THE MATRIX OF CARE: MEDICAL DECISION-MAKING AND HOSPITAL-BASED CHILDBIRTH

Abstract

This dissertation explores how clinical decisions are made in obstetric care. Through a 19-month ethnographic case study of an OB/GYN unit in a large, urban hospital and 30+ in-depth interviews with OB/GYN healthcare providers, I examine the practices surrounding gestation, labor, and c-section and vaginal delivery – including the activities of maternal care providers and patients – and the practices and technologies present in this hospital unit. Most broadly this dissertation asks and answers the question: How are clinical decisions made in hospital-based medical practice? I expand current understandings of hospital-based medical practice in the U.S. with three novel contributions. First, I apply an inhabited institutional framework to medical decision-making to reveal the connected factors that inform medical practice. The conceptual payoff to this approach is the matrix of care, an abstract concept which captures the intricate and connected network of factors that influence, enable, and constrain the provision of medical care to patients in hospitals, and a related state of connected care, an empirical manifestation of the matrix of care, characterized as the non-individual nature of patient medical care within a hospital due to the joining of patients, providers, organizations, stakeholders, and the uncertainties of medicine. Second, I show that three influences on medical decision-making – medical professionalism, evidence-based medicine, and shared decision-making – are institutional mythologies central to contemporary medical practice. Third, I demonstrate the social and clinical significance of the two-patient dilemma – characterized as the condition in which the necessary care of the maternal patient and fetal patient occurs simultaneously and in which the health of one patient may jeopardize the health of the other – in medical decision-making. This repositioning of the sociological view of medicine is important because it is through the lens of institutional theory that the factors underlying medical practice become visible, and through which the factors that guide and shape medical decision making are evident. This dissertation remains in conversation with clinical and sociological research surrounding reproductive healthcare delivery and makes empirical contributions to literatures on medicine, organizations, and institutions. This dissertation also contributes to research on reproductive health for relevant populations across the Midwestern United States.