"All that is necessary for the triumph of evil is for good men to do nothing" Edmund Burke, 18th century Philospher.

"A long habit of not thinking a thing wrong gives it a superficial appearance of it being right." Thomas Paine

"The welfare of humanity is always the alibi of tyrants." Albert Camus

"Choice is the essence of ethics: if there were no choice there would be no ethics, no good, no evil; good and evil have meaning only insofar as man is free to choose." Margaret Thatcher, March 14, 1977

“It is difficult to get a man to understand something, when his salary depends on his not understanding it.” ― Upton Sinclair

Explaining the Cause

I am a practicing obstetrician who is a strong supporter of patients rights to informed consent and refusal. I believe a patient has the right to choose her own path given true and not skewed informed consent. Following that tenet, just as a woman should be able to choose to have an elective c/section she should be able to choose not to have one, as well. The American system of hospital based obstetric practice has been eroding those choices for women for quite some time. Due to concerns of economics, expediency and fears of litigation women are being coerced to make choices that may not be in their best interest.

I have had a long relationship collaborating with midwives and find the midwifery model of care to be evidenced based and successful. I was well trained at Cedars-Sinai Medical Center in the mid 80's to perform breech deliveries, twin deliveries, operative vaginal deliveries and VBACs, and despite evidence supporting their continued value, hospitals are "banning" these options. Organized medicine is also doing its best to restrict the availability of access to midwives.

Home birthing is not for everyone but informed choice is. Medical ethics dictates that doctors have a responsibility and a fiduciary duty to their patients to provide true, not skewed, informed consent and to respect patient autonomy in decision making. Countries with the best outcomes in birthing have collaboration between doctors and midwives. This is not what has been happening in the hospitals of America. Its time for a change and the return of common sense.

The midwifery model of care supports pregnancy as a normal function of the female body and gives a legitimate and reasonable alternative to the over-medicalized model of birth that dominates our culture. Through this blog I hope to do my part to illuminate what is wrong with our maternity care system and what is right with it. I do not expect all to agree and that is OK. We must all understand that given honest data it is not always reasonable to expect two people to come to the same conclusion. Our differences should be respected.

Sunday, March 30, 2014

Time to upgrade!

Greetings to all of you who have loyally supported me on this blog and at supportdfischbein.com. I was encouraged by so many of you to modernize and consolidate a lot of my internet activities and I finally listened. I plan to continue blogging on relevant topics and entertain and inform on
Dr Stu's podcast as well as post all sorts of events and news on my new Facebook page. Of course, the Fearless Pregnancy site where you can purchase my book is still there, too. All of these are linked through my completely revamp web site, Birthing Instincts with Dr. Stu, where you can read and learn about home birthing options including VBAC, breech and twin deliveries. There is also a current events page which lists upcoming seminars and lectures and gatherings. I am still at 3 locations including my Century City office, my Thousand Oaks office and the Sanctuary Birth and Family Wellness Center. Please check out all these sites and give them likes and stars and shares. According to my web guru, Renee, this blog site will remain up but future blogs and such will be posted on the new web site. See you over there. Warmly Dr. Stu

Wednesday, January 29, 2014

The Hazmat Birth

On the header of my blog are a few of my favorite historical quotes. I think my favorite has become Albert Camus’, “The Welfare of humanity is always the alibi of tyrants!” Fear is the easiest way to manipulate. And claiming safety is a perfect way to shut down any discussion. It’s good for you. It’s safer for the children. You don’t want to put your baby in danger, do you? We live in a world where ACOG admits that 2/3’s of its guidelines are not based on good scientific evidence. Yet they put them out anyway. In my world, on a daily basis, I am told directly or from print media about manipulation of women through skewed or even overtly false information. When it comes to pregnancy the bowing to the false god of safety has become the standard. Your baby is too big. Your baby is too small. Your pelvis is inadequate. The head is smaller than the shoulders which might get stuck. The fluid is decreasing. The cord is around the neck. You are 3 days overdue and your placenta is getting weak. VBAC is too dangerous. Your breech baby’s head might get stuck. Hospitals are safer. Induction is easy. Cesarean sections are routine.

Then there is the mockery of choosing an alternative to the fear based standard birthing world. Home delivery is for pizza! Having your baby at home is like driving your child without a seatbelt (This is the latest flippant simile from a doctor in Australia. Which, by the way, was how my generation grew up and I don’t recall massive death on the highway). Or as Jim Gaffigan, the comedian, quips, “when I told my friends we were having a home birth they said, Yeah, we were going to do that but we wanted our baby to live!”. Choosing a home birth is selfish! Why would you pick a lesser trained midwife? How would you feel when something goes wrong!

