So how do obstetricians learn about women? And what do they learn?
In Britain at present medical training is being remodeled as part of a program called “Modernising Medical Careers.” There are 1,500 consultants in obstetrics and gynecology, and the plan is to develop new training modules in specific skills and achieve 1,000 more consultant posts. These upper echelon obstetrician/gynecologists will work in larger units and have fresh opportunities to specialize. Drawing on reports from the Royal College of Obstetricians and Gynaecologists (1,2), two clinical lecturers writing in the British Medical Journal list these skills as:
Management of infertile couples
Preparing for obstetric leadership on the labour ward
Ultrasound imaging in gynaecological conditions
Fetal medicine (3)
In spite of the fact that the Royal College of Obstetricians and Gynaecologists’ reports state that the purpose of reforms is to offer women improved care, this BMJ article, which aims to attract students into obstetrics, does not contain a single reference to women.
A budding obstetrician’s personal qualities are described this way: “The ability to adapt to rapidly changing situations is essential, and a sense of humour is useful when you are faced with difficult situations. Enthusiasm, agility, and an intention to enjoy life are key features for this role.” Again, there is no mention of women. “If you want a challenge, excitement, and an adrenaline rush, but also a fulfilling career, look no further than obstetrics and gynaecology”(3). The focus is entirely on intervention, management, technology, and surgery.
Electronic rapid responses to the BMJ careers article were enthusiastic, for example, “The excitement on labour ward just goes up and up all the time” and “My hands-on surgical experience far exceeds that of my friends at the same stage in other surgical specialities”(3).
Maybe we must accept that this is what obstetrics is all about. Women patients are machines constantly breaking down, or at risk of doing so, and obstetricians the engineers who can prevent this happening and deal with actual and imminent disasters. The two university teachers who collaborated over that article opened it by stating, “For obvious reasons, obstetrics (care during pregnancy and childbirth) is as old as humankind. No other specialty gives the opportunity to be a surgeon and a physician and to save two lives for the price of one”(3).
I think they have got it wrong. Midwifery is much older than obstetrics, and yes, dealing with and averting emergencies must be exciting, but the care of women in pregnancy and childbirth is much more than that, and defining this care as obstetrics leads to interventions that inevitably prove iatrogenic.
Women need midwives. But they also need obstetricians who acknowledge and understand midwifery skills, and who learn from midwives.
One great advantage of the traditional system of obstetric training in Britain is that medical students and interns learn from watching and working alongside experienced midwives. This is how they get an idea of how to keep birth normal. Every caregiver should know how to use movement, posture, massage, language, and silence; how to give unobtrusive emotional support and respect the natural rhythms of labor and birth, and hold back. Far from seeking an adrenaline rush, he or she needs to be able to “center down” and honor the physiological process.
This experience can only happen when midwives have autonomy, sensitivity, and self-confidence, which comes with continuity of care, and one-to-one midwifery, which enables the midwife to develop a relationship with each woman through pregnancy, birth, and postpartum. When midwives work in this way, they teach budding obstetricians precious skills. If obstetricians are deprived of opportunities to work in that kind of setting, they are de-skilled, and are unable to convey the quality of care that is a vital element in birth.
I have observed midwives working with women in many different cultures and in countries across the globe, and see that they often have to protect women from obstetricians, their adrenaline rush, and what the authors of that article call the “Red Savina Habanero,” (the world’s hottest chilli pepper) of medicine. The successful obstetrician seems to be an adrenaline junkie.
Some obstetric teachers are aware that the formal syllabus contains little to do with women, and invite a National Childbirth Trust teacher in to give a talk to their students. The Royal College of Obstetricians and Gynaecologists now has a regular slot on birth trauma in its educational program. When I address students on these courses, I note that many of those participating are working for the first time in the United Kingdom. The authors of the BMJ article have some special tips for them: “Getting informed consent may be an unfamiliar task, so practise some mock scenarios with your friends”(3). (It is not clear why their friends should be best for this task, but it is better than nothing. And there is no mention of informed refusal and what an obstetrician should do about that.) The novice obstetrician is also counseled to be “flexible and receptive,” but the authors rather spoil this by adding, “You will be working closely as a team,” thus implying that flexibility is necessary only in relations with peers and is not required with their patients.
Some senior lecturers teach students communication skills. Unfortunately, this is often limited to learning how to clarify, explain, and elicit a positive response to proposed interventions.
Others are more imaginative, but may meet institutional resistance. When one lecturer in obstetrics in a London hospital introduced a teaching method that included having medical students act being pregnant women in a prenatal clinic, students objected vehemently. They refused to have their legs raised and spread apart in lithotomy stirrups. They said they felt “humiliated.” Instead of using this to gain some insight into how women may feel, the experiment was axed.
I met a woman recently who thanked me for being instrumental in setting her son on a fulfilling obstetric career path. This was a surprise. I speak in schools occasionally, to pupils of any age. She reminded me that I had been invited to lecture about birth to the pre-university class at a prestigious boy’s public school. (In the United Kingdom that is a private one.) I arrived with my baby doll and foam rubber vagina and acted giving birth, pushing and breathing as the tissues of the vulva fanned out, and demonstrating the thrill and sexual arousal of an undirected spontaneous second stage in which the woman responds to the waves of power and elemental desire sweeping through her body from her uterus. I had been anxious that the privileged youths sitting in the front row, legs spread wide, hands in their pockets, supercilious, even sneering, expressions on their faces, would think I was a mad woman. But I gave my all.
Apparently this young man decided there and then that he wanted to be an obstetrician, and now he was fully qualified. I wonder how often he had the opportunity to see a normal second stage. Not often, I suspect. But at least he knew what it could be like. Most obstetricians don’t. They don’t realize that getting a woman into an alien environment, kick-starting labor, clock-watching dilatation of the cervix and descent of the presenting part, putting her up on a delivery table, harpooning her to a fetal monitor, standing watching her critically, fixing her legs in stirrups, and telling her to hold her breath and push as hard and as often as she can—all these are interventions that make birth abnormal.
We need to bring drama into obstetric education—theater, role-play (not just with friends, but including childbearing women who can teach from their own experiences), and also conversation analysis of real-life talking. Communication skills are still dealt with at a level that might be suitable for training laundry detergent salesmen, but not caregivers in childbirth. Role-play, drama, comedy, women’s personal accounts of experiences in pregnancy and childbirth, are all valuable tools to teach understanding and develop skills in communication.
Of course, obstetricians must have technical skills. They need to know how to turn a baby from breech to vertex, for example, how to tackle hemorrhage, and perform a cesarean section. But there is more to obstetrics than that. Episiotomy and suturing of the perineum, for example, is not only a question of why, when, and how, but of the effects that surgical genital mutilation and subsequent repair can have on women’s feelings about their bodies, their self-esteem, their sex lives, their relationship with a partner, and even with the baby.
I haven’t heard of any university using conversation analysis in obstetric education. It is deconstruction not only of subject matter, although clearly important, but of pauses, breaths in and out, intonation, inflexion, and all the sounds we make that convey understanding, surprise, sympathy, and validation of what a woman is saying. It is about listening reflectively and responding, about the flow of a relationship, not just how to put over ideas and get the client on your side (4,5). I suggest that conversation analysis could enrich and add a new dimension to obstetric education and reflective practice.
Obstetric education should not be only about the aggressive management of childbirth and medical and surgical interventions. It must include the obstetrician’s role in interacting with women, and increase awareness and understanding of this.