Dr. Donald R. Coustan, the chief of ob-gyn at Women & Infants Hospital, reflects on his career as his retirement approaches.

The Providence Journal / Bob Thayer

Dr. Donald R. Coustan, the chief of obstetrics and gynecology at Women & Infants Hospital and the Warren Alpert Medical School of Brown University, will retire at the end of September after 17 years in the position. Trained at Yale Medical School, he came to Women & Infants in 1981 to serve as director of maternal-fetal medicine. His research has focused on diabetes during pregnancy.

Coustan, 64, says he’ll continue to do patient care and oversee residencies and fellowships at Women & Infants.

He recently sat down with Journal medical writer Felice J. Freyer to discuss the changes he’s seen in obstetrics over the years. Below are excerpts from their conversation.

In your career you have seen shifts in the culture of childbirth, from the natural childbirth movement to today’s demands for painless, scheduled births. What do you make of it all?

The pendulum always swings back and forth. When my wife and I were having our kids… I can remember with our first child [in 1969] my wife didn’t want to have an epidural. She had some whiffs of nitrous oxide. The second baby came along [in 1971]; she had an epidural. The third one was 1975 and she wanted the epidural at about 36 weeks. [Laughs.] …And then this whole guilt thing about if you don’t have a natural childbirth you’re somehow a bad mother. Nowadays we’re actually more toward the “everybody wants an epidural” side of things. …

We can deal with people who don’t want to have any kind of intervention and we can help people who do — and we tend to be much less judgmental in either direction than we used to be.

Is the common thread through all of this that women are more in control of what’s happening?

Yeah. Childbirth has gone from a medical procedure to a less medical procedure. And I think that’s fine. It took us all a while to get used to it. My God, having husbands in the delivery room — …One of the first husbands in the delivery room at Yale was an assistant football coach for the Yale football team. And I’m giving the wife nitrous oxide and I hear this clunk, look over and he’s out cold on the floor and I wasn’t sure who I should really attend to. …

Now, it would be unusual not to have a husband or a significant other there, and it turned out that it was not a bad thing.

But hopefully I think people are also learning that the birth is an important thing but it’s not the end, it’s the beginning. I think the parenting experience is a much more important thing, at least in my experience, than having the baby. I mean, you gotta bring it up.

You say that childbirth is a less medical procedure, but the rate of cesarean sections has gone way up.

I’ve been here 25 years. When I was first here it was about 22 percent. I sent each physician their cesarean section rate each year, along with the hospital-wide cesarean section rate. And I would write a letter with it that said “I don’t know what the best cesarean section rate is. As far as I’m concerned the best cesarean section rate is when every cesarean section is done for a good reason and everyone who needs one gets one.” … Just by sending everyone their cesarean section rate, it went down to about 17 percent in the mid-’90s. Despite that it’s been coming up. In ’03, ’04, it was just under 30. Now it’s about 33, 33½ percent.

So there’s been a huge change. And there’s a lot of reasons for it. [In response to new studies pointing to risks, there are] no more breech vaginal deliveries, or very, very few. Fewer vaginal births after cesareans. …And concern about litigation, sure.

Then, patient choice.

Do doctors at Women & Infants get pressure from patients to perform cesarean sections even when there’s no medical reason?

We have begun to see some patient requests. … Of the 33 percent, my guess, unencumbered by data, would be maybe 3 or 4 percent would be patient choice.

The data are not good enough one way or the other to say you shouldn’t or you should [perform a cesarean on patient request]. …

It’s not medicine that’s telling women to have a cesarean section. It’s their friends, it’s Oprah, it’s the thought that you can schedule it and go in when you want and it’s convenient. I think that’s the generational thing that’s going on.

Did you ever think you’d see the day when a third of babies would be delivered by cesarean section?

When I was a resident the cesarean section rate was 5 percent and we had to get a consultation if we were going to do a cesarean. So, no, I never thought I’d see it. I mean, now, yeah, I think we’ll probably see the day when it will be 50 percent, and the increase will be because of patient requests.

What’s your personal feeling about that?

Oh, I’m horrified by it. But I’m trying to get used to it. . ... I don’t want to sound like that’s a medical opinion. It’s emotional. Maybe that’s why it’s time for me to retire.

Looking at the world of obstetrics throughout your career, what’s your assessment?

I think we’re a whole lot better off than we were 25 years ago, and we really shouldn’t lose sight of that. I would point to the perinatal mortality rate –– the rate of stillbirths after 20 weeks gestation and newborn deaths up to 28 weeks of life. In 1970 it was 23 per 1,000 live births. By 2002, it was 7 per 1,000.

That’s not to say we don’t have whole lot more to do. And a lot of the answers I think are political rather than medical. For example, we’re taking a bunch of people off RIte Care. … If [an immigrant] doesn’t have health care, when they have a baby, that is a citizen who now doesn’t get a good start.

If somebody is born in Providence at 27 weeks we’re going to take care of them no matter what. But if they had access to good health care maybe they wouldn’t have had a premature birth. It costs a whole lot more to take care of one [premature] baby than it does to provide access to health care for a whole lot of people.

ffreyer@projo.com