“The Times, They Are a-Changin’”

Authors

  • J. Christopher Glantz MD, MPH

    1. Christopher Glantz is a Professor of Obstetrics and Gynecology in the Division of Maternal-Fetal Medicine, University of Rochester School of Medicine, Rochester, New York, United States of America.
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Errata

This article is corrected by:

  1. Errata: Erratum Volume 38, Issue 3, 275, Article first published online: 1 September 2011

  • Bob Dylan, 1963.

Address correspondence to J. Christopher Glantz, MD, MPH, Division of Maternal-Fetal Medicine, University of Rochester School of Medicine, 601 Elmwood Avenue, Box 668, Rochester, NY 14642, USA.

Nothing gives one a better historical perspective than having lived through history. This may be one of the arguably few advantages to getting older, and certainly applies to the practice of medicine. The body of medical knowledge expands inexorably, technologies appear and advance, the two are integrated into standards of care, and newly evolved practices then are propagated through training of new generations of practitioners. The populace adapts to the new paradigms, generally by acquiescing but in some cases by shaping the nuances of these standards.

Klein et al analyzed the attitudes of older versus younger obstetricians (1). Compared with older obstetricians, younger obstetricians were more accepting of technology and less invested in the philosophy that vaginal delivery is an integral component of the normal birthing experience for many women. This finding is not unexpected—as one is trained, so one believes and practices, and in today’s teaching hospitals, rates of labor induction, intrapartum epidural anesthesia, and cesarean section are at record highs.

My residency training was in the early 1980s (dating me as a history-appreciating—i.e., older—obstetrician), when the natural childbirth movement was in full swing, when many women put great personal importance and self-worth on vaginal delivery with minimal-to-no intervention or medication, sometimes to the point of despair and a sense of failed womanhood should labor not go as per birth plan. The irony to those of us who trained three or four decades ago is that we were perceived as the “bad guys” by natural childbirth advocates then because of 15 to 20 percent cesarean section rates (thought to be unconscionably high then but unattainably low now), labor induction rates half of what they are now, and for offering effective pain relief. In contrast, in Klein et al’s study and in light of today’s skyrocketing intervention rates, we “advanced obstetrical age” physicians might be mistaken for progressives! What may seem more surprising is that, as the profession of obstetrics has become overwhelmingly female, what should be a natural process of childbirth has moved even further into the realm of routine intervention and disease orientation. One should note, however, lest we old-timers pat ourselves too vigorously on the back, that the numerical age-related differences in Klein et al’s study tended to be small, and the overall opinions generally were in agreement regardless of the absolute difference in strength of those opinions. For example, although younger obstetricians were less likely than older obstetricians to consider vaginal birth empowering (26% vs 39%), neither group strongly endorsed this concept. Although younger obstetricians were more likely to consider a cesarean to be like any other birth (20% vs 11%), most younger obstetricians did not hold this opinion. Times may be “a-changin’,” but attitudes not by so much.

Of course, none of this happened in a vacuum. Society today embraces technology, be it computers, 3D movies, GPS systems, or orbiting space stations. Medicine proudly announces new advances in diagnosis and therapy, many of which are based on complicated technologies that are described in glowing terms by the media (2). Who wouldn’t be impressed? What could be more exciting than watching the latest cutting-edge medical miracle (often involving some sort of procedure) on one’s new high-definition television screen? Somehow, the headline “Miracle of Birth Occurs for 83 Billionth Time” seems less compelling in comparison (3). Obstetricians certainly are no exception, and offer medical technology as the means to optimal safety in the birth process. The implication is that, more often than not, a woman’s body cannot be trusted to give birth successfully: labor induction, cesarean section, or both are what is “best for baby.” Whether for reasons of faith in medicine, trust in technology, submission to a system they are unwilling to challenge, lack of faith in themselves, or fear of anything less than the perfect baby, the result has been women’s widespread acceptance of increasing medicalization of pregnancy and concurrent evaporation of enthusiasm for natural childbirth, trends that obstetricians are only too willing to perpetuate (4).

In addition, as women have made gains in the educational and workplace environs, many have wed their life trajectories to the philosophy of maximal productivity, multitasking, double-booked schedules, and optimal efficiency (4). Natural childbirth is relegated to a quaint historical footnote. Why wait for the spontaneous onset of labor when it can be induced? (5) Better yet, why labor at all when one can have a scheduled cesarean section? Who has time to let nature make the call—how is one supposed to maintain a schedule amid such uncertainty? Rather than procedures purportedly imposed on reluctant, disempowered women in years past, these same obstetrical interventions today may be demanded by women in the last illusion of control of a process that is inherently unpredictable; for their obstetrical caregiver not to accede to these requests may be equated with questionable ethics (6). In addition to be best for baby, interventions are portrayed to be best for mothers too.

With some variation depending on the population surveyed, female obstetricians appear to buy into this mindset as well (7). Whether it is because of socialization, nuances of their training, or response to demands of “health care consumers” (also known as pregnant women), the end result is that younger (mostly female) obstetricians do differ from older (mostly male) obstetricians. Klein et al controlled for gender to isolate the effect of age, but did not report on whether an effect of gender occurred other than that no significant interaction was found between age and gender. Although female patients usually are satisfied with their care regardless of provider’s gender, they often express an initial desire for a female (8) perhaps for reasons of modesty, personal comfort, or a perceived greater sensitivity and empathy of a female obstetrician to a woman’s needs (9). It would be interesting to see the other side of Klein et al’s data: control for age to isolate the effect of gender (vs socialization) on attitudes (10).

I speculate that training and socialization play a bigger role than gender. But then again, growing numbers of women today accept and often request interventions that several decades ago would have been considered threats to their very sense of self. In this light, a younger obstetrician—woman or man—who is more agreeable to this way of thinking may actually be the more attuned to current mores such that we older obstetricians once again find ourselves on the wrong side of the line.

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