Over the years, I have frequently been asked by women how they should pick an obstetrician-gynecologist. Or, sometimes they will ask how to tell if the one they are currently going to is any good. This is an important question because the average woman who seeks care from an obstetrician-gynecologist is at a huge disadvantage in terms of knowing whether they are receiving high-quality, high-value care or not. Unfortunately, far too many Ob/Gyns seem to care more about the bottom line than they do their patients. Most doctors are pretty good at the superficial things: a caring bedside manner, pretty paintings in the waiting room, friendly smiles from the office staff, etc. Most pregnant women are going to have a good outcome and a mostly pleasant experience during their pregnancies and deliveries. Therefore, most patients are superficially satisfied with most doctors, even the very worst doctors.

So, how can a woman tell the difference in the good, the bad, and the ugly?

Let’s say you’re pregnant and you’re looking for a good obstetrician. What information do you need and what questions should you ask in order to pick a great doc? Another way of thinking about this is, What are the markers of quality that are measurable and objective which can help to distinguish one OB/GYN from the next?

Here are some questions you could ask, along with some good, bad, and ugly responses.

What is your Cesarean delivery rate?

  • The Good: My total Cesarean Delivery rate is under 25%, while my primary Cesarean Delivery rate is under 15%. My rate among mothers at term whose baby is head down is under 10%.
  • The Bad: My Cesarean Delivery rates are consistent with the national averages.
  • The Ugly: My Cesarean Delivery rate is around 50% – or I don’t know my Cesarean Delivery rate.

The Cesarean Delivery rate in the United States is too high; this high Cesarean rate is associated with an increase in maternal death and harm without any substantial benefit to babies. Conscientious obstetricians work hard to have a rate significantly lower than the national averages and follow evidence-based guidelines and recommendations that allow for a lower and safer rate. Average Ob/Gyns perform Cesareans on nearly one in three women whom they deliver and they typically are not working hard at all to reduce those numbers. Their patients have higher rates of complications and death and their babies are no better off for it. Really bad docs are even worse than this.

If a doctor tells you that he doesn’t know his Cesarean rate, you can assume that it’s bad. He may legitimately not know his numbers, but his lack of concern about perhaps the most important indicator of quality for his profession shows his lack of concern for his patients and his patients’ outcomes.

One caveat: if you see multiple doctors in a group, then the rate that matters is the rate of the whole group or perhaps the hospital at which you will deliver. Unless your doctor is offering you continuity of care and plans on being at your delivery, then you have to assume that the average of the whole group applies to you. Also, increasingly, many hospitals employee laborists; these are doctors who only deliver babies at the hospital. If you are going to be delivered by laborist, then the doctor who takes care of you in the office becomes irrelevant and you’ll need to find out the rates of the laborists, whom, by the way, you are unlikely to meet before you deliver.

Unfortunately, the trend in recent years has been away from continuity of care and towards things like large group call pools and/or laborists. While taking less call is great for physicians’ lifestyles, it’s bad for patients. I have never met a patient who said she was excited about being delivered by a stranger. Continuity of care during your pregnancy is associated with a lower risk of interventions and Cesareans, better outcomes, and higher patient satisfaction.

What is your episiotomy rate? What is your rate of third and fourth-degree perineal lacerations?

  • The Good: I don’t cut episiotomies and I only rarely ever have a third- or fourth-degree laceration.
  • The Bad: I only cut episiotomies when they are necessary and we do see a few third- or fourth-degree tears in a year.
  • The Ugly: I usually cut them on first-time moms or on anyone who I think is going to tear because you get a much nicer repair if it’s cut rather than letting you tear on your own. And we do have a few women who have severe tears, but we have a lot of experience repairing them and our women do great.

There are two separate issues involved in this question. The first one is in regards to episiotomies, which significantly increase the risk that a woman will suffer a tear into the rectum (fourth degree) or the rectal sphincter (third degree). These tears are associated with things like fecal incontinence and pain. The one factor we have the most control over to prevent severe perineal trauma and these negative outcomes is to not cut episiotomies. We have known this since the mid-1980s. It is really unacceptable at this point for people to continue to cut them on a routine or even occasional basis.

Should an episiotomy ever be cut? Yes, they are times when cutting one can be beneficial, but these times are excessively rare. In nearly 4000 deliveries in my career, I have cut one less than five times because of these rare indications.

The second issue is this: How good is the doctor at preventing severe tears? Unfortunately, a whole generation of practicing obstetricians were trained to cut women and so they learned little and put little emphasis on preventing tears. The science of how to prevent severe perineal lacerations is very young and so the bulk of practicing obstetricians aren’t very good at it. Again, in my career, in which I have not cut episiotomies and during which I have placed an emphasis on preventing severe perineal trauma, I have had less than 15 third- or fourth-degree lacerations. Many physicians still have a rate of around 5%, which is completely unacceptable.

What do you do when a baby is not head down at term?

