Something Nice

Letter dated 12/9/09

Dear Dr. Fischbein,

I just wanted to say thank you to you and the rest of the lovely staff at The Woman's Place for providing such exquisite care. Both Aaron and I really appreciated you taking the time to talk with us at the follow up appointment last week. I wanted you to know that we fully agree and support The Woman's Place and what it represents. Wanting a different experience than your "standard hospital birth", was what drew me to your practice in the first place. Both Aaron and I could not be more thrilled with our choice.
Wishing you all the best,


Jeni Halverson

And a Merry Christmas to all of you! Stu

Community Standard ?

So, I finally got tired of being ignored and called Dr. Torres as he apparently did not have the courtesy to return my e-mails and letters. He told me that members of the OB committee met last week and decided there was no need to have any meetings or discussion about making a breech delivery protocol. Although in September I was assured that I would have some input in the discussion, it did not happen. Since no one but me in the community offers breech deliveries, he states that I am outside of the "community standard" and elective breech deliveries would not be allowed. When I pointed out that Terry Cole also does breech deliveries he mumbled something about not caring what Dr. Cole does at Community Memorial Hospital down the road. When I asked if only one doctor in our department was doing a certain special surgical procedure would that, too, be outside the "community standard" and be banned? He had no honest answer. I received a letter later today reiterating our conversation and suggesting that I seek privileges at another institution if I wanted to do breeches. This is a disingenuous suggestion as changing hospitals is not a simple task. So while I am credentialed to perform breech deliveries at my hospitals and ACOG and SOGC support this option the administration has made a final decision not to allow this without any meeting, hearing or due process. A sad day for the women of Ventura County. I am looking at all options and am open to any suggestions. Dr. F

What Keeps Us Going....

Those of us that support a woman's choice, informed consent and the midwifery model of care often feel we stand alone. A thank you to this lovely nurse from Washington state for sending words of encouragement. SF

Dr. Fischbein:

I just had to take the time today to say thank you for all that you are doing for women and babies in this country. I first heard of you during an interview you did for "The Other Side of the Glass". I have since searched for and found other videos of you online. I was completely taken aback that there was an outspoken OBGYN who was being vocal about support for things such as breech deliveries and delayed cord clamping. You are a real hero in the birth world. It is so difficult to find MD's who are openly supportive of such things.

I am a registered nurse and I work in a small, community hospital in Washington state. I am a nursery and postpartum RN there. While I don't do labor and delivery, I am present at deliveries to be there for the babies. Lately, I have been asking myself how much longer I can stand there and watch the things that are being done to women without full consent.

I am very passionate about women's birth rights but lately I find myself wanting to give up. I find that I am simply beating my head against the wall and making a journey upriver without any paddles for my poor, dilapidated boat. Yet it never fails... just when I am ready to throw in the towel and give up on the whole political mess, another sick (or traumatized or injured or harmed) baby is placed in my arms and it serves as the fuel to keep me going. Despite the fact that we live in the information age, it seems nearly impossible to educate. It seems so hard to get the truth out and to be heard above the throngs of other voices out there.

There is a running joke we have in the hospital where I work. If a nurse says something, it doesn't mean a darned thing. But if a physician walks in and says the exact same thing, it's taken as gospel truth. We laugh about it because the words are exactly the same, but it makes a difference to patients who it's coming from. Patients trust their physicians implicitly. This is why I am so happy you are being so outspoken about the truth. Midwives and nurses and lay people have been shouting these messages for a long time, but I believe it will make a much larger impact on people if the same messages are being delivered by obstetricians (pun totally intended!)

Thank you for taking time out of your personal life to be an advocate for women and babies. You are making a difference. It is my sincere hope and prayer that if we all just continue talking about this and continue our attempts at educating women, that somehow, some way we can afford change through the upper ranks of administration and government. It is tiring, but it is worth it.