Ah, the something goes wrong theory of birth. Perfectly understandable in today’s fear based, litigious world. Risk management is something we all do every day. As individuals we just don’t have departments staffed with lawyers to do our personal risk management. Even if you could afford one can you imagine your life with every decision being scrutinized for safety and risk? Susie, you are not allowed to have that chocolate chip cookie because we have calculated that the risk/benefit ratio is adverse to your long term health and the viability of your family unit. Laughable? Far-fetched? Maybe, but this is the climate of the standard medicalized world we now live in. You cannot eat in labor because there is a 1/100,000 chance you might aspirate in an emergency. You must have an IV just in case. Please sign these consent forms about surgery and death after your next contraction. Sorry, hospital policy says you have to wear those belts continuously.

This past week I came upon a top secret correspondence from a local hospital that read something like this: “The OBGYN Department and the Infection Control Division would like to remind you that eye protection (e.g. glasses, goggles) and a face mask are required for all providers participating in a delivery.  We thank you for your cooperation with this important safety issue. The last sentence is the sinister one. Putting that tagline on anything gives it the appearance of concern and reasonableness. This may seem like a small thing but its insidious message is a continuation of the threat to all of us who value individual autonomy and see vaginal birth as something beautiful. This hospital, likely complying with some edict from some committee or oversight organization and almost certainly without a single adverse event in their institution, has turned the birth of a baby into a hazmat situation. My call to the author of this correspondence for clarification went unanswered. For those who have actually attended an un-medicated birth, a home birth or a water birth, can you imagine what the mother must think if she were to look down at a goggled and masked face catching her baby? I understand for an unscreened mother wearing protection would be a reasonable choice. But most women are screened and, unless there has been a series of incidents, universally requiring this garb is not about safety. It is about protecting the institution from liability. Plausible deniability should a worker catch something who was not wearing the hazmat protection hospital policy required. The risk managers are just doing their job. However, I believe minimizing risk must be weighed against common sense and personal choice in a free society. Sadly, common sense is losing and will continue to do so until the masses lose enough services or are inconvenienced enough that finally tort reform becomes a hot political topic.

Why have they come forth with this new rule now would be a logical question. Has there been some epidemic of exposures? I mean, vaginal birth without mask and goggles has been going on for millennia. No, it’s simply a symptom of the micromanaged and over-regulated reality we are now living in. I also just read an editorial about getting rid of the doctor’s white coat. Why now? Has there been an epidemic of disease spread by the hospital lab coat? Changing dirty coats makes good sense but banning them? Will the next suggestion be changing clothes between hospital wards, between rooms? And why won’t your own clothes be carriers of bad humours and thus need to be banned. And I can tell you that wearing scrubs from home and all day and night from the ward, to the call room to the cafeteria does not sound exactly hygienic. Wearing disposable gown and gloves makes sense in an infectious disease setting but in the maternity ward, really? So the why now question is really that someone somewhere just thought it up in response to usually an isolated incident. There are legions of administrative personnel whose job it is to try to diminish risk. The foolishness is they believe they actually can in every case no matter what the consequences down the road. Their job is to protect their job and their institution and their tyranny is always justified by safety.

There are two realities in the birthing world as I see it. One is fear based, often absurd, seeing pregnancy as illness, believing that interventions make benefit greater than risk and using safety as a canard for control. The other is trusting of nature, understanding of the imperfections of life and looking at pregnancy as wellness and a normal function of the female body. I have lived in both worlds and have a unique perspective. The first is uncomfortable and often riddled with self-deceit cloaked in cognitive dissonance. The latter is my choice and I try to be a vanguard for it. This past week I had the good fortune to attend a beautiful home VBAC in the hostile birth world of Santa Barbara and an inspirational water birth in Beverly Hills. I wore a t-shirt and sweat pants and was goggle-less and mask-less and I am delighted to report I am well and happy. 
All good things, Dr. Stu

Sunday, November 17, 2013

Home Birth & Apgar Scores in the AJOG October 2013, some clarity.

In the October 2013 issue of the American Journal of Obstetrics & Gynecology (AJOG, also known as the Gray Journal) there are two “research” articles discussing outcomes related to birth setting. In today’s blog I take a critical look at both of them so if asked about them by a prospective client you can give a salient response. Since science has been corrupted by money and ideology it is difficult to know what to believe these days making reliance on common sense and clarity of intent that much more important.

The first article begins on page 323 and is titled, “Apgar Score of 0 at 5 minutes and neonatal seizures or serious neurologic dysfunction in relation to birth setting”. This ominously titled article is authored by Amos Grunebaum, MD out of Cornell University with multiple co-authors including Frank Chervenak, MD who we all know to be fervently biased against home birthing. In a previous blog I have been critical of the authors of this article for their deviation from scientific norms by promoting their paper through an uncontested press release more than a month prior to its publication. Thus, headlines received prior to any critical review. Let’s take a look at the data and methodology of this study and then analyze their conclusions.

The stated objective is to examine the occurrence of 5-minute Apgar scores of 0 and seizures or serious neurologic dysfunction for 4 groups by birth setting and birth attendant (hospital physician, hospital midwife, birth center midwife, and home midwife) in the United States from 2007-2010. They used birth certificate data files from the U.S. Centers for Disease Control’s National Center for Health Statistics for singleton newborns >37 weeks and >2500 grams.