  • The Good: I recommend that we attempt to do what’s called an external cephalic version (ECV) and turn the baby at around 37-weeks. This works about two-thirds of the time and can save you an unnecessary Cesarean Delivery. ECV is a safe and useful procedure.
  • The Bad: Sometimes we’ll attempt an external cephalic version if you want but I usually just recommend doing a Cesarean because ECV has some serious risks associated with it and it usually doesn’t work anyway.
  • The Ugly: Most women are head down when they go into labor. If you show up in labor and the baby is breech, then we’ll just do a Cesarean.

Babies are not head down in about 3% of pregnancies at term. ECV is a safe procedure that works about two-thirds of the time and can save a Cesarean, but most Ob/Gyns don’t do them, even though it is recommended by our evidence-based guidelines. They will overplay the risks and undersell the successes, as in the second example above. Even worse, many docs don’t even check at 36-37 weeks to see how the baby is turned.

How do you recommend delivering twins?

  • The Good: We deliver twins vaginally as long as the first baby is head down. Women and babies do better with vaginal birth of twins and we highly encourage it.
  • The Bad: If both babies are head down when you go into labor, then sometimes you’ll be able to deliver vaginally. If the second baby isn’t head down, then a Cesarean is safer and you’d hate to have a vaginal delivery with the first baby and then have to have a Cesarean for the second one. It would’ve been easier just to have a Cesarean to begin with.
  • The Ugly: Twins are a high-risk pregnancy and we always deliver those by cesarean.

Twins are almost always better off being born vaginally than by Cesarean; both mom and babies do better. But, once again, many Obstetricians just won’t do it. Protip: If your doc says that she does offer something like twin vaginal delivery or ECV or vaginal birth after Cesarean (VBAC), ask her about percentages. Many bad and ugly docs will give lip-service to anything you ask, but ask them to back it up with numbers. 

  • What is your vaginal delivery rate for twin pregnancies?
  • In what percentage of your women who are not head down at term do you attempt an ECV and how often are you successful?
  • What percentage of your patients who are eligible for a trial of labor after Cesarean attempt one and what percentage are successful?

Again, an answer of “I don’t know” means that their numbers are bad. Run. Good answers to those three questions might be:

  • (Twins) At least 70% deliver vaginally.
  • (ECV) Almost all of my women attempt a version and it works about half the time.
  • (VBAC) Probably two-thirds of my patients who are eligible for a VBAC try one and about 85% are successful.

Who will deliver my baby? Will I see the same doctor (or midwife) throughout my pregnancy?

  • The Good: We try to see all of our own patients and deliver our own patients as much as possible. Of course, we have families too and we can’t always be there, but we deliver our own patients about 90% of the time.
  • The Bad: You will be delivered by whoever is on call.
  • The Ugly: We don’t deliver babies but we work with a team of laborists who work in the hospital who are available 24/7.

It’s your pregnancy. Which of those options sounds best to you: to be delivered by someone whom you hopefully develop a trusting relationship with over several months (or years), or by a complete stranger? Having a baby is at once the most joyous and most frightening experiences you are likely to have in your lifetime; do you want to do it with a stranger? No.

Women have a choice in this matter. I understand that doctors are providing fewer good options, but women have the choice to find a doctor to provide the experience they want and to change the marketplace through action. Don’t be afraid to leave a bad doc for a good one.

Here is the attitude you should look for when picking an obstetrician: He or she should want you to have the best outcome possible (lowest risk of Cesarean and other interventions combined with the lowest risk of adverse neonatal outcomes) while allowing you as much freedom over the process of giving birth as possible. You should be allowed wide latitude in choices you might make during your pregnancy and delivery and you should be supported and encouraged to have the experience you want.

But I already have a great Ob/Gyn!

Do you? I don’t doubt that you have someone who is pleasant and whom you might even trust, but don’t be afraid to ask questions like the ones above. Or just think about how you have already been treated in the past.

Let’s say you’ve already been seeing your gynecologist for a few years and you’re wondering if you’re with a good doctor, whether pregnant or not. Here are some clues:

  • If your doctor does yearly Pap smears on you, you don’t have a good doctor. We haven’t recommended yearly Pap smears in 20 years and no guideline currently supports this practice. Your doctor either blatantly disregards guidelines or just doesn’t care about evidence-based medicine. The yearly Pap smear is actually harmful to your reproductive health (but it’s good for your Doc’s bottom line).
  • If your doctor does yearly pelvic or breast exams and you are under 40, if she recommends that you perform self-breast exams (without a personal increased risk of breast cancer), or if she tells you that you need a pelvic exam in order to get a birth control refill, you don’t have a good doctor. Even though these practices are common, none are evidence-based and all are, in fact, harmful.

