American Journal

of Obstetrics and Gynecology volume


number 3

OCTOBER 1, 1975

The relationship of medical socialization (o~stet~cians and general practitioners) to complications in pregnancy and delivery, birth i~j~~, and rnalf~~ati~~ DONALD


Sun Bernardino,



In this paper, cemus data were used to assess the effectiveness in birth delivery of obstetricians and gerteral practitioners. Although the data reported require some qualijkation and additional! research, ~el~rni~~~ results indicate that general pra~t~tio~Ts report ap~o~~~~e~~ three times more birth ensues arbor ~~o~t~o~ (&an do obsidians) at birth. Both groups (obstetricians and general practitioners) report approx’mately the same number of complications in meanly and delivery. It was natively cor&tded that the simila.~~ in d&posed complication was probably due to diagnostic error. This error, in ~ombi~tion with sample differeences and differing delivery technigues, resulted in the conseqwnt dqferences in rates of birth injury and malformation.

IN MEDICINE, as well as in many other fields, there is a continuing controversy over the expansion of specialized training and the role of the specialist. Sterna focused on the problem in the following statement: “Specialization in medical practice, an imperative concomitant of developments in medical science and From


Rec~iv~d~or Revised

Stale College.



Accepted November

technology, has then after a period of considerable opposition become one of the marked characteristics of modern medicine. This has raised proMems of certification, of the relationship of the specialists to one another and to the general practitioner, of the reiation of physicians to patients, and of the marketing of medical services-problems the solutions of whic:h are basic to the future efficacy of medicine.” At present, the problem has assumed emotional and political overtones. An example is the female setf-help movement, which rejects both male chauvinism and medical specialization. Frankfort3 described the gynecologist as, “so focused on the reproductive tract that women rarely think of reporting problems in other parts of the body. The need to deny that the live person lies behind the collection of parts leads to the cold im-


16, 1974.

4, 1974. 26, 1974.

Reprint reps& Dr. Don&d F. Caetano, State College, 550 State College Parlay, Bernurdino, California 9.2407. Not for quote or publication of author.


Califomk San

expressed consent




Fig. 1. Copy of certificate. personal manner.” Here the stereotype of the cold im~rsonal specialist (treating parts but not people) is raised to justify a claim for midwifery and other forms of paramedical treatment. In the face of these appeals the trend to increased specialization proceeds, and medical schools continue to primarily train specialists.’ In this paper a limited investigation of this problem was made using census data to compare the rates of birth injury and/or malformation for obstetricians and general practitioners. While it is known that certain ethnic, occupational, and educational groups have high birth mortality rates,2 relatively little is known about the effects of medical specialization. Specifically, we wanted to know if obstetricians tend to reduce the extent of birth injury or malformation. If so, was this due to specialized training, or to some other factor?

Birth delivery seemed to be a most appropriate focus since many argue that this is a natural function-an area of “primary care” where the mir~istrations of the general practitioner, the paramedic, and the midwife are more than adequate. These data are limited to a particular specialty (obstetrics) and are not intended to make a general statement concerning the efficiency and practicality of specialization in other areas of medicine.

Methods of research Census data (i.e., San Bernardino County, 1973)’ were used to compare cases handled by obstetricians and general practitioners. Each birth certificate required the delivering physician to state his state license number, diagnoses, (i.e., whether case exhibited com-

Medical specialization

and pregnancy and delivery complications;


I. Live births delivered by genera1practitioners and obstetricians, by complications in pregnancy and delivery, birth injury, and malformation* -Compli4xdo7ts


General practitioners (40 doctors) Obstetricians (37 doctors) Totals *San

During Pegnancy

During delivery

112 7.8% 253

207 14.6% 753



10 0.7% 9


Total deliwi~~s

28 1.9% 34

1,421 1007’ 5.191

O.i%% 62

BernardinoCounty, 1973census.

plications in pregnancy and delivery), and whether a birth injury and/or malformation occurred. A copy of the certificate is presented in Fig. 1. By using the state license number and referring to the California Geographical Directory of Physicians (1973),* we were able to determine the names of delivering physicians.Then, by using a publication of the County Medical Association, which identified each physician by specialty, we were able to determine whether each live birth was delivered by a general practitioner or an obstetrician. There were some problems, one of which was our inability to randomly assign subjects to obstetricians and general practitioners. Thus, the two samples(i.e., thosetreated by obstetriciansand general practitioners) could have been substantially different prior to delivery, and the resultant differences in injury and malformation could hardly be attributed to the varying skills of the delivering physician. In spite of this, we do have some control (on the similarity of samples) since doctors did premeasure or diagnose all cases prior to delivery. These diagnosesindicate that the groups were similar in complicationsin pregnancy and delivery. The data on complications will be presented and discussedfurther in the Resultssection, The data regarding complications, injury, and malformation might also be biased by the varying diagnostic standards used (by general practitioners and obstetricians) to categorize cases.In general, doctors use the term complications to refer to any occurrence or condition which deviates from the normal course of pregnancy or delivery. Birth injuries are those abnormalities which are a result of delivery. f~~~~o~io~ are abn~)rmalitiespresent at birth, due to either hereditary or environmental factors (e.g., cleft palate, club foot, spina bifida). In the last resort, we can only rely on the diagnostic expertise of the physician, and also assumethat the large sample(N = 6, 612) would tend to cancel out errors. Still another problem is the accountability of the

