How Fear Rules Maternal Healthcare

Is fear hijacking American prenatal care? Author and obstetrician, Lissa Rankin, talks about the impact of fear on health and healthcare.

One of the most powerful factors guiding maternal healthcare is something that’s rarely discussed. It’s fear — fear of rare complications or that a physician might miss something. Fear that a baby won’t be perfect or a patient might sue. These types of fear mean that traditional prenatal care in the U.S. revolves around batteries of tests and interventions designed to ward off or rule out every potential risk. It adds up to American maternal healthcare being the most expensive in the world, even though statistics show we aren’t delivering the healthiest babies to the healthiest moms. In fact, the U.S. ranks 60th in global maternal health outcomes and our maternal mortality rate is rising. Could fear be to blame?

Sometimes fear is exactly what you need to recognize your health is in danger or for a physician to realize her patient needs a more thorough evaluation. It’s the jolt that motivates you to see your doctor or face your bad health habits. It’s the nagging anxiety that makes a physician keep a close eye on a patient. That’s what normal fear is for — to put you on high alert. False fear, however, can hijack healthcare by making patients and physicians focus on the wrong priorities.

Traditional prenatal care in the U.S. is designed to address the scary reality that 15% of mothers will experience some type of pregnancy or childbirth complication. Physicians, often scrutinize pregnant women, even healthy ones, for potential risks. Much of that is driven by a natural desire to prevent maternal and newborn harm, but it’s equally driven by demands on physicians to detect even uncommon risks (and prevent lawsuits) by loading up on tests, treatments and interventions. The problem is, excess use of interventions comes with its own risks for patient harm and doesn’t necessarily deliver better health.

This imbalance of fear and risk aversion on both sides of the patient equation not only impacts patient outcomes, it’s causing doctors to leave maternal healthcare in droves. For many, the stress of highly litigious patient care and ridiculous workloads is too overwhelming. Lissa Rankin, MD, author of the, “The Fear Cure, Cultivating Courage As Medicine For The Body, Mind, and Soul,” (Hay House, 2015), left her career as an obstetrician/gynecologist in 2007 when she realized work-related fear was ruining her health. Eventually, she also recognized that her fear was also her cure when it demanded she dramatically change her life.

She writes that chronic fear can lead to serious diseases by bathing our bodies in stress hormones. But it can also open our eyes to all that needs healing in our lives, including the physician-patient relationship. Rankin says, “I included a whole chapter in The Fear Cure about how physician and patient fear causes both to veer into over-diagnosis and over-treatment. It’s a huge problem, not only fiscally, but from the standpoint that many interventions are unnecessary and potentially dangerous. It happens in all avenues of medicine like when thousands of patients undergo screening and interventions to prevent one adverse health situation. It doesn’t make sense when you look at the data and recognize how many people undergo unnecessary treatment in order to prevent one death. It’s staggering.”

How does this show up in prenatal care?

It shows up in the form of one-size-fits-all medical mandates like our recent national ban on vaginal birth after cesarean (VBAC). Check out the American College of OB-GYN’s practice bulletin on VBACs here. VBACs hold a less than 1% risk for potentially life-threatening uterine rupture. That 1% risk and fear of potential lawsuits drove most hospitals in the mid-2000’s to ban VBACs and mandate that 100% of C-sections patients have all subsequent births by C-section too. When data on rapidly increasing C-section rates showed dangerous levels of patient harm resulting from unnecessary C-sections, many hospitals loosened their bans. Preventing rare VBAC complications by forcing patients to have unnecessary surgery that wound up increasing maternal and newborn mortality and morbidity rates turned out to be a dangerous approach to risk mitigation.

Why is healthcare designed that way?

It has a lot to do with the way physicians are educated and trained, partly in response to our society’s tendency to sue when things go wrong. Rankin says, “I think it has a lot to do with our worldview and expectations. In many cultures, there’s no expectation of perfection and people aren’t attached to the outcome of perfect health. In the US, we have enormous attachment to perfection and zero tolerance for anything less. We’ll do anything to veer away from anything uncertain and pregnancy holds a lot of uncertainty for families and doctors. That makes them very uncomfortable. People make 99% of their choices based on their craving for comfort, certainty and avoidance of things that scare us. We try to control for that by accessing medical interventions.” It turns out, that might not be the healthiest way to make medical decisions.

How do we balance fear and uncertainty to make better health choices? Rankin suggests learning to identify real fear versus false fear and then identifying our own level of risk tolerance. Real fear is the kind our bodies are hardwired to feel when our lives are in danger. Rankin says, “It’s rare that our life is genuinely threatened. Most of the fears that plague us today exist only in our imagination. That’s false fear.” It’s the “what ifs” and uncertainties that in medicine we take great pains to prevent with extra tests, treatments and interventions that can sometimes result in an unhealthy cascade of medical care. Identifying risk tolerance means figuring out what level of uncertainty you’re OK with. If you’re OK not knowing your risk potential for every possible outcome — then you’ll probably feel comfortable with less medical scrutiny. If you’re not OK with that, then risk intolerance might veer you towards more intervention.

Take for instance, this common scenario: A doctor tells a healthy patient, “I’m afraid you won’t be able to push your baby out if it gets any bigger so let’s induce your labor.” This is a false fear. In reality, there’s no evidence she can’t deliver vaginally through spontaneous labor. Uncertainty, however, causes the patient to agree to the induction. When her body doesn’t respond by dilating her cervix the way it probably would have if she’d waited for natural, spontaneous labor, her doctor says, “I’m afraid your labor won’t progress. Let’s do a C-section.” The mother, now worried her body has failed her, agrees to surgery. When her normal-sized baby ends up in the NICU because respiratory issues indicate he’s a little premature, she wonders why she agreed to an induction in the first place.

What’s the solution?

Rankin recommends a radical transformation in how we approach all types of healthcare. She recommends focusing on factors we know contribute to real health like nutrition, exercise, a sense of purpose, community, love and happiness and save the medical interventions for when they’re really needed. Rankin says, “This won’t be easy and in fact it requires a complete paradigm shift, but I believe that’s what’s it will take to turn health and healthcare around.”

For healthy women who are pregnant now, you might lower your risks for unnecessary medical intervention by accessing prenatal care from midwives who view pregnancy as a more normal physical event than obstetricians often do.

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