Here’s another clue: if your doctor prescribes birth control pills to you and did not encourage you to get a long-acting reversible contraceptive (LARC) like an IUD or an implant before giving you birth control pills, he’s not a good doctor. Also, if he didn’t explicitly tell you the failure rate of birth control pills before giving them to you, he’s not a good doctor. I see new patients all the time who come in with a long-standing prescription for a birth control pill and I ask them if their doctor ever explained to them about LARCs. They almost universally say no. I also ask them if they are aware of the failure rate of birth control pills or if their doctors ever told them the failure rate. They almost always say no to that as well.

The outcome differences between LARCs and birth-control pills, the patch, or the vaginal ring are huge. If a woman comes in expressly asking for help to not get pregnant, it is unethical to give them a product that has an 8.4% per year failure rate and not even tell them that the failure rate is that high.

Both the yearly Pap smear and the yearly prescription for birth control pills is a coercion to get a woman to come in once a year to see the doctor. While I am not against having a woman come in once a year to see me for an annual preventive exam, I am absolutely against threatening her with pregnancy or cervical cancer as a means of doing so. Yearly exams for the most part for younger women should focus on mental health screening, exercise, weight control, effective contraception and family planning, substance abuse screening, sexual function, etc. The ole Pap, pelvic, and breast exam have little part in ethical and evidence-based gynecologic practice.

If your doctor can’t follow straight forward and clear evidence-based recommendations about Pap smears and birth control, how can you trust him to make complex decisions that affect the life and health of you and your baby?

If you are already pregnant, and you seem to be getting lots of ultrasounds or non-stress tests, or you’ve been told that you’re high-risk and therefore need these extra tests, be very leery.

There are very few indications in pregnancy that are evidence-based for women to get antenatal testing but antenatal testing is an ATM machine for many obstetricians. It’s not unheard of for women to get routinely around 10 ultrasounds and 6-8 nonstress tests during their pregnancy. Many women are told that they need twice-weekly testing after 32-weeks. They miss dozens of days of work and focus a lot of anxiety and stress on these tests that are often ordered only so that the doc can make a buck.

While there are some women who benefit from these tests, they are far and few in between. There is no evidence that doing tests two times a week as opposed to once a week is better, even among women who do need the tests. Many women receive these tests just because they are over age 35, because they are obese, because they have diet-controlled gestational diabetes, because they have a history of hypertension but aren’t currently on medications, because they have a history of preterm labor, because they smoke, or because they have a suspected big baby. None of those are indications for antenatal testing.

The true indications for antenatal testing are few. They are mostly necessary for women who have diabetes requiring medication, particularly pre-existing diabetes, for women who have a history of a prior fetal loss, whose babies have severe growth restriction, who have preeclampsia or chronic hypertension with end-organ damage, or a few other rare reasons. These sorts of women aren’t found that often in average Ob/Gyn practices, but that doesn’t stop many practices from abusing these tests for cash.

If your doctor routinely does an ultrasound at around 36 weeks to see if the baby is head down and/or see how big the baby is, you have a bad doctor. This intervention, while making money for the doctor, is not recommended and is associated with net harm because the ultrasound is so inaccurate in predicting the size of the baby that many women receive an unnecessary Cesarean because they’re worried about a big baby for no reason.

If your doctor has ever recommended bed rest to you while pregnant, you have a bad doctor. Bed rest is a dangerous and ineffective intervetion that our professional societies recommend against.

Unfortunately, doctors are heavily incentivized financially to perform excessive ultrasounds, tests, and other procedures and surgeries. I won’t even begin to talk about all the unnecessary surgeries that happen.

In fact, doctors look for all sorts of ways to “monetize” women. Your doctor might’ve even gone to a weekend seminar to learn these tricks. Perhaps your doctor employs a pelvic floor physical therapist and tells you that you need pelvic floor physical therapy while pregnant and postpartum, despite the lack of scientific evidence that these invasive and embarrassing procedures benefit the vast majority of women. Perhaps your doctor owns a bone density machine and tells you that you need to have your bone density measured just because you are menopausal, even though the guidelines recommend waiting until age 65 unless you have significant risk factors. Maybe your doctor sells her own line of vitamins, nutraceuticals, or cosmetics. Maybe she recommends vaginal cosmetic procedures or other non-evidence-based, risky, and often harmful cash-paying procedures involving a laser or some other such gizmo. Your doctor learned these at a weekend course and bought a franchise in order to exploit you financially. Maybe they have talked to you about bioidentical hormone therapy and they suggest that you use a local compounding pharmacy they have partnered with or even provide the medications for you through a franchise that they own. RUN! All of these things are pure quackery and do not benefit you but they do help your doctor enrich himself.

I am fortunate enough to practice with partners who answer all these questions correctly. Good docs exist, who put the patient above profit. Find one.

BTW, the graphic at the top is based on the famous Clint Eastwood movie, The Good, the Bad, and the Ugly. This was the last film of a trilogy of movies called the Spaghetti Westerns, because they were American Westerns made in Italy by Sergio Leone. The first two films were called A Fistful of Dollars and For a Few Dollars More. Somehow, those titles seem relevant to modern Ob/Gyn practices too …

Il buono, il brutto, il cattivo