In order to trust the results of any study we must first trust the information upon which the study is based. A retrospective study of birth certificate records, especially as used in this study, is ripe with unreliability. A simple example is the inability to determine precisely who attended a birth as the signature on the record does not mean that practitioner was actually there. I have signed birth and death certificates in my career for patients I did not care for simply because I was the physician on call and was asked to do so by the hospital staff. In 2003 the standard Certificate of Live Birth was upgraded to include the location of birth as hospital, birth center, or home. And it was further specified as accidental, intended, or unknown if intended. In 2008, only 27 states were using this upgraded form yet the Grunebaum study admits to using all U.S. births from 2007-2010 that met their inclusion criteria of >37 weeks and >2500 grams (of the 16,693,978 births they included 13,891,274). The second study I will discuss calls this methodology into question as their use of the more accurate revised form had them exclude nearly 50% of American births in the year 2008 alone. To summarize, birth certificate information is notoriously unreliable and often does not differentiate whether the birth was planned or unplanned, attended or unattended. Yes, someone has to sign it but it does not mean the doctor or midwife signing actually attended.

The authors then rely on the 97.5% of states (?) that had collected data on the presence or absence of neonatal seizures or serious neurologic dysfunction in their birth certificates. I would question the reliability and collection methods of this data. The definition of a neonatal seizure is seizures occurring in the first month of life. Birth certificate data is usually filled out in the first couple days of life. I am not sure how the authors then used this data responsibly. Also, it would be important to know long term outcomes of the neonates who experience seizures or serious neurologic dysfunction and how that correlates to lifelong disability. This study does not clarify this endpoint.

The term relative risk (RR) is used in this study to emphasize their conclusion that homebirth attended by a midwife has an overall 10.55 RR of a 5 minute 0 Apgar score. The RR is slightly higher in primips than in multips for all categories but RR can be quite misleading especially in the headline of a press release which was their intention, I believe. The overall risk in this study of a 5 minute Apgar score of 0 in the hospital attended by a physician was 1.6/10,000 births. For home births with a midwife it was 1.63/1,000. While this is a 10-fold increase it is still rare when you consider all the other risks of birth. It is purposeful deception to use statistics selectively in this way. Especially when they conclude that all obstetric practitioners must disclose this information to all pregnant women who express an interest in out-of-hospital birthing. “Surprisingly”, this article concludes with a recommendation that concurs with an article written last year by Dr. Chervenak on the professional responsibility of physicians to recommend against planned out-of-hospital births to women who express an interest in it. Amazing that based on a risk of .163% of a 5-minute Apgar of 0 doctors are told to advise against home birth but a 33% risk of surgical birth is no problem. A higher risk of infection, breast feeding issues, psychological trauma, mother-baby separation, induction/augmentation are not reasons to warn mothers against hospital birthing? The skewing of data to funnel women down the medical path is without shame. What more can I say?

Well, on this article there is one more glaring point to make. I could not find anywhere in this article a distinction between a live born newborn with a 5-minute Apgar of 0 and a stillborn. If a woman at term was diagnosed with an intrauterine fetal demise at term and chose to have her baby at home would that count as a 0 Apgar at 5 minutes? Finally, I have spent more than 27 years working in hospitals with NICU teams. When a baby is born with a very low or zero Apgar at 1 minute it is pretty much standard of care for the NICU team to rush in and perform their initial magic of resuscitation. Even if the baby were to be allowed to expire at 30 minutes or was to be revived only to die hours or days later the Apgar score at 5 minutes would not be a 0!! I would submit that the risk of 0.16/1000 for a 0 Apgar at 5 minutes in the hospital setting as quoted in the article is artificially low. And if this reasoning sounds logical then the entire premise of using the 5-minute Apgar score as a marker of quality of care by practitioner or location is undermined and serves to fit the Chervenak model of selective ethics! Maybe it would be professionally responsible for physicians to tell their patients that!

(Please see my comments following this blog)

The second article on page 325 in the October 2013 issue of the AJOG is titled, “Selected perinatal outcomes associated with planned home births in the United States” by Y.W.Cheng, MD et al, from UCSF. This was a retrospective study, also, of term singleton live births in the U.S. in 2008. Of the over 4,000,000 births that year, 2,081,753 met the study criteria of using the 2003 birth certificate revision discussed above. Of these births 0.58% were planned home births. They found that planned home births had a higher rate of 5-minute Apgar score less than or equal to 4 with a RR of 1.87 (3.7/1000 vs. 2.4/1000) and a RR of 3.08 for neonatal seizure (6/10,000 vs. 2/10,000). They also concluded that women with planned home birth had fewer interventions such as operative vaginal delivery and induction/augmentation. They also broke down planned home births by CNMs or “other” midwives.

