By Jessica M. Scully
Nicholas Rubashkin’s (MD, MA) interest in labor and delivery as a human rights issue began with a tragedy on a Mother’s Day early in his career as an obstetrician. A woman in labor was transferred to the hospital where he worked after having fetal complications during a planned home birth. Rubashkin was the delivering obstetrician.
“I was trying to help support this woman to have the experience she wanted and to be honest with her about the medical complications she was having,” Rubashkin said. He and other members of the medical team explained her labor needed to be induced, but the woman initially didn’t agree to an induction. When she eventually did, it was too late. The infant died shortly after Rubashkin conducted an emergency cesarean.
Rubashkin later learned the reasons for the woman’s refusal. She knew that many inductions aren’t medically necessary and didn’t trust the medical team to make decisions in her best interest rather than for the team’s convenience or due to liability concerns. The more Rubashkin learned about how women are treated in labor and delivery in the United States and internationally, the better he understood the woman’s perspective and the more convinced he became of the need for change.
“The mistreatment that happens to women, the abuse of women at birth facilities, and the lack of evidence-based care that’s provided to women, it’s just, in my mind, such a huge injustice,” Rubashkin said.
Now part of the UCSF Institute for Global Health Science’s (IGHS) first group of PhD students, Rubashkin is working to help end that injustice. Through the program, he’s learning the skills he needs to ask and answer research questions that will help ensure women’s rights are respected when they give birth.
Rubashkin came to the program after spending a year in Hungary on a Fulbright scholarship. He selected Hungary after the European Court of Human Rights decided Ternovszky v. Hungary, which effectively determined Hungarian women had a right to give birth at home. Before the decision, medical professionals were forbidden from assisting at home births, which made such births less safe. It was, Rubashkin said, the first time the European Court addressed women’s rights in childbirth.
Rubashkin and his fellow researchers surveyed Hungarian women who’d given birth to understand the women’s relationships with their physicians. He learned that 60% of the women tipped their physicians. The primary purpose of tipping was to ensure the physicians showed up for the deliveries. But women also tipped in hopes the physicians would treat them more respectfully.
Rubashkin found that women who tipped did get better quality of service, though they still experienced high rates of disrespectful care. Women who did not tip, however, were even more likely to be treated poorly, he said.
While involved in the project, Rubashkin decided he needed to deepen his research skills through a program of graduate study. He found a perfect fit in the Institute for Global Health Sciences’ PhD program.
The four-year program, which launched in 2016, is a transdisciplinary combination of coursework, research and mentorship. Students spend the first two years at the UCSF Mission Bay campus studying public health, public policy, economics, development studies and implementation science. They also have teaching residencies. After passing a qualifying exam, students conduct research for their dissertations and take on professional activities, both with guidance from mentors.
Soon after beginning the program, Rubashkin discovered that research groups at UCSF are already testing interventions to enhance respectful maternity care. After learning about the SPARQ project at IGHS, he joined the team and became the first author on a paper published in the October 2018 issue of Reproductive Health.
A common critique of person-centered care, Rubashkin said, is that it sounds wonderful but is difficult to define and measure. Based on the SPARQ team’s review of the literature, it’s a fair critique. Researchers were developing creative interventions, but how they defined and measured what they were trying to do wasn’t consistent, Rubashkin said.
For example, shared decision-making between health providers and patients is an important component of person-centered care. The team found studies noting that an intervention had been designed to improve shared decision-making, but the researchers who designed the study neglected to include ways to measure whether shared decision-making occurred. In other studies, researchers felt shared decision-making was the only component of person-centered care. Interventions that focused exclusively on delivering information to women didn’t always improve the quality of care, Rubashkin said. In essence, women were happy to receive quality information about their childbirth options, but to enhance the overall level of person-centered care the information needed to be delivered in an environment of trust, support, continuity and with a respect for physiologic birth.
Information-heavy shared decision-making interventions have largely not been effective in lowering the excessive use of cesarean sections, a problem that will be the focus of Rubashkin’s dissertation research. Caesarean rates have increased in the United States in recent decades. In searching for a reason, researchers have focused either on pregnant women’s health risk factors or their decision-making process, asking whether increasing obesity rates have led to more cesareans or if women need to be better informed to choose a vaginal birth.
But the real causes may have much more to do with healthcare providers than pregnant women, Rubashkin said.
“The scientific process in obstetrics that for all intents and purposes appears to be person-centered, that presents to women “choices” for their deliveries, in actuality may be hiding system-level drivers of cesarean use and repackaging them as individual decisions,” he said.
For example, African American women are much more likely to have first and second-time cesarean births than white women, even when low-risk groups are compared, he said. The reasons are not totally clear, but likely relate to the historic decimation of Black midwives in the United States, poor access to quality obstetric care, and to racism within clinical interactions. Current shared decision-making interventions Ignore these social and historical factors, and instead seek to improve the “decisions” Black women are making.
“C-sections are overused in African American women. We need to listen to Black women’s concerns and their proposed solutions. I recently attend the Black Mamas Matter Alliance Conference and Training Institute in Atlanta, and I plan to incorporate lessons learned into my dissertation work.”
Rubashkin expects to finish his doctorate in 2020. He hopes to then use what he’s learned to help scale up midwifery care nationally and globally and to help end use of unnecessary medical interventions in labor and delivery. Rubashkin feels his experience in the IGHS PhD program has given him the skills he needs for future success.
“Now I know enough to design my own studies and work with my own data,” he said. “I’ve got a full range of tools that I’m already using, and that’s exactly what I wanted,” he said.