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Guest Post: Overuse and Obstetric Violence

By Katharine Hikel, MD
Co-chair, Women’s Health Council of the Right Care Alliance

As a women’s health activist, I was encouraged to see the Lown Institute cover issues of access and overuse in maternity care. Drawing attention to the maternal health crisis has become increasingly important, and I appreciate that Lown has been addressing this issue by giving experts a platform at the Lown Conference, and featuring links to articles like this commentary by Dr. Neel Shah on the disturbing lack of access to maternal care in rural areas. 

The OB-GYN field’s reliance on outdated and misogynist definitions of women’s physiology drive overdiagnosis, overuse, and overtreatment.

However, there’s a crucial point missing from the Lown Institute’s coverage – and most coverage in general – of women’s health issues. It’s rarely mentioned how the OB-GYN field’s reliance on outdated and misogynist definitions of women’s physiology drive overdiagnosis, overuse, and overtreatment. Nearly every aspect of women’s health and maternity care has a set “normal” standard that does not apply for many women – the 28-day menstrual cycle, the 39-week pregnancy term, and the “due date” are just a few examples. 

These not only alienate women whose physiology is outside the “norm,” it leads to one-size-fits-all maternity care, with worse outcomes for both mothers and children. In no other specialty is the natural physiologic ‘bell curve’ of normal function so robustly ignored and repressed, and artificially narrow standards institutionalized as a legitimate form of what many mothers regard as abuse.

Our “one-size-fits-all” maternity care system is leading to worse outcomes for both mothers and children.

Sadly, it’s not unusual for women to be coerced into having cesarean sections they don’t want, a traumatic experience characterized as obstetric violence. Doctors may insist on a c-section if a woman isn’t progressing in labor fast enough (according to the arbitrary “Friedman Curve,” one centimeter of dilation per hour). Some hospitals even have internal policies allowing doctors to override a woman’s decision and force her to have a c-section if they believe the possibility of benefit to the fetus outweighs harm to the mother. Postpartum PTSD from these forced interventions also remains unaddressed, though it’s becoming evident that much of so-called ‘postpartum depression’ is a response to abusive conditions of American childbirth. 

Women are subject to obstetric violence in other gynecological procedures as well. At some teaching hospitals, medical students still perform pelvic exams on anesthetized women without their consent, even though this practice is morally indefensible and has been banned in several states. 

The ACOG is not being nearly critical enough of its own revenue-extracting culture of provider-dominant care.

Why is no one doing anything about this? There is a lack of patient-focused leadership at the top of the pyramid. The American College of Obstetricians and Gynecologists (ACOG), the leading OB/GYN specialty organization, is not being nearly critical enough of its own revenue-extracting culture of provider-dominant (not patient-centered) care. 

In the face of an increasingly unsustainable model of maternity care (see Dr. Shah’s piece on closures of hospital-based obstetric services), the ACOG argues that obstetricians must be reimbursed more, rather than embrace proven alternative models of maternity care, like midwives and birth centers. 

The ACOG argues that obstetricians must be reimbursed more, rather than embrace proven alternative models of maternity care.

I live in rural Vermont, where ACOG’s dominance of costs and services  – embedded in the costly ‘mine is bigger’ management hierarchy of a teaching hospital monopoly – has driven healthcare premiums to one-quarter to one-third of working families’ incomes, with maternity care at the top of the revenue stream. It’s malignant paternalism to push the valuation of maternity services (or any services) onto patients — to exploit the ‘value’ of childbearing so that the OB/GYN establishment can retain its growth, instead of downsizing to affordable, sustainable levels.

ACOG doctors led the fight in Vermont to dismantle our once well-integrated, affordable home-birth culture, and to deny every attempt made by midwives, clients, and supporters to open a freestanding independent birth center — the other affordable alternative for rural women. Thanks to the ACOG, Vermont remains the only New England state that lacks that choice for women.

So while it’s a relief to see the Lown Institute recognizing the overuse of surgical birth (let’s call it what it is), the problem will not be corrected without addressing the underlying culture of OBGYN/ACOG, which maintains its own outdated and fiction-based ignorance of the broad range of normal in women’s actual physiology. We have a long way to go.