Christina Harris, RN

Laboring Patient Sits in Lobby

Last night I had a MediCal patient in labor. She had planned to deliver at Pleasant Valley Hospital but because there is no MediCal pediatric coverage there she had to go to St. John's Regional in Oxnard. There were available empty labor rooms at Pleasant Valley Hospital but there were none at St. John's where the nurses described the labor floor as "swamped". So, because of the failure of the hospital administration to solve this problem and, likely, in continued violation of their licensing requirements my actively laboring patient had to sit in the waiting room for nearly 2 hours until a room and bed became available. In this particular case she would have liked pain relief a lot sooner. Conincidently, I had sent an e-mail earlier that day on this issue to the administration:

Hi All, I spoke with Mike Murray and Laurie Bingham one week ago about the absence of MediCal pediatric coverage at Pleasant Valley Hospital. We had a cordial conversation where concerns on all sides were expressed. My colleagues and I would like an update on what is being done to remedy the situation and a timeline for when we can expect this issue to be resolved. Several of our patients have been inconvenienced by having to go to a hospital not of their choosing. It is also more difficult for us to travel back and forth. We believe the hospital has a legal obligation to provide MediCal patients a pediatric option and cannot turn them away from Pleasant Valley. We are happy to work with you on this but that would require the respect of being kept in the loop. I am available to discuss this at any time. On behalf of the patients we care for and their desire to deliver in their own community we hope to hear from you promptly.

Sincerely,
Stuart Fischbein, MD
for The Woman's Place, Inc.

No response so far. On behalf of our patients and the Camarillo community we will keep inquiring. SF

Another Letter to Chairman

Below is an e-mail sent today. Just the latest in a series of attempts to get the OB department at St. John's Regional Medical Center to honor their word to me and obligation to the community.

Dear Juan, I just saw another patient at 36 weeks who is breech. She meets all the ACOG criteria for a vaginal attempt should efforts to turn the baby fail. I have been patiently waiting since September for a promised meeting about breech deliveries. I submitted a protocol to you through Claudia at the last department meeting per Dr. Niesluchowski's suggestion. I would like to be able to offer this woman a vaginal birth at St. John's. I am competent, willing and privileged to do so but seemed to be blocked by the inaction of our department. I am asking again for you to contact me to schedule a meeting to discuss forming a breech protocol. Further delays seem unreasonable. I would like to work with the department on this to be sure that patients in our community are given all viable options. Please work with me on this. As I am aware of the slow process involved I would like permission on a case by case basis to perform selected breech deliveries. I would be happy to discuss each individual case with you or the incoming new chairman.

Sincerely, Stuart

Visit to Washington DC

Returned late last night from a 20 hour turn-around trip to Washington DC advocating for patient focused care. The trip was organized by Docs4patientcare.org which is a grass roots organization formed as an alternative to the AMA. Like most of my colleagues, I don't know any doctors that belong to the AMA or think that it represents practicing doctors and the interest of their patients. Unfortunately, the AMA still has name recognition and its endorsement of the Health Care Bill has been used by the Obama administration as a sign that doctors support his plan. Nothing could be further from the truth.

We have a Hypocratic oath that in effect states we are to serve our patients. The current legislation would be so cumbersome and overbearing that serving our patients best interests would become impossible. A group of doctors gathered from several states at the Heritage Foundation. We met with some leaders from the Heritage Foundation who explained a little bit about the process of lawmaking. I am still scratching my head. Apparently, the current bill is purposely designed to be vague. The supporters have not read it, don't need to and never intend to. This is common practice in lawmaking which the rest of us might find curious. Its supporters just want to pass anything, claim victory and then spend the next 3-4 years trying to figure out how to pay for it and create the micromanaging details and definitions. It is a set-up for rationing, legal disputes and chaos. I am still shaking my head.

I visited with Senator Feinstein's office and had a very cordial conversation with her aide, Kristin Wikelius. She initialized the conversation by saying she only had a few moments to spend with us and reiterated standard reasons Senator Feinstein supports the bill. However, she listened and dialogued with us for nearly 40 minutes. I stressed the importance of patient decision making, non interference in doc-pt relationship and my belief that the Senate bill would most certainly lead to rationing and be a massive hindrance to good medical care which takes place in exam room, not boardroom. Also, I discussed the inevitable future shortage of doctors and why I felt few good people would choose that as a profession and many my age would quit if this bill passes. I cannot possibly state here all that is wrong with the current bill. I would suggest going to the Heritage Foundation website and reading some of their analysis of the bill and what the Congrssional Budget Office has to say.