doctor who signsthe birth certificate. That is, does the signature actually mean that that particular sloctor delivered the child? Is it possiblefor an obstetrician to sign for a general practitioner, or vice-versa? For example, the senior obstetrician (at one hospital) had signed for over five hundred live births. An inquiry assuredus that while he may not have been present during labor, he or another obstetrician (unoer his charge) waspresent at the actual delivery. This appears to be the casein all of the local hospitals. In lieu of this, we felt quite confident that certificates signed by obstetricians represented children who were derivered by obstetricians, and those signed by general practitioners were delivered by general practitioner?. The fact that a senior obstetrician may sign for another obstetrician was deemed unimportant to the present study, sincewe had no interest in comparing individual doctors. In general, the above-mentioned limitations are found in all research utilizing censusdata, an1 were anticipated. They limit, but do not eliminate the possibility of drawing exploratory inferences. On t.hc other hand, censusdata had somedistinct advantages. The large sample, collected over a period of time, enabled us to uncover long-range trends which were not perceived by practitioners, particularly those delivering only a few casesper year. And unlike direct observation, questionnaires,or interviews, censusdata hasthe advantage of being unobtrusive. That is,the researcher wasnot required to intrude on the research situation, and our subjects were unaware that they were being studied. The unobtrusive factor was particularly important in this study, which necessarilyinvolved a sensitive comparison. The sample The samplewascomposedof all live births delivered by physicianswho were membersof the county nedical association(N = 6, 612). Children delivered by out-ofcounty doctors were not included becausethey con-




II. Crude



rate (X 10,000)

bv medical


GENERAL P~TITIO~~S OBSTETRICIANS Differences analyzed by test of the differences between proportions. were significant (Z = 3.46; p < 0.01).


III. Crude


rate (X lO,O~O) by medical

Differences between groups


GEWIRAL ASTIR OBSTETRICIANS Differences analyzed by test of the differences between proportions. were significant (Z = 4.16; p < 0.01).

stituted a distinct and unusual type of delivery. After inquiring at local hospitals, we were informed that out-of-county doctors were often general practitioners who came in to do emergency work. Emergency deiiveries are often problematic, and their inclusion would have biased our results. There are two obstetrics residency programs in the county. One is located at a large prepaid health plan hospital, the other at a local community hospital. Since physicians (including residents) practicing at the health plan hospital do not belong to the county medical association, they were not included in the study. The community hospital employed a first-, second-, and third-year resident obstetrician. The first- and thirdyear residents were on duty during the entire period covered by the study. The second-year resident spends six months at UCLA, and was absent during half of the study. All of the deliveries of these residents were included in the obstetrics category. This seems quite justified, since their work is closely monitored (by senior obstetricians) and the training of the third-year resident is quite advanced. A comparison of county, state, and national statistics indicates that these results may be generalized to most of the country. For example, the county infant mortality rate (an index of prenatal care and medical facilities) is 16.9 (per 10,000 live births). This stands midway between the national rate (17.7 per 10,000) and the California rate (15.8 per 10,000). The per capita income for the county is $9,429 per year. The national average (1973) was $9,965 (U. S. Census Report, 1970f.’

Differences between groups

aural-urban and ethnic group ratios were also approximately the same as the national average.

Results Table I presents a comparison of the diagnoses of complications during pregnancy and delivery (columns 1 and 2), birth injury, and malformation (columns 3 and 4). Row 1 presents the work of 40 general practitioners (1,421 deliveries); row 2 the work of 37 obstetricians (5,191 deliveries). The cell frequencies show both the number of diagnoses and the percentages (which are comparable). For ease of comparison, Table I was “broken down” into several subtables (Tables II, III, and IV). Table II presents a comparison of rates of birth injury by obstetricians and general practitioners. As one can see, the differences are quite dramatic. The overall rate for obstetricians is 17 birth injuries (out of each 10,000 live births) as opposed to 70 (out of each 10,000 live births) for general practitioners. Thus, general practitioners had approximately four times more birth injuries when compared to obstetricians (Z = 3.46, p < 0.01). Table III compares crude malformation rate by medical specialization, Here again, the differences are quite large. Per 10,000 births, obstetricians had 65 malformations compared to 190 for general practitioners (2 = 4.16, p < 0.01). That is, approximately three times more malformed children were delivered by general practitioners. We have hypothesized that these differences may be