Their findings and the presentation of their data in style seemed much more neutral and unbiased. For instance, they do state that infants born to women with a planned home birth are more likely to have a neonatal seizure (6 vs. 2 per 10,000, still a small number) but also say that NICU admission was lower among infants of planned home birth (RR 0.23). They did emphasize that outcomes for homebirths with CNMs did not differ significantly from hospital births but that with “other” midwives the risks were greater. However, I could not find a definition for “other” midwives in the article.

I found the self-reflection and critiquing of their own research to be honest and refreshing in stark contrast to the first article’s air of certainty which feels like smugness to me (my bias!). Cheng, et al admit their study has limitations. “As a retrospective study, it may have included confounding or missing data that could potentially bias our findings.” They go on to say, “….administrative data, such as birth certificate data, may contain inaccurate information.” Now isn’t that refreshing to hear from a researcher? They also honestly admit they could not identify or differentiate women who planned a home birth but who were transferred to hospitals which they admit occurs in 10-15% of planned home births  (Notice the use of 10-15% rather than the skewed numbers of up to 47% Dr. Chervenak used in a previous opinion piece last year). This could elevate the risks at home but they admit they cannot be sure. Finally, Dr. Cheng concludes, “Because of the complex tradeoff between maternal benefits and neonatal risk, women who contemplate location of birth should be fully informed about both sites”.

Here are 2 articles, side by side, both presenting a selected endpoint on the outcomes of term singleton births by location and practitioner. However, the difference in style and honesty is striking. The first article has a co-author with a deserved reputation for skewing his data to fit his ideology. While I cannot quantify his influence on his fellow co-authors I can use experience and common sense to recognize bias, selective data mining, intentional omissions and flaws in methodology and conclusions. It is important for all of us to look at research with a critical eye. Understand that relative risk is rendered far less meaningful when we are comparing a small number to a multiple of a small number. I must agree with Dr. Cheng. Once the sperm and egg unite there are risks assumed. True, not skewed, informed consent must be given about all options. And respect for the individual is paramount for it is the essence of ethics to respect the autonomy of patient decision making and it cannot be expected that given the same information two people with differing life experiences will always reach the same conclusion. Finally, good science does not need to be preempted by a press release. I have been concerned of late that science is more and more being corrupted by money and ideology. While we may not prevent this we must remain aware of it and read critically and maintain a healthy skepticism.   

Dr. Stu

Tuesday, September 17, 2013

We need a better way to dialogue

The American Journal of Obsterics & Gynecology has recently published Dr. Chervenak's response to my letter to the editor which I wrote in response to his opinion piece against planned home birth. I have commented on this in a couple of blogs on this site (see November 2012). I even went so far as to put together a power point presentation breaking down his arguments and would be happy to debate him in an honest forum. My letter was published last April but the AJOG rules of LTE are very restrictive and I was limited to 400 words. In his rebuttal to me letter he continually sites that I did not prove what I said or that I lacked documentation or failed to provide supporting evidence. These tasks are pretty much impossible with 400 words. A fact I am sure Dr. Chervenak is aware since his rebuttal to me was allowed 641 words. This is the serious defect in our ability to communicate differing views to the powerful in academia and simply leads to childlike finger pointing and ego inflation without any real chance of clarity and honest dialogue. His reliance on studies, often ones in disrepute, skewing of data and denial of or failure to accept evidence and common sense contrary to his desired outcome of his opinion piece is a common thread in many of his thoughts and papers. I accept that he is a bright man with differing views than mine. My point is not to convince him of alternatives. My ideal is to present clarity over agreement so readers and my medical colleagues have the basis on which to make their own decision. Here is a link to his original article (which might be password protected), my 400 word limit letter to he editor followed by his 641 word response.  Lastly, kudos to the American Journal for publishing a midwife's response, as well, which I have also posted.