I then met with Cecelia Daly, aide to Congressman Elton Gallegly from my district here in Westlake, California. Again, a very cordial conversation but with the difference being that the congressman is opposed to much of the bill. In both offices, we did discuss some things I thought would be helpful. Taking small steps and correcting those things first rather than a massive government overhaul/takeover. But it is clear that the goal of this administration is a takeover of 1/6th of the American economy for ideological reasons. I would suggest that we all look closely at supporters or endorsers of this bill. They either do not understand how the true delivery of care to patients takes place or don't care because they are idealogues of socialism or they have a vested financial interest in a government takeover and stand to gain enormous sums of money from the bill's passage. This is, sadly, the feeling I got from talking to so many people yesterday. Let's be clear that this bill is not about health care. The doctor and the patient are at the bottom of the list on the agenda.

One suggestion proposed by a doctor from New York was interesting. It will never come to pass because it would actually work and mean smaller government and less control. He suggested that doctor's be given a tax deduction for providing free care to those in need. This would eliminate a huge waste of bureaucratic administration and the need for any expansion of Medicaid and all the expense, waste and fraud that goes along with it. Another doctor from Georgia told me this metaphorical story. A child asks his father why the cost of bread has only risen 4 times in the last 20 years but the cost of health care has risen 20 times during that time. The father responds by saying that is because people pay for the bread.

Lastly, I did not get to meet with Senator Boxer or her staff because they could only offer a 7PM appointment and I had to leave for the airport at 4. But just some thoughts about the Senator's postion. Some of my midwife colleagues are happy because Senator Boxer sponsored the birth center-medicaid bill. But her support of the overall health care bill will likely end up killing out of hospital birthing by midwives. My logic is that licensed midwifery in many states has to have backup doctors. With the passage of this bill, without tort reform and with the crushing of the spirit of the private doctor there will be no incentive to back up midwives and birthing center births. I hope I am wrong but I know I am not. The birth center bill is an example of a small good thing. But all the small good things that could possibly work will be crushed by the massive health care bill. I urge all of you to contact your elected officials and express your concerns about more government intervention in our profession. And do it now for tomorrow will be too late. My experience from yesterday tells me they will listen and our voices can make a difference.

Pediatrics pulls out

Just a quick note to say that all the pediatricians on staff at St. John's Regional Medical Center have decided not to cover MediCal babies born at St. John's Pleasant Valley Hospital. As of December 1st they refuse to be on call for any patient who does not have a pediatrician. And since MediCal patients usually use MediCal providing doctors and there are now no pediatricians at Pleasant Valley Hospital who accept MediCal there is an obvious dilemma. My understanding of the explanation I have been given is that it is a combination of fearing that midwife deliveries are risky exacerbated by a recent tragic outcome, lack of an NICU for backup and poor reimbursement for their services. While I understand the latter two reasons, I am uncertain as to why they feel midwifery and its low risks patients are considered higher risk than physician patients. I have spoken to administration and offered to attend any meeting to help answer questions they may have about midwifery and to get some answers to my questions, too. So far no invitation has been offered. I had a low risk MediCal patient scheduled for a routine repeat c/section tomorrow morning at Pleasant Valley Hospital that I was ordered to either move to St.John's in Oxnard or cancel due to a lack of pediatric coverage which is required by their policy. This is inconvenient for and undesired by both the patient and my staff. I have been told they are working on a solution and are aware of the urgency of need for a resolution. For should a MediCal patient show up in labor at Pleasant Valley their would be no pediatric coverage. Hopeful they will come up with something soon.

Each one of these new twists and obstacles makes it crystal clear that another option for birthing in our community is essential.

Am off tomorrow night to Washington DC to meet with Senator Feinstein's office and Congressman Gallegly's staff on Wednesday. The topic will be the Health Care Bill with focus on reminding our representatives that medicine is not an inert commodity. We are patients and health care practitioners. We are individuals. Medicine takes place in the privacy of an exam room and is a very personal decision. Government probably won't listen but they really have no business being in the business of health care. But you already know that's my take. SF

Dog days

Have not written in a while as not heard anything back from multiple cordial attempts at contacting the OB committee at St. John's Regional Medical Center about their "promise" to set up an ad hoc cmmittee on protocols for breech as well as reviewing others. Does this seem like a broken record? They make demands under severe threat. I respond with requests at their recommendation which they ignore. Feel free to right a letter or to call Dr. Juan Torres, current head of OB there. Let him know your dissent with their policies and their nonresponsiveness. For, every delay causes potential harm and inconvenience to some patients.