Medical specialization

due to medical specialization. However, an alternative hypothesis is sample bias. Since we had not randomly assigned expectant mothers to general practitioners and obstetricians, it is possible that a disadvanted group of patients selects to be treated by the general practitioner. These mothers may also have had more physical and emotional problems, which might have led to complications and a higher rate of birth injury and malformation (for general practitioners). However, the data on diagnosed complications in pregnancy and delivery do not indicate sample differences. For instance, Table IV presents the data on diagnosed complications in pregnancy and during delivery. In effect, these comparisons represent a pretest for differences. That is, the doctors measured the physical and/or emotional condition of mothers prior to and at delivery. Since the subsequent rates of injury and Inalformation differ significantly, we expected to find that general practitioners had diagnosed significantly more cases with complications. However, this was not the case, since differences were not statistically sign&cant. For example, the bar chart to the right (Table IV) compares the percentages of cases diagnosed as having complications in pregnancy. General practitioners report a slightly larger percentage as having had complications (i.e., 7.8% > 4.8%: (P > 0.05). The bar chart to the left presents a comparison of diagnoses of complications in delivery. Here, once again, differences are very small (i.e., 14.6 > 14.5: p > 0.05), and statistically insignificant. Given these data, we could conclude that the samples were similar and that the subsequent differences (in injury and malformation) were solely due to differences in delivery technique. This seems plausible in the case of injury, but highly improbable given the nature of malformation-which is often hereditary in nature. It seems more likely that the samples were dissimifar, that the general practitioners treated a disadvantaged group with more complications, which they failed to diagnose. Thus, the injury and malformation differences were probably due to a combination of sample differences, diagnostic error, and differences in delivery technique. Diagnostic error is also included, since many of the malformations and injuries could probably have been prevented with an early diagnosis and clinical intervention. The higher rate of injury (when compared to malformation) also supports this explanation, since it is due to the effects of sample differences, diagnostic error, and delivery techniquewhereas malformation rate is a result of sample difference and diagnostic error, without the added effects of delivery technique. Another hypothesis was examined. This was that

and pregnancy

and deiiery



Table IV. Percentage

of cases diagnosed as having complications (in pregnancy and delivery ) by medical specialization PERCEIWAGE DIAGIKBED HAVIITG Cc%uIpLICATIONS DELIVEBY









-i Differences analyzed by test of the differences iretween proportions. Differences between groups were insip:nificant (p > 0.05).

general practitioners possibly deliver more emergency cases which are often problematical and result in high rates of injury and/or malformation. This does tend to be the case, since out-of-county doctors, who are known to do a great deal of the emergency work, had the highest rates of injury in the study (Le., 200 out ttf each 10,000 births). As a result, these doctors were not included in the sample. Finally, the small residual reaching local doctors would have an equal chance of receiving emergency attention from ez’tfapran obstetrician or a general practitioner.

Comment As in any scientific pursuit, we have answered some questions and have raised others. One particularly provocative question was raised by the similarity in the percentages of diagnoses of complications (both in pregnancy and delivery) by general practitioners and obstetricians. One would expect obstetricians to report a much higher percentage in both classes--particularly complications in pregnancy. One factor is the diagnostic capacity of the obstetrician. One would assume that his specialized training would lead him to perceive more symptoms, resulting in a higher percentage of diagnosed complications in pregnancy and delivery.

Another factor is the referral system, One would assume that general practitioners would refer large numbers of complications (both in pregnancy and delivery) to the obstetrician. If this were a fact, the vast majority of complications would end up in the hands of the obstetrician, and he would have reported an extremely high percentage of complications in delivery. Such is not the case, however, since the percentages of complications in delivery for obstetricians and general practitioners are approximately the same. This may indicate a failure of general practitioners to refer many such complication pregnancies to the obstetrician. Perhaps such patients are in rural areas, or cannot afford to pay for an obstetrician, or the general practitioner may consider child delivery a routine procedure which does not require specialized attention. The data we have do not enable us to answer this question. At this stage we can only note that the general practitioner’s high rate of injury and/or maiformation should encourage referral, even if the patient is poor or resides in a rural area. Additional research should attempt to clarify some of the questions raised in this study. It would be informative to probe the referral system, attempting to determine how it works and under which conditions it is inoperative. It would also be informative to obtain the attitudes of general practitioners and the public toward specialists and in particular to obstetricians. Data could also be gathered to clarify the relationships of social class, and which class(es) utilize general practitioners or obstetricians, and their subsequent birth injury or malformation rates. More precise information on the type and extent of injury and malformation, including varying means of reaching these diagnoses, would also be invaluable. Finally, investigations should be conducted in other medical situations to determine whether specialized medicine is more beneficial than general treatment.

