Inertia in Obstetrics

Stick figures playing tug of war, illustrating the forces pulling on decisions about obstetric care

Inertia refers to the idea that something that is staying still is likely to continue to stay that way until something forceful sets it in motion. Sometimes it feels like there’s a lot of inertia in the policies and protocols of American hospitals. So let’s take a look at the forces involved in changing obstetrical norms:

Forces that tend towards change:

New research

When I first started attending births, the episiotomy rate for vaginal births was somewhere around 85-90%. A few years later, a study came out showing that episiotomies were likely causing more harm than good, by increasing the numbers of large tears that needed surgical repairs. Because this clearly showed harm (rather than showing something was ineffective) it had rapid and dramatic change, most providers adapted and the rates dropped pretty quickly. Even then there were old school docs who refused to change.

Patient Requests

Recently there has been a big push towards providing care that increases patient satisfaction, and this has made some birth places much more likely to accommodate the requests from their customers. In some cases, it’s led to changes in policy! I teach in a hospital that used to have a mandatory nursery stay when the family came up to postpartum from labor and delivery. After many, many requests and poor feedback from customers, the hospital switched to couplet care, cross training all the nurses to provide for families and keep them together.

Changing Trends and Competition

You had better believe that hospitals keep an eye on their competition and will make changes they had been resisting when others in the area make them. I noticed that when one hospital in my area changed from an ice-chips-only policy in labor to a policy that allowed for clear fluids, all the others in the area followed suit in close order.

Forces that tend towards staying the same:

Current policies and procedures

In order for a doctor or hospital to change how they have always done things, there needs to be at least a small admission that the way they did things before was wrong or misguided. Sometimes that is really hard! When the idea that doctors and nurses should WASH THEIR HANDS was first presented, the doctor who advocated for that was drummed out of the profession and it was decades before the idea caught on. I’m sure thousands on women died because the profession could not admit their dirty hands were the problem. Similar changes play out on a much smaller scale all the time.

Malpractice concerns

Obstetricians get sued. Frequently. In a 2017 survey, 85% of OBs reported that they had been sued. Malpractice insurance in the US ranges from $85000 to $200,000 *per year* for an obstetrician. So it’s totally understandable that an OB might be thinking about possible lawsuits while attending births. In an ideal world, it wouldn’t be a factor in management of care, and wouldn’t lead a care provider to restrict a pregnant person’s options, but that’s the world we live in. Some policies might specifically limit what the provider is covered for as well.

Training and experience

I once worked with an OB who was very supportive of VBAC. He was the go-to recommendation of all the doulas for clients who were preparing for a VBAC, and he did a wonderful job supporting them, even making exceptions to policies for those clients to achieve their goal. And then one day, like a switch flipped, that all changed. He had a bad outcome in a VBAC birth and got sued. One (very) bad experience and suddenly he was no longer comfortable with VBAC at all, and was a stickler for policies.

This kind of thing isn’t unusual. Negative experiences can absolutely leave people feeling vulnerable to similar bad results in the future, and want to control things as best they can. Training can drill into people that some things (like breech birth, for example) are unsafe, to the point that it can be very hard to change that impression, no matter what evidence and training comes.

In Summary

There are a multitude of forces at play in making institutional change in a system that is plagued by lawsuits. Because of all the competing forces, change might not be as fast as you think it should be. But a broader understanding the forces at work can help you better advocate for systemic change in your area.

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