Provider Bias

When a woman has a procedure such as an induction, episiotomy, forceps or vacuum assistance, or a C-section, what is the likelihood that the procedure was truly necessary? It’s common knowledge that some doctors and midwives have much higher incidence of interventions than do other care providers, even with a similar patient profile. If you have a doctor who feels more comfortable with performing a C-section than with handling the unpredictability of normal, natural labor, then the odds that you’ll have a C-section are fairly high, even if you are low-risk. A few generations ago, doctors were trained to cut episiotomies in every woman. Even today, there are some doctors who will cut more women than not, although there is little to no evidence of any benefit and quite a bit of harm from its routine use.

These doctors were trained with the belief that episiotomies were either necessary or beneficial. So they cut, even when the dictum to cut women’s vaginas was made with absolutely no evidence whatsoever. And they trained their students to cut, just because that’s what they had been taught. An episiotomy is necessary to insert forceps, but forceps are rarely necessary in women laboring spontaneously and undrugged. Yet even after the extremely high forceps rate dropped, the high episiotomy rate stayed, probably because so many doctors had never or only rarely seen an actual spontaneous birth over an intact perineum. So when the vagina was fully stretched to accommodate the baby’s head, doctors thought the woman was going to tear, so they cut her, as they had been trained was usually necessary. There are a few reasons to do an episiotomy, but in most instances, they are done simply because the provider was trained to do it, regardless of the evidence.

Many times when I see that this or that doctor has a high rate of any given intervention, I wonder how many of them were actually necessary, and how many were due simply to his or her having been trained to view them as necessary or beneficial. Here is a case in point, the press release of a study which shows that Asian women who have white husbands are much more likely to have a C-section (33.2%) than white women who have Asian husbands (23%).

Because birth weights between these two groups were similar, the researchers say the findings suggest that the average Asian woman’s pelvis may be smaller than the average white woman’s and less able to accommodate babies of a certain size.

However, it’s also likely that the doctors of these Asian women saw their larger (white) husbands and concluded at the first hiccup in labor (or maybe even before labor started) that their babies were too big for them to birth. I remember watching “A Baby Story” once in which the doctor wanted to induce the mom because her husband was big and tall while she was short. So she was induced a few weeks before her due date because the doctor was afraid the baby would be too big. I can’t remember for sure whether she ended up giving birth vaginally, but I do remember that the baby was small — in the neighborhood of 6 lb. Ah, but you see, the doctor saw “big husband” and concluded “big baby,” with no other evidence supporting his conclusion.

When doctors suspect a big baby, they are more likely to remove it surgically than allow the woman to give birth vaginally — irrespective of the baby’s actual birthweight, or the mother’s ability to actually birth larger babies. This video (one of my favorites!) is “Dedicated to all the care providers that told us we weren’t able to birth our babies.” It’s a streaming slideshow of women who were diagnosed with CPD (cephalopelvic disproportion — the baby’s head is too big to fit through the mother’s pelvis) and went on to vaginally birth larger babies — some of them were a pound or more bigger than the babies that were supposedly too big. Question CPD.

Because of the much higher C-section rate with suspected big babies (compared with babies who actually were that big, but were not predicted to be big), without any decrease in shoulder dystocia or fetal injury — the main worries with large babies — the researchers in this study concluded,

Ultrasonography and labor induction for patients at risk for fetal macrosomia should be discouraged.

Prejudice is a big topic in America today, and is a loaded word. Nobody likes to be called “prejudiced” nor to be the victim of prejudice. You wouldn’t accept prejudice over the color of your skin, so why accept prejudice because of your body type or the estimated fetal weight, which may be fairly inaccurate, especially at high suspected weights?

This is why it’s so important to know your care-provider’s biases before going into labor. If you’re comfortable with the idea of having an unnecessary C-section, then don’t worry about your doctor’s C-section rate. But if you’d really rather avoid a C-section unless it’s necessary, then you should ask your doctor about his or her C-section rate and philosophy. And don’t accept, “I only do C-sections when necessary,” because he might find — as the doctors of yesteryear did with episiotomies — that they’re “necessary” in the majority of cases.


This poll is multiple-choice so you can choose more than one answer, if you had more than one care provider for your birth(s).


One Response

  1. Wonderful as usual. Will be sharing this at my ICAN meeting tonight!
    ~ Kimberly

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