factors have in common? They are all about atmosphere. They make about as much sense as choosing a provider because of the color of the office walls or the type of magazines in the waiting room. Sure they might make you feel more comfortable, but they will do nothing to protect you in the event of an emergency.

Of course, “natural” childbirth advocates like to pretend that they will not have complications, and as long as you are pretending, you might as well pretend that wearing your own clothes is more important than the skill level of the provider.

This is a classic example of the “natural” childbirth obsession with process over outcome. Most obstetric providers (obstetricians and CNMs) are obsessed with outcome. The goal is the birth of a healthy baby to a healthy mother. All efforts are governed by that goal.

In contrast, “natural” childbirth advocates are obsessed with the “birth experience” and not just any birth experience, either. It must be the pre-approved, highly stylized experience that they have idealized. No pain relief, a birth ball, and, as the blog author emphasizes above all else, a perineum untouched by the provider, except, of course to sew up the lacerations that occurred spontaneously.

How should women who care about the outcome choose a provider? The first step is to make sure the provider is qualified. What is her training? How long has she been in practice? How many deliveries has she done (this is especially critical in choosing a CPM since they usually have paltry clinical experience)? Has the provider been disciplined by the relevant professional board? Has the provider been found guilty of malpractice or paid out a settlement? All obstetricians will be sued once or twice and insurance companies often force settlements. However, alarm bells should ring if the provider has been sued six times and paid out multiple claims.

It is also important to find out about the hospital, if you are choosing a hospital. Does the hospital have a level three nursery? Is there a pediatrician or neonatologist available around the clock in case the baby is born with a problem like difficulty breathing? Has the hospital been downgraded by JACHO, the hospital accreditation board? Have there been any maternal deaths at the hospital and under what circumstances did they occur? This can often be difficult to find out because hospitals usually insist that patients and families cannot discuss a legal settlement if a case is settled.

In other words, the most important factor is safety. What level of safety can the provider and hospital be counted on to provide? Only after that has been ascertained can the atmospherics be considered.

Like many “natural” childbirth advocates, the blog author displays an astounding amount of denial about the risks of childbirth and complete indifference to what training is required to be a good, safe provider. She asserts in the comment section:

I mean, if I was going to get a complicated and rarely performed procedure done, I would probably want to ask my surgeon about his experience and skill level – how many of these procedures have you done, and what were the outcomes? But, with a relatively common, non technical event, like a physiologically normal vaginal delivery, I think practice patterns for common interventions, informed consent, and basic practical questions (can my partner spend the night in the post partum room?) make much more sense…

No ob/gyn can finish a residency without doing a serious number of deliveries, vaginal and cesarean. I don’t think skill level is a big issue there.

First there is the assumption that complications will not occur. Second there is the assumption that skill means merely technical skill. Sure any obstetrician can do a vaginal delivery or C-section, but the skill that counts far more is clinical judgment, knowing how to prevent, diagnose and manage complications. All obstetricians are essentially equal when it comes to most clinical skills, but they are not equal when it comes to judgment.

I’m not suggesting that the atmospherics are irrelevant. They can make a big difference to the mother’s comfort level and certainly deserve consideration. However, they take a back seat to safety concerns. Once you have found competent providers, you can choose between them based on the atmospherics. Dwelling on your intact perineum is cold comfort if your baby dies of a preventable cause.