Conciusions In this study, census data indicate that general practitioners and obstetricians were approximately the same in the percentage of mothers diagnosed as having complications in pregnancy and delivery and that general practitioners reported approximately four times more birth injuries and three times more malformations when compared to obstetricians. While this study is exploratory, and has all the strengths and weaknesses of census data, several tentative conclusions suggest themselves. (1) The samples treated by obstetricians and general practitioners were similar (as the diagnoses of complications suggest), and differences in rates of

birth injury and malformation were due to differing delivery techniques. This hardly seems probable, since malformations are, by definition, often due to hereditary factors. (2) The samples were dissimilar, with the general practitions treating a disadvantaged population having many more cases of complications (both in pregnancy and delivery) which they failed to diagnose. Since early diagnosis can often curtail both birth injury and malformation, subsequent differences were due to the joint effects of sample differences and diagnostic error. This seems plausible, but fails to account for the greater rate of injury (when compared to malformation). (3) Finally, an interaction of all three factors {sample differences, diagnostic errors, and delivery technique) could account for the differences. Sample differences and the failure to diagnose (and treat) complications in pregnancy could account for the increased rates of malformation. Sample differences and failure to diagnose (and anticipate) complications in delivery, plus faulty delivery technique, could lead to the even greater difference in birth injury rates. The latter explanation was accepted as the most plausible, since it enabled us to simultaneously explain facts which appear contradictory (i.e., the difference in malformation rates, the even greater difference in injury rates, and the similarity in rates of diagnosed complications). In final conclusion, it appears that the differences (in malformation and injury) are due to a combination of medical expertise (diagnostic and delivery skills) and sample differences. It does not seem feasible that these differences were due to emergency deliveries by general practitioners, since out-of-county doctors doing emergency work were excluded from the sample. The data also indicates that large numbers of patients with complications were probably not being referred to obstetricians and, as a result, were not receiving the specialized diagnostic and delivery skills which he has to offer. It was suggested that the lack of referral be studied in future research, and that every effort be made to get complicated cases to the obstetrician. It is also necessary to state that this is an investigation of a very limited area of medicine. We are not saying, or implying, that general practitioners do not provide a necessary and invaluable service to patients. We only wish to suggest that decisions (to seek medical attention) be based on fact and not emotion, and that more research be done to indicate those situations in which specialized treatment is most beneficial to the patient. Only in this way can the relationship of specialized and general medicine be clarified and rational decisions implemented.

Medical specialization

1 would like to thank Dominic Bulgarella, Michael Ginder (San Bernardino Public Health Analyst), Pansey Hawley (Director, San Bernardino March of

and pregnancy and delivery complications

Dimes), and Eileen of this paper.



for help on e#%rlier drafts

REFERENCES 1. Blumberg, M.: Trends and projections of physicians in the United States, 19672002; a technical report sponsored by the Carnegie Commission on Higher Education, 1971. 2. Chase, H.: A study of risks, medical case and infant mortality, Am. J. Pub. Health 63: Sept. 1973. 3. Frankfort, E.: Vaginal Politics, New York, 1972, Quadrangle Books, pp. 32, 33. 4. Medical Examiner, the State of California: Geographical Directory of Physicians, 1973.

5. Statistical Health Services, San Bernardino CountyPublic Health Department: San Bernardino Count\ Mech mixed Birth and Death Records, 1973. 6. Stern, B.: The specialist and the general practitio ler’. 111 American Medical Practice in the Perspectives of t Century, New York, 1945, Harvard University Press, 1’. YtiO. 7. U. S. Bureau of Census: U. S. Census of Populatican and Housing: 1970, Washington, D. C:.. 1973. !‘. S. Covernment Printing Office.

Note to authors: Change in reference style The Editors and Publisher have agreed to add the article title to references in the AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY. References will now conform to the style of the Cumulated Index Medicw, viz., name of author, title of article, name of periodical, volume, page, and year. Authors are always encouraged to limit references to sixteen for the following JOURNAL sections: Obstetrics, Gynecology, and Fetus, Placenta, and Newborn.

The relationship of medical specialization (obstetricians and general practitioners) to complications in pregnancy and delivery, birth injury, and malformation.

In this paper, census data were used to assess the effectiveness in birth delivery of obstetricians and general practitioners.though the data reported...
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