Dr, Fischbein's LTE:
In a recent opinion piece, “Planned home birth: the professional responsibility response,” Chervenak et al1 argue against the ethics of home birthing stating that advocates of planned home birth have emphasized 4 points: patient safety, patient satisfaction, cost-effectiveness, and respect for women’s rights. “We provide a critical evaluation of each of these claims and identify professionally appropriate responses of obstetricians and other concerned physicians to planned home birth.”
Regarding patient safety, the authors say, “Maternal and fetal necessity for transport during labor is often impossible to predict.” Home birth women by definition are selected based on their health. They labor as nature intended without interventions. In experienced hands, transport is rarely “impossible” to predict. The authors state the most common reasons for transport are pain relief and prolonged labor, neither being unsafe. The argument against home birth in the United States continues by presenting safety data from South Australia, a system that has no resemblance here.
The authors state, “It is antithetical to professional responsibility to intentionally assign any damaged or dead pregnant, fetal, or neonatal patient to this category, even if the number is small.” Yet ample evidence exists that similar cohorts of normal women delivered out of hospital vs a hospital have cesarean section rates of 6% and 24%,2 respectively. By that standard the increased morbidity of the hospital model if held to the same standard would be professionally irresponsible.
Regarding patient satisfaction, the authors assume the high rates of transport undercut the raison d’ĂȘtre of planned home birth. A Dutch study from 2008 showing persistent levels of frustration for up to 3 years in 17% of transported women is cited.3 That implies an 83% satisfaction rate. A fairer comparison would be the satisfaction rate of US women with successful home vs hospital births. I disagree with the solution of supporting “homebirth-like” environments in the hospital setting.
Minimal savings in cost comparison data from Britain are cited, vs US cost comparisons. The cost of a typical home birth in the United States is about 35% of that in hospitals. Savings over a cesarean birth approach 80%.4 When cesarean section rates approaching 35%5 are factored in, the savings is even more significant.
Regarding women’s rights, the authors avoid using the beneficence-based model of ethics which, as with vaginal birth after cesarean, supports a woman’s reasonable choice.6 Instead it is stated, “From the perspective of the professional responsibility model, insistence on implementing the unconstrained rights of pregnant women to control the birth location is an ethical error and therefore has no place in professional perinatal medicine.” But home birth advocates do not support unconstrained rights or rights-based reductionism.

Dr. Chervenak's Rebuttal:
Dr Fischbein claims that our criticism of planned home birth from the perspective of the professional responsibility of obstetricians does not succeed. Ethical analysis of planned home birth, like ethical analysis of all topics in obstetric and medical ethics, should be both evidence-based and argument-based.1
On the topic of patient safety, Dr Fischbein states that the need for transport can be predicted in “experienced hands” but provides no documentation for this claim. The Birthplace in England study reported on transport rates as high as 45%.2 Dr Fischbein bears the burden of proof to identify evidence-based criteria for the reliable prediction of the need for transport and fails altogether to meet this professional obligation. He then states that “pain relief and prolonged labor” do not indicate unsafe clinical conditions, again without supporting documentation. The claim that the experience in another country does not apply in the United States requires Dr Fischbein to demonstrate the disanalogy, which he does not do.
Dr Fischbein states that a cesarean delivery rate in the hospital setting of 24% results in an unacceptable increased morbidity when compared to the out-of-hospital cesarean delivery rate of 6%. As applied to planned home birth, the claim is absurd, inasmuch as cesarean deliveries are not performed in the home setting. Even if the comparison were not absurd, simply reporting the rates of a procedure in the absence of outcomes data does not count as evidence-based reasoning. Worse, the paper that Dr Fischbein cites provides outcomes data on care in birth centers.3 Planned birth at home, the focus of our paper, is not planned birth at a birth center. The outcomes in the latter cannot be represented as the outcomes of the former. The disanalogy is obvious–and egregious.
Regarding patient satisfaction, our point in citing the Dutch experience was–and remains–that in one of the most highly developed home birth systems in the world there are significant rates of failure to achieve patient satisfaction. A dissatisfaction rate of 17% is high per se and therefore intrinsically clinically significant. Asserting the obvious corollary of 83% satisfaction should be read for what it is: an attempt to distract the reader from a substantial, documented problem with planned home birth. Dr Fischbein then states that he disagrees with national efforts to improve the homelike setting of hospital delivery without any supporting reasons. Asserting conclusions in the absence of supporting reasons is what Plato–long ago–had Socrates in the Dialogues characterize as “mere opinion,” which never counts as argument-based reasoning.
As to cost-effectiveness, we emphasized that analyzing the cost of home birth by comparing charges for home birth to charges for hospital birth is incomplete and therefore potentially misleading. Dr Fischbein’s invocation of relative costs of vaginal vs cesarean delivery does not address relative overall cost. His claims about comparative cost are therefore incomplete and misleading.
As to women’s rights, Dr Fischbein invokes the ethical analysis of vaginal birth after cesarean delivery by Charles,4 who argues that the autonomy of pregnant women is justifiably constrained by the professional judgment of obstetricians about what is medically reasonable.4 Dr Fischbein neglects to inform his reader that Charles4 bases her argument explicitly on our approach to obstetric ethics. Having rejected our approach (albeit without any supporting argument), Dr Fischbein invokes a paper based on it. Dr Fischbein succeeds in both deceiving his reader and violating the principle of noncontradiction. This principle forbids simultaneously holding a proposition and its denial to be true and is therefore a disabling mistake in both evidence-based and argument-based reasoning.
Planned home birth is a serious topic in obstetric ethics. Judgments about its ethical acceptability must therefore be deliberative–explicitly appealing to the results of evidence-based and argument-based reasoning.5 Dr Fischbein’s letter does neither and therefore makes no serious contribution to how obstetricians should understand their professional responsibility concerning planned home birth.

