RHI Health Blog of the Week

The RHI Health Blog of the Week is awarded to an exceptional health-related post appearing during the previous week (Wednesday to Tuesday).

This week's award goes to Midwife With A Knife's post "It's not your fault, except when it is," which discusses what should be said to patients in those small percentage of stillbirth cases (about 10%) that are due to the actions or inactions of the patient, such as uncontrolled diabetes or patients who did not comply with recommendations for regular fetal monitoring. I quote extensively from this post because to do otherwise would not do justice to this fine piece. The post reflects both a physician's concern for her neediest patients as well as her frustrations with those patients:

Most diabetic stillbirths, in fact, occur in patients who are non-compliant with their blood sugars, insulin, and their fetal monitoring regimens. During pregnancy, I give them my "You need to do these things, otherwise your baby could be seriously damaged or die" talk (dead baby talk for short). And despite the dead baby talk, a subset of our patients will not follow our recommendations. Now, I know most of our patients are very poor, but they all get free care through us. We have a baby van that tracks them down and brings them to their appointments. We make sure that they have the appropriate emergency Medicaid so that they can get their insulin. And in fact, few of them have jobs, which makes it easier for them to make their appointments. And we never ask them not to bring their 12 screaming children into the waiting room. We just want them to come however they can, with or without screaming children. Without hospitalizing them for their entire pregnancy and administering their insulin to them (and sometimes we do that, but it's not practical to keep people hospitalized for 9 months of pregnancy because they're non-compliant), we could not do more to make them able to comply. And, rather than telling us they're not taking their insulin, etc. they bring in fake blood sugars. I think it is a case of denial...they don't believe it will happen to them. That combined with the fact that many diabetics don't feel bad until they're really really sick.

So, these noncompliant patients get dead baby talk after dead baby talk. And they have a much higher rate of fetal death than the compliant patients (whose rate of stillbirth is still higher than the general population, but not by a lot). So, when these women come in with their stillbirths, although part of me wants to say (just to be compassionate), "This is not your fault", the other part of me keeps me from saying those words, because they're not true.

I don't know that it really helps the patient to hear "This is not your fault" when it is kind of is their fault. In some ways, these women are suffering a consequence of their lack of personal responsibility (I know it sounds pretty harsh to put it like that). If these women choose to get pregnant again, they deserve to know that they increased their risk of having a stillborn child by their bad behavior. Because if they behave the same with the next pregnancy, they may very well get the same result. And the only thing that's worse for a mom than a single stillborn baby is recurrent stillbirths.

In fact, when women come in for their postpartum visit, and I get to the part of the visit where we talk about the pathology/autopsy results and talk about what caused the stillbirth, I will tell women, "We know that diabetics are at a high risk for stillbirth. And we know that taking your insulin regularly and showing up to have your ultrasounds and have your baby monitored decreases that risk. I see here that your blood sugars weren't well controlled and that you didn't come in for your monitoring visits. My recommendation to you, so that you don't have to go through this again, would be that you avoid pregnancy until you're able to do the things we recommend you do to decrease the risk of stillbirth. If you want to have a safe pregnancy as a diabetic, you have to do these things." At which point I launch into my contraceptive spiel and make sure they have an internist who takes care of their diabetes between pregnancies. We can never get diabetic stillbirths down to 0, but we could get them pretty low, if we had the assistance of the patients.

The thing is, this feels very much like telling the patients that their dead baby is their fault. And in many ways, it is. Telling them that seems unkind. Not telling them that seems unkind. I just worry that laying it out like that does more damage than it prevents. At the same time, I worry that not laying it out like that will do more damage. For now, I'll continue to tell them that they may have been able to prevent the stillbirth, simply because it seems like maybe the best thing for me to do is to empower them to avoid having a repeat stillbirth.

The award is presented every Wednesday. If you would like to nominate a post for the RHI Health Blog of the Week, please contact me.

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