Contingent Care

Abstract

This dissertation seeks to understand obstetricians’ lived experience of decision-making in childbirth and investigate how the organizational context within which obstetricians work influences how they make treatment decisions. Understanding how obstetricians make decisions in childbirth is important because maternity care in the United States is in crisis. Our system is failing women on multiple accounts: between 1990 and 2013, maternal mortality more than doubled in the United States, and is higher than most other high-income countries. Furthermore, women continue to suffer from abusive practices by maternity care providers who dismiss their concerns and sometimes outright refuse to honor their self-determination in childbirth. Today multiple stakeholders acknowledge a need for maternity care reform; this creates new challenges for health care policy and opportunities for social science research. Obstetrician-gynecologists provide the majority of maternity care to American women, and this dissertation examines their lived experience of decision-making in birth and analyzes how a range of social forces affect this process. To investigate this phenomenon I performed 50 in-depth interviews with obstetricians from Massachusetts, Louisiana and Vermont about how they make patient care decisions in birth. The specific research questions and analysis for each chapter evolved through an iterative process that combined analytical grounded theory and template analysis. I present this in a three-article format. In article one I show how shift-work models of labor and delivery pose challenges to using a patient-centered approach to decision-making. Obstetricians either work shifts in labor and delivery or they work on-call for their patients’ births. The current thinking is that shifts are good because they allow work-life balance for doctors, reduce fatigue, and reduce convenience-based decisions. Shift work models assume that doctors and patients are interchangeable because doctors will follow protocols and standards of care produced by medical professional organizations. I argue shift work does not work in practice the way it does in theory. I explain how there are not standards for many decisions in birth, instead these decisions are characterized by medical uncertainty. In these cases, doctors rely on patient-centered approaches to make decisions. But shift work limits doctors’ ability to use patient-centered approaches. I found that shift-work models of hospital care do not provide doctors the opportunity to get to know their patients and understand their preferences. In practices that do not depend on shift work, the doctor patient relationship is far less fragmented and doctors tend to experience less conflict with their patients and are less likely to rely on stereotypes that reproduce social inequality. In article two I examine obstetricians’ understandings of convenience as a motivation in decision-making. Anecdotal evidence suggests that obstetricians sometimes make clinical care decisions less out of concern for their patients and more out of concern for their own time and schedule. This may be a particular problem in on-call models. In this paper I show doctors’ stories match anecdotal evidence: Some obstetricians make clinical decisions in birth based partially on their own convenience. Yet others actively resist the temptation of convenience, even in on-call care. A key dimension of this difference lies in doctors’ understandings of the nature of time in labor and the safety of interventions. Some doctors have a faster-the-better approach to birth and believe the routine use of interventions is the best way to practice in labor and delivery. These doctors frame their own convenience as legitimate because it overlaps with the idea that speeding up the labor is inherently good. Alternatively, other doctors believe time in labor is productive, and that interventions should be used judiciously because they increase risk of harm. These doctors cannot easily legitimize convenience because it conflicts with the reduction of interventions as a key dimension of this philosophy. I argue that because shift work poses serious challenges to patient-centered care, cultural change is a better avenue for reducing births of convenience. Article three addresses an ongoing question in medical sociology about whether physicians maintain control over their clinical work amidst challenges to their authority. Patient empowerment and standardization are two movements that sociologists have theorized in terms of weakening of doctors’ clinical discretion. I uncover how obstetricians draw on the conflicting nature of these approaches strategically to maintain their power in the face of a threat. Standards and patient empowerment act as countervailing powers; they drew on one to off set the challenge to their authority posed by the other.