Midwife's Letter To the Editors:
The clinical opinion related to planned home birth by Chervenak et al1 requires a midwifery response.
Home birth is a complex choice that includes the rights of women over their bodies; these rights do not go away because health professionals or governments ban them. The authors suggest that women’s rights should be superseded by the clinician’s obligation to protect the pregnant woman and the “fetal, neonatal patient.” This paternalistic discourse privileges the baby’s rights over that of the woman’s. Any risk to the baby’s health dominates with woman’s rights and risks to the woman’s health subjugated. A civilized society considers women to be more than just vessels to grow babies. To postulate that women’s opinions, concerns, and intelligent consideration for their own health and their baby’s health should be superseded by an obstetrician is unacceptable. The argument by Chervenak et al1 that a woman’s right to make decisions and control what happens to her body is a “purely contractual model” and “rights reductionism” is contrary to the human rights movement. The United States, as a signatory to the Convention for Elimination of Discrimination against Women, recognizes this important principle.2
The authors assume that hospital birth and obstetric intervention will confer improved safety and better outcomes but the US cesarean section rate has increased far more than its rate of decreasing perinatal mortality and the United States is one of the few developed countries with increasing maternal mortality, yet Caution needs to be taken when discussing safety and safer care; until such a time as there is no mortality or morbidity associated with childbirth, no one can promise complete safety regardless of birth setting.Women worldwide cite the loss of personal autonomy and increasing use of interventions in hospital birth as unsafe for both them and their babies and see this as an unacceptable risk. When this is put in the context of comparable perinatal outcomes for the baby many women consider that hospital birth provides an increased risk with few benefits for them.
If women are supported, listened to, and provided with information they will make decisions based on the best outcome for them and their baby. Health professionals providing maternity services should be seeking to provide safe, woman-centered care for all women regardless of where they choose to birth.

Wouldn't it be great if those on high in academia with opposing views were willing to come and speak at, say, the international breech conference or a gathering of homebirth advocates? Wouldn't it be great if academia invited those of us with legitimate alternate points of view to speak at their conferences. The dialogue would be amazing. I have heard all of their arguments but I can tell you that almost none of the residents and students have ever heard any of mine. Sadly, this tit for tat silliness through edited letters that take months to publish and can be quite time consuming for those of us not on academic salary is a poor way to communicate. What happens mostly is what ACOG district VIII is doing next week in Hawaii by having a lecture on home birth at their conference given by Amy Tuteur, a notorious anti-midwife, anti- homebirth blogger. C'mon academia, you can do better. We have so many outstanding intellects and actual practitioners of the trade who are willing to have courteous dialogue in real time.

Dr Stu

Thursday, September 5, 2013

From their fruits ye shall know them

Today is the Jewish New Year, Rosh Hashana. It is a time for renewal, a time for family and, soon, will come a time to atone for one’s sins on Yom Kippur. In order to really ask forgiveness for a sin we must first recognize that we have sinned. Once recognized, moral teaching would hope that we accept self-reproach. Penitence is showing remorse for having done wrong. Only to a penitent man can come redemption, and a man redeemed will experience happiness and joy in work and life much more readily.

“It’s not who we are but what we do that defines us”, so says the superhero in a recent Batman movie. And while not all movies contain such wisdom, on occasion they do. Good men and women, loving to their children and respectful of their parents, can sometimes do bad things. It does not mean they are bad people. For example, a businessman may be a great father and donate time and money to local charities but end up going to jail for embezzlement a la Bernie Madoff. Which leads me to my point; how does a good person become a bad doctor? How has a hospital become more of a danger to birth than a benefit? Specifically, how have the practitioners of medicine evolved from the noble, “first do no harm”, to embrace a culture of expediency, cowardice and fear. And how has the hospital machinery, what is considered the norm today, really performed when it comes to outcomes over the last generation?

If you have followed my writings, talks, blogs and more recently my podcasts you will know the answer to many of these questions. More than 50 years ago the takeover of medicine began by the profiteers who, by definition, looked at the business side of medicine as if it were an automobile factory. How to become more efficient? How to avoid liability? How to control costs? Essentially, how to control everything! But medicine is not automobiles. It’s people, individual people, often with life altering issues that don’t fit the assembly line thinking. It’s messy by the businessman’s standard. But rather than realize that, or maybe even despite realizing it, there was just too much money to be made and power to be had by taking it over. Lost in this was the lonely patient. And soon even the practitioner, the person actually doing the work, was just a cog in the machine. Initially, a very noisy cog but gradually the noisy cogs get “greased” and became what they once detested or they are beaten up and replaced by the system. Doctors either become a “part of the crew, part of the ship” (to ironically quote another Pirate story) or they were tossed overboard, sometimes metaphorically and sometimes literally.

With the seeming inevitability of a government takeover of healthcare and the race to socialized medicine this metamorphosis will be complete. The designed impersonalization of the system frees any one or group of people from responsibility. And once an immense and monolithic entity is freed from any culpability it will always lead to corruption and tyranny. It will be like the current Internal Revenue Service scandal of oppression where no one is responsible and those that should be plead the Fifth Amendment and are never brought to task. However, unlike the IRS, those that seek the takeover of the health care system will sugar coat their motives under the disguise of “safety”. “The welfare of humanity is always the alibi of tyrants” was written by French Philosopher Albert Camus almost 60 years ago. Awareness of this mechanism is of utmost importance for it explains much about the fruit our system is baring.

