Big City Hospital vs. Small Town Hospital

As we all know, a woman’s choice of care provider and birth place has a profound impact on her experience through pregnancy, labor and delivery. As doulas, we have a unique perspective, because we witness a wide range of styles, ideologies and philosophies in various settings. Every hospital has its own “culture” when it comes to labor and delivery. At times, traveling to an unfamiliar hospital with a client brings with it a degree of culture shock.

A recent birth inspired us to consider the differences between the care women receive at smaller, rural hospitals vs. larger, metropolitan hospitals. At first glance, the smaller, rural hospitals might seem less advanced or perhaps not as shiny and new as their larger counterparts. Parents might gravitate towards “bigger and better” or a place that they believe can cure every ill. But is that the right choice?

First, let’s explore “Big City Hospital." It houses the best surgical center in a 250-mile radius. Everyone knows that it is the place to go if you suspect a heart attack, because their emergency department sees them frequently and is quick to jump in and take appropriate action. This culture may very well save your life. However, this electric atmosphere, carried over into the maternity ward, may lead to unnecessary and harmful interventions.

Every woman who comes into this hospital gets a plastic bracelet with a barcode on it, and every time a nurse comes into the room to carry out orders and and chart on the computer, she scans the barcode. This is essential since there are 50 labor and delivery rooms and at least 15 or 20 women in labor at any given time and patients can easily get mixed up. Nursing shifts change every four hours and the nurses are way too busy with paperwork and tracking four or five monitors each to spend individual care with any one woman or provide much labor support. The “house resident” is in charge of everyone’s care until he or she thinks it is close enough to call the on-call doctor with a report. All of the labor management is done via the nurse, to the resident, over the phone to the doctor, back to the resident and nurse. Depending on the practice, the doctor that actually catches the baby may be one of ten or twelve rotating physicians or midwives, who may or may not have any idea who she is, what her history holds, or what her goals are.

At Big City Hospital, labor is “managed” using Pitocin and pain medication to keep women from taking up much needed room space or “getting too tired.” The staff has seen many rare and unusual circumstances, including some scary and tragic situations and their reactions and management style reflect their past experiences. They are scared that the next woman to walk through the door could be the one to have X, Y or Z happen.

On the flip side, consider “Small Town Hospital.” At Small Town Hospital, the emergency department rarely sees serious injuries or illnesses. The surgical center only does minor, routine procedures. The maternity center has a total of 10 rooms, which are almost never completely full. Usually, there are three, maybe four mothers there at any given time, and only one or two in labor. Small Town Hospital never has more than three nurses on call, who come in for 12 hours shifts, and it would be next to impossible for a woman to “fall through the cracks” in this place. There are four physicians and two midwives who practice there and they are a team, backing each other up and supporting each other’s clients whenever needed, always in the manner that they know the original care provider would use.

When a mother in labor comes into Small Town Hospital’s maternity unit, no one turns her into a barcode. Her nurse immediately learns the mother’s name and this nurse stays with her until her shift is over. When that happens, she comes in with the next nurse and introduces the mother to the next nurse. At Small Town Hospital, the entire staff knows each other well. They work together every day. They know each other’s styles and share a culture of individual care and support. They are easy-going and patient, since there is no rush to clear out rooms. At Small Town Hospital, there is an overall atmosphere of respect for the human body’s ability to birth and a desire to provide a pleasant experience to every woman who walks through the door. They are prepared to handle medical complications, but they know most women will not need their skills. 

As a doula at Big City Hospital, I feel like I am wandering in the wilderness, a lone voice trying to break through a very thick fog. At Big City Hospital, I am a foreigner. They don’t speak doula. They speak a language with these kinds of phrases:

1. “We have policies. It’s how things are done.”
2. “If she wants to be in a hospital, we have to have the monitors on to know what is going on.”
3. “We can’t leave the cord attached because the baby will bleed out.”
4. “You’re just going to be fighting against yourself pushing if you’re not on your back.”
5. “I need to check your cervix now.”
6. “You’ll be fine during your c-section, we do this all the time. It is really no different than a vaginal birth.”
7. “We need to take the baby to the nursery for a bit, but you just rest and we’ll bring him back when we’re done.”

It is easy to be a doula at Small Town Hospital. Here, I am at home, where they speak doula. I am on a team of players who are on the same page with the same goals. I know the nurses by name and they know me by name. We know what mom needs and we are all working together. Every single time is a rewarding, empowering, joyous experience at Small Town Hospital. What they say:

1. “Sure you can get in the tub. Just make sure you keep drinking water.”
2. “Do whatever feels best to you.”
3. “Is there anything I can get you or do for you?”
4. “You’re doing great. Just let me know when you start feeling a lot of pressure so I can give the doctor time to get here.”
5. “Would you like me to check your cervix?”
6. “Of course we’ll leave the cord intact for as long as you like. That’s pretty routine.”
7. “There’s no rush to weigh the baby. Just enjoy holding him.”

(Please note: these hospitals are fictional representations and these statements are general observations from our experience and perspective. We acknowledge that there are wonderful, mother-friendly and baby-friendly large teaching hospitals, and there are small hospitals and birth centers who do not serve women well.)

Ultimately, it boils down to serving each individual woman as just that: an individual. Not a number, a statistic, a pawn in a huge system, or a barcode. A person. A mother. Our hope and prayer is that every mother can be in a setting where she knows she is valued and respected, where every woman counts.

Has this observation been true for you? What has been your experience at large, metropolitan hospitals? What about small, rural hospitals? How much does hospital culture affect the labor experience?

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