Safety or Cognitive Dissonance

(Posted with permission) A couple months ago I cared for a woman in labor who strongly desired a VBAC. In the two years since the birth of her daughter by cesarean section for breech she had struggled with anxiety and some mild depression. This lovely woman had done her research and educated herself about breech delivery. She realized that she had not been given true informed consent about her reasonable options and her hopes for allowing her body to work as nature intended were not respected. She had valid concerns that her depressive symptoms were exacerbated by her feeling of helplessness and by some resentment towards the medical system that had failed her. Upon the good news that a second baby was on the way she was determined to empower herself and find a way to affirm her body’s ability to deliver vaginally. One major obstacle stood in her way. She lives in Ventura, California. In a county where VBAC is truly treated as a four-letter word. Community Memorial hospital, Ventura County Medical Center, Simi Valley hospital, St. John’s Regional Medical Center in Oxnard, Pleasant Valley Hospital and, even, Cottage Hospital in nearby Santa Barbara all “ban” VBAC. At the one institution where it might be possible to have a VBAC in Thousand Oaks, the protocols and restrictions are so rigid that they, themselves, limit the chances of success. I met this couple early in their pregnancy when they came to me as an option for the reasonable choice of a VBAC out of the hospital. Since they live up in the hills of Ventura and their home is under construction they happily chose to birth with me and a licensed midwife at a Birth Center in Ventura. Given true informed consent of the benefits and risks of VBAC and repeat cesarean section derived from much of the information in the NIH VBAC Consensus Statement from 2010, the decision was well informed and an easy one for them to make. Her chances of avoiding a surgical birth and all the joys of an un-medicated vaginal birth were 75-80% and her risks of a problematic outcome were about 0.33%. As the pregnancy progressed it was evident that, like her first baby, this baby was going to remain frank breech. She tried all the usual remedies including acupuncture, chiropractic and external version with no success. We then spent much time reviewing the options when a baby is breech. She was fully aware that the problems of finding a practitioner willing to perform a breech delivery extended far beyond Ventura County. Despite the refutation of the 2000 Hannah paper by many authors. The more recent PREMODA study, Glezerman article and the 2009 statement by the Society of OB/GYN of Canada supporting the retraining of selective vaginal breech delivery it is pretty much a given that breech = c/section in most parts of the country. I have discussed the breech issue before and suffice it to say that most doctors of my generation were trained to perform selected breech deliveries but have given it up. The reasons given are always “safety”. Safety is often a canard for something else when it flies in the face of obvious academic disagreement on this issue. I have also written on the trinity of expediency, economics and litigation-mitigation as one possible explanation. Younger physicians do have the excuse that they were never trained in breech and therefore, for them, c/section is the only option. However they should honor the ethical duty to at least inform women of the data and offer to refer them to someone who may be able to offer them a vaginal choice. In a recent conversation with another client about these issues I began to formulate a theory as to why knowledgeable physicians so quickly condemn, obscure and ridicule the choices of VBAC, breech, often twin vaginal birth and home delivery. I think my colleagues are good people. They are certainly intelligent and most keep up on the academic literature. They must be aware that at the very least there is good evidence by reputable researchers and institutions that support the safety of these choices. Ethics and true informed consent would dictate that at least they give patients unbiased information and options even if they are not comfortable with them. Yet there is the common scenario of physician certainty that to choose one of the options is dangerous and deserving of ridicule. Ridicule of the choice and derision of those of us who would offer it. How does one justify doing only surgical births as a matter of policy when they must know otherwise? Physicians of my age in their fifties tend to be the leadership of the Obstetric Departments of hospitals. They were almost certainly trained to do twin and breech deliveries. VBACs were the norm and require no special skill. They must know of the phrase, “Primum Non Nocere”, first, do no harm. Yet they skew their counseling to convince women of the safety of a surgical birth, sometimes say really mean things to women who question this and act unprofessionally towards their colleagues who differ with them. Why? My theory: COGNITIVE DISSONANCE! The term cognitive dissonance is used to describe the feeling of discomfort that results from holding two conflicting beliefs. When there is a discrepancy between beliefs and behaviors, something must change in order to eliminate or reduce the dissonance. There are three key strategies to reduce or minimize cognitive dissonance: • Focus on more supportive beliefs that outweigh the dissonant belief or behavior. • Reduce the importance of the conflicting belief. • Change the conflicting belief so that it is consistent with other beliefs or behaviors. Let’s examine what is happening in light of this definition. A physician or group of physicians is subject to a hospital policy banning VBACs, breeches and many twin vaginal births. This policy may or may not have been their own creation or they may have succumbed to pressures from other departments like anesthesia or risk management. Nonetheless, it is a policy of the hospital to which they must comply in