How is it that good, well-meaning people inside the system have let this happen and may even support it? It is human nature for members to want to be accepted in their group and for many it is their dominating psychological motivation. When the businessmen, lawyers, politicians and administrators who run health care now send out a message of how things are to be done, well, who are the nurses and doctors, dependent on the system for their livelihood, to complain? And so these good people who admittedly love their families and possibly regularly attend their church just easily surrender to EMR and to limited formularies and to restrictive policies like VBAC bans and mandatory lab tests and one size fits all lengthy admission forms and annual board recertification and silly mandatory human resource seminars. Need I go on? Policies and actions that put individual patient’s desire and rights off the radar screen if not dead last. Not only do the caregivers submit but they begin to defend their behavior as “standard of care”! They join committees and participate in this bureaucratic process so as to be accepted and “part of the crew…” Even when they know there are other options and evidence supported choices. I suspect that the administrators and their ilk know this, too. And in order to justify the correctness of their position they ridicule or ignore evidence to the contrary. This is called cognitive dissonance and I have written on this before. (“Safety or Cognitive Dissonance” May 27, 2012  http://www.supportdrfischbein.blogspot.com/2012/05/safety-or-cognitive-dissonance.htmlhttp://www.supportdrfischbein.blogspot.com/2012/05/safety-or-cognitive-dissonance.html   )

The failure of good people to stand up on behalf of each individual family they care for may be practical but let’s not call it right. The good people that leave their home each day to drive to work at the local hospital do not say to themselves, “Let’s see what mischief I can cause today for some poor suffering patient” or “Let’s see how impersonal I can make our policy so that I limit the institution’s liability”. But somehow that is what happens each and every day for over 50 years in this profession. In 1970, the cesarean section rate in the United States was < 6%, In 1990 it was 22% and now in 2012 it is 32.8%. There has been little decline in the neonatal death rate between 1970 and 1990 and almost none in the last 23 years. Yet the cesarean section rate has gone up 500% since 1970 and over 50% in the last generation with no measurable benefit. Did something suddenly happen to an American woman’s pelvis in one generation? While some modifications of policies are all too slowly reappearing we still have archaic, often ridiculous policies affecting laboring mothers negatively. Some are restrictive movement, restrictive oral intake, standardized charting requirements leading to interruption of natural labor, 90% epidural rates, mother-baby separation and over testing for questionable indications often resulting from economic gain and fear. This fear comes, not so much in the mother, but emanating from the practitioner who endures the realities of the professional climate rather than speak out. A great proportion of women do not have fond memories of their birth process and many women will suffer lifelong emotional and physical trauma from unnecessary inductions and cesarean sections. Babies, too, do not benefit from what is so often considered standard care. Early induction or surgical birth leads to increase risks of lifelong health issues. Ubiquitous standardized policies of immediate vaccination, eye care in culture negative moms and interruption of bonding are for what benefit again?

Courage is the rarest of good human traits. It is not courageous to stand up in front of a group and say what they want to hear. It is courageous to take a moral stand into the lion’s den. My colleagues are good people but they are not courageous. Those that purport to run healthcare, the businessmen, their lawyers and the politicians are worse because they disguise their motivation in the sheep’s clothing of safety. They have to know these outcomes are not what they should be. They have to know the policies they follow when it comes to birth are often dead wrong. How could a 33% cesarean section rate be acceptable to them. Why do they treat mothers and babies as two separate entities? There is so much reliable data that other options are reasonable. They do not respect the individual or the right of informed consent and refusal. And, quite frankly, in normal healthy mothers their statistics and outcomes are awful. Individuals are often good people. When they join organizations, however, they can become conflicted and end up doing bad things. The outcomes of groupthink are easily corrupted and rarely pure and morally upright. Just look at history. The fruits of the impersonal system of healthcare we call normal are rotting and subjugation to this model has not led us to higher ground. On this we should reflect and repent and the Jewish New Year can be an inspirational time to do so. We can redeem ourselves by doing better on behalf of our patients and our souls. Our acts are what define us. “From its fruit shall the tree be known.” (Matthew 7:16)

Shana Tovah, Dr. Stu

Tuesday, August 27, 2013

Student Intern Experience

For 2 months this summer I had a premed student spend 3 days a week with me as a student intern. I had a great time with Marybeth and it was a learning experience for both of us. What follows is a brief summary of her experience and I am hopeful that more students will follow in her footsteps. I look forward to the day when current medical students and possibly even obstetrical residents will desire to step out of the academic medical bubble and experience another way of doing things. Dr. F

"I started my internship hours on Wednesday, 18JUN13.  I arrived at The Sanctuary Birth and Family Wellness Center for 1300 in order to do requisite confidentiality paperwork and got a brief familiarization with office procedures such as prepping files, keeping track of client due dates, etc.  Dr. Fischbein had 4 clients scheduled for the day.  I got to participate in 2 ultrasounds, both were 20 week anatomy scans and both families wanted to know the sex.  One of his clients is pregnant with twins.  After Dr Fischbein chatted with patients, he referred to me if I had any questions and gave my direct patient contact time.  I also took a fundal height using a tape measure on the twin's mama's belly.  Because one of his clients canceled, I used the most of my hours at the clinic to read up on the twin situation and review the chart to see if the twins were monochorionic and/or monoamnoitic or not.  