As I have said before, there is unlikely to be any movement toward respect for patient autonomy in this current model. The hospital has no competition and employs an economic model that favors ts policies as long as they live in a vacuum. So we need to create an alternative option for women and maybe then they will understand what we all do. Decisions belong to the informed patient. Amy Tinney, RN LM is working with me to organize our dream of a free standing birthing center, staffed by midwives, doulas, chiropractors, acupuncturists and doctors. A birthing center that also contains an surgery center option where c/sections can be performed. With safe policies that favor mother-baby and treat birth as a natural process. We are in the discovery phase of our planning but are confident that before 2010 is out we will have it up and running. We are open to any suggestions or offers of expertise or help. Comment here or e-mail me anytime.

Amy and I attended the wonderful Tribute to Women at The Sunrise Birth Center tonight. It was an elegant affair reflective of Karne and all the dedicated birth goddesses, new mothers, artists, musicians and generous donors. Bought some great smelling candles from Krystal McCauley. It was nice to see so many of you there. The Birth Action Coalition will benefit from the event and soon will have non-profit status. Things are happening. I heard there is an event next week in Santa Barbara hosted by Laurel Phillips in support of her birthing center dream up there. I have heard through the grapevine that there are happenings on the west side with Sacred Entrance as well. So, the movement is gaining momentum.

Lastly, I am flying to Washington DC Tuesday night to spend 10 hours on Capitol Hill. I am going as a representative from Docs4patientcare.org to speak with the offices of Senators Boxer and Feinstein about patient centered issues, protecting the sanctity of the doctor patient relationship and reminding them that one size fits all medicine cannot work. You can be sure I will put in the word for midwifery and its wonderful benefits and reigning in those that lobby against it and asking for a loosening up on all the regulations restricting access to them. We have to try.

You can be certain I will persist in getting a response from Dr. Torres. It would be so much easier and more professional for him to honor his word. The hypocrisy of that department is legend around the community. But I am biding my time, taking the high road and documenting everything they do. Oh, and I was interviewed last week by a writer from the Washington Post about the breech restriction. She has attempted to contact Dr Torres and Niesluchowski but as of Friday had no response. Watch for the story and I will post it once it comes out. So I guess there are things happening and worth wrting about. We will chat soon. Hope you all had a great Thanksgiving. Stu

Mid November Update

Several weeks have passed and nothing new on the breech privilege front. I have patiently waited for the promised formation of a committee to discuss a breech protocol at my 2 hospitals. I have e-mails from September telling me the chairman would be in touch with me shortly. Well, at yesterdays OB Department meeting I did present my breech protocol and again reminded the chairman of the importance of addressing this issue. Patient's deserve the choice. We shall see how soon a meeting is set up.

I was interviewed by a writer from the Washington Post this week. She is doing a story on breech deliveries. She was introduced to me by Robin Guy, from the Coalition for Breech Birth in Ottawa, Canada. I will link the story when it comes out. She was very interested in what has happened at my hospitals and the process, or lack of process, that led to the banning of elective breech deliveries.

A group I have put together continues to research the options for a free standing maternity center. A place where the midwifery model of care and patient choice can occur free from the encumbrances of modern day hospitals. We are very excited about the project and have a highly motivated group. Anyone with any thoughts or suggestions feel free to contact me or Amy Tinney.

I will be going to Washington, DC again on December 9th for less than 12 hours to meet with our California Senators. I was asked by Docs4patientcare to lobby for reason and sanity in the healthcare debate. I plan to focus on just a couple of key points including the value of midwifery and the need for less special interest regulation that stifles innovative ideas that would lower cost and improve outcomes. There is so much about the massive health care bills circulating in the Senate and House that is just plain wrong that I don't even know where to start. So I will concentrate on just a couple of things. I am honored to go to represent the patient and practicing doctor. I have no delusion that anyone will actually listen but try, I must.

To all, a peaceful and loving Thanksgiving holiday. Stuart

AARP and the House Bill

Those of you who know me know that I am fervently against the house bill on "health care reform" that apparently passed yesterday. This abomination of a piece of mutating legislation that no one has read and no one understands has been called by the Wall Street Journal editorial page as "one of the worst pieces of legislation in American history". If you are not well informed on this issue please consider checking out www.docs4patientcare.org and soon because it will negatively alter the basic nature of America . For the determination of Congress and the President to just do something, no matter if it makes no sense, is cost prohibitive, destructive to patient care and decried by the majority of Americans, should be frightening and maddening to all of us.