order to continue to practice there. When evidence in the literature clearly conflicts with that policy it must be very difficult to justify that evidence with what they are doing. Rationalizing and reliance on only those papers that support the policies satisfies strategy 1 in reducing cognitive dissonance. Ridiculing those, like me, who offer options based on that ignored evidence and dismissing patient’s honest inquiries as ill-informed helps to satisfy strategy 2. Finally, emphasizing only the risks of the banned choices and diminishing or ignoring the risks of surgical birth helps to make the information fit their belief and fulfill strategy 3. I submit that a good and moral person would have a very hard time living with themselves when performing c/sections they knew were not necessary. Especially when they are fully aware that there are other evidenced based choices that women may choose. This inner struggle with truth cannot be reconciled without the theory of cognitive dissonance. Living and working in a community where its conformity or ostracism is an awful choice. Good men and women in such a setting may have to alter their values in order to survive. One explanation is to believe it’s a form of the Stockholm Syndrome where the hostage begins to identify with his/her kidnapper. Believing, despite evidence and training, that the policies you are upholding are absolutely right complies with my theory as to why so many doctors and institutions are able to ban reasonable choices and vehemently condemn and vilify those that think or act otherwise. When my client found out she was breech again we sat down and had an hour long conversation about choices. We discussed the risks of home birth, VBAC and breech. None of which, on the merits alone, were reason to give up her only hope of a vaginal birth that was so important to her psyche. We came to the conclusion that she wanted to try and since obviously no hospital would even let her, an out of hospital birth became the reasonable option. She went into labor in the early morning hours and over the day progressed and, with contractions spacing out, then stalled out at 8 cm. Had she been a primip and vertex she would have been a great candidate for pitocin augmentation and possibly an epidural. But because she was breech and a VBAC we knew that transfer meant a c/section. The doctor on call at one of the local hospitals had a reputation for being most unfriendly toward home birth transfers so we decided to go to Ventura County Medical Center and accept whichever doctor was on call. They preferred to stay local and not to drive 60 miles to a friendlier back-up scenario. Pleasantly surprised, we were well received by the doctor and staff at VCMC and after a couple hours of admission proceedings she had a repeat c/section, a healthy baby and an uneventful postpartum stay. At a home visit a few days later we revisited her birth experience and she felt much better about the end result because she knew she had been given the opportunity to try. About 2 months postpartum around 10 AM on a Friday she had a knock on her door from an investigator from the Medical Board of California. They were seeking her signature on a release of records to investigate a complaint about my care as a possible violation of the California Medical Practice Act. The patient and her family were delighted with her care and had no complaints so politely refused to cooperate with the investigator. Clearly the complaint came from someone outside of the mother's primary care providers with knowledge of the circumstances of this birth. Since that information is kept confidential I can only speculate that someone without the background of history and factual procedures specific to this case felt that “safety” and standard of care was at issue here. They knew what I offered her was not within community standard since no one in the area allows VBACs or vaginal breeches and home delivery, in every case, is frowned upon. While this complaint was recently closed as unfounded by the Medical Board it is likely that every transfer of care in this community may well generate another letter. It is unlikely there will be any revelation that the care offered to this family was within reason. That would disturb the bubble of cognitive dissonance in which they live. Whereas writing the letter strengthens the delusion that only their model of care is the correct one. In an ideal world the evidenced based, literature supported option of VBAC and/or selected breech delivery would be something best performed in a supportive hospital environment. But since the same people who complain about me do not offer these choices women are left with skewed options that are often less safe and certainly less nurturing. Writing indignant letters of complaint makes those that deny choice feel better about themselves. Self-reflection is not a value or a virtue in these physicians and institutions. They fail to teach future generations of obstetricians the skills needed to deal with breeches and twins. They seem to accept as safe and normal that 33% of all women need c/sections. They believe that normal human birth need be treated as an illness. They selectively choose which science fits their model and conveniently ignore anything else. They vilify and harass those that provide common sense choices they do not approve of. And they use fear and derision as a tactic to convince patients they are foolish to question their authority. I remain hopeful that women and families will demand options and that organized medicine will see the error in their ways and return to accepting common sense and evidenced based care. I have no doubt that my colleagues who have drifted away from this reality can wake up and be kind and accepting of alternatives. Only if their world continues to be filled with cognitive dissonance could good, moral men and women deny informed consent and still go to bed at peace each night To continue in this fog is unthinkable. Happy Memorial Day, Dr. F