Dr Fischbein prefers to sit with patients in his office fully clothed first and discuss their concerns before they go to an exam room.  He likes to take his time with patients.  So we did another ultrasound, this time a vaginal one to try to get a gestational date because they are more accurate for crown rump length that early than the belly ultrasounds.  It's was a struggling pregnancy and before the end of my internship it did result in a miscarriage.  Then there were 3 pap smears with 3 CBCs and 3 breast exams.  

The internship continued in this fashion. In order to meet my first goal of learning about the birthing process, I attended on home visit with Dr. Fischbein, one homebirth, and one post-partum visit.  The homebirth was very intense for me.  Initially I just observed quietly while she labored and pushed in the birth pool.  Occasionally the midwives asked me to fetch warm water for them and such.  Dr. Fischbein mostly hung back on the couch so that the midwives could do their thing without him interfering as he is there for backup.   This mama had been laboring for many hours and was getting tired so they called Dr. Fischbein into action.  After mama did some solid pushing in the tub, on the birth stool, seated in her husbands lap, and in their bed, everyone agreed it was an ok time to help with some forceps.  Dr. Fischbein always found a way to pull me in and give me lessons on things, so while mama was pushing from her own bed, she was at the edge with a foot up on my shoulder and I held her leg so I was right up close and personal with this birth.  He first assessed the head by finding the sulcus because he told me you can only use forceps when baby is in certain positions, otherwise it is too dangerous. He explained the risks like bulldogging shoulders and dystocia to the mama and daddy. Once he determined baby was in a good position for what type of forceps he would be using, he numbed mama with some novocaine in case he ended up doing an episiotomy.  I got to see him get the forceps in place, again right up close and personal with a foot on my shoulder and her leg in my hands, and with each contraction mama pushed, he wedged the forceps with baby out a little more, and I had a front row seat to all of this.  He did end up doing the episiotomy, a quick clean cut which gave more room for the forceps and within seconds baby was out and on mama's chest and she had the drug free homebirth that she wanted after all.  It was amazing.  The cord stayed attached for quite awhile as it finished pulsing so that baby could get all her good oxygen and blood from there.  The family had their time to be gentle and relax and the midwives went back to work with the rest of it, helping the placenta, etc, and then Dr. Fischbein was back in the game to repair the tear.  He explained that sometimes mamas get tears along the sides from forceps but this mama luckily didn't.  I held the spotlight while he repaired the cut.  I'm not going to lie, it was a lot of blood.  A lot of blood.  Once he got done with the repair, it hardly looked like much had gone on down there at all.  

Overall I participated in over 20 ultrasounds, some for pregnancy, some for fibroids, some for cysts.  By the end of the internship, I was able to start making out images on my own.  Like anything, it is its own language in a way, and you have to develop fluency in it.  Ergo, I was easily able to meet my goal of learning how to use ultrasound as a diagnostic tool.  

In order to achieve my third objective, like all the previous objectives, it depended upon what the patients presented.  Nobody needed an external version and nobody ended up being a breech vaginal delivery.  I did, however, do urine tests, which is really simple and just involved dipping a color-changing wand into the urine and comparing the results to the answer key if the urine had any protein or sugar in it.  I also attended LE Leche gatherings and was able to assist pre-natal mamas in preparing for breastfeeding.  One mama asked if drinking beer really helped to increase supply and I was able to provide her with sound, good guidance.  It was pretty nice that Dr. Fischbein would just refer to me when any of his patients had breastfeeding questions.

I enjoyed everything about this internship.  It was an absolutely amazing experience.  The only thing I really felt disappointed by was that I didn’t get to see more breech work or a breech delivery. I’m very grateful to SMC for having such an opportunity to design one’s own internship and incredibly grateful to Dr. Fischbein for patiently allowing me to walk in his shadow for two months. I am also amazed by how much I learned and did in just 2 short months with Dr. Fischbein.  He was an incredible mentor."

Monday, August 26, 2013

VBAC is Normal

All you have to do is look at Beth's face to understand the miracle of normal birth. Baby Maiya, born by VBAC today at the Santa Clarita Birth Center in Newhall, CA. Keeping it positive. No other words necessary! Congratulations Beth & Robert. Thank you Renee, Juli & Victoria.  Dr. F