For AARP (the American Association of Retired Persons)to publically endorse this bill is baffling. Almost all experts agree this bill will hurt the elderly. So why would they endorse anything at this time. Why not wait until it has been reviewed, critiqued and examined by the CBO and the public? Why would they endorse a bill that is still changing and no one understands? Some claim that AARP has an economic interest in the billions from insurance policies they sell and that this piece of legislation will benefit them. Whatever the reason, their decison to endorse is premature and seems to throw their constituents under the bus. I called and had a cordial conversation with a representative of AARP. She had no answer for the question of "why now?". I told her that because they could not explain their position I could no longer support AARP and would not be renewing my membership. I would encourage you to call and ask questions for yourself.

Practice Update

It has been a while since I blogged on the local situation. I was waiting for clarifcation of a written discrepancy from my hospital regarding breech deliveries. One letter says patients must have a c/section unless delivery was imminent and another letter said they could choose to have them performed at the Oxnard facility. I finally received written notice this past Thursday that the unwritten ban on elective breech deliveries is correct. Women who are breech are to be told that they cannot labor at these facilities. Apparently, if they choose an option that is considered well within the norms of worldwide obstetrical practice, the attending practitioner will be disciplined.

The reasoning for this position seems to be a circuitous argument against choice. They selectively quote ACOG recommendations for breeches (Committee Opinion #340) to be performed "under hospital-specific protocol guidelines for both eligibility and labor management". Yet they have no protocols or guidelines so therefore elective breech deliveries cannot be performed. Also, they do not seem to be in any hurry to write them. It has been suggested that I work with the OB department to develop such guidelines. I have written a set of simple guidelines for this most natural of processes. I have extended an offer in writing, both in the past and presently, to contribute to the process but have yet to have any invitation from the OB committee. Meanwhile, patients have to wait in limbo.

Finally, in the context of the breech discussion, the hospital administration states that their facilities are not suited for procedures that challenge established professional norms. Once again, clarifying their position that a patient's choice of a breech delivery is outside the norm for a trained, skilled practitioner. Those of us that perform breech deliveries and keep up on the current literature and evidence know that there is nothing special about this "procedure". Breech labors progress or don't like any other labors. They succeed or stall like any other vertex labor. On occasion they require urgent intervention like any other labor. They do not require any special staffing or equipment. Any unit that can do vertex deliveries, high risk obstetrics and elective c/sections can surely handle the laboring woman with a frank or complete breech.

I must respect their position even though I disagree with it. Hospital's have the right to make choices for whatever reason and to have those choices honored. I just wish they felt the same about the patients they profess to serve. In my opinion, they are missing out on a great marketing opportunity. I have expressed this to the CEO but his options are limited as he defers medical decisions to the OB committee. So, what to do? Well, they say, "If you can't beat them, join them." However, what if joining them is out of the question because it compromises your values? My hope is to compete with them. To provide another model to deliver obstetric care in a facility that is midwifery model and patient friendly. This is what I am working on and will keep you posted. Have a good week. SJF

Excerpts from an essay by Rich Winkel

Hi All, I was scheduled to do a webcast on "Thought Crime Radio" with Janel Miranda and her co-host Rich Winkel last Monday but came down with the flu. Janel sent me some of Rich's writngs and literature searching which I found provocative and certainly worth sharing. Please take a moment to read:

The American Way of Birth: Trauma and Brain Damage

(excerpt from a letter to a legislator)
by Rich Winkel

Munchausen Obstetrics

... I've been horrified to discover a pattern of wholesale
institutionalized medical malpractice and quackery surrounding the
business of birth and child health. I can't account for how this
could have come to pass, but the science is difficult to ignore.

First let me mention the epidemiology: a steadily rising rate of
symptoms of trauma and brain damage, including ADHD, autism, mental
illness and addiction among US-born people, a trend dating back to
the post-WWII period when certain obstetrical practices became
commonplace.

These practices are now thoroughly entrenched and seem to be immune
from appeals to science, human rights or common sense. It appears
that medicine views the bodies of women and children as some kind
of empty wilderness waiting to be conquered and colonized.......

The huge dinosaur of american obstetrics is
creating generation after generation of unconsciously traumatized
and often subtly brain-damaged people, people whose lives are often
subsequently burdened with criminal behavior, learning difficulties,
ADHD, addiction, depression and other mental illnesses and symptoms
of brain damage. These iatrogenic outcomes are entirely preventable,
in fact in most cases can be avoided at less cost than the procedures
which cause them. The question of whose interests are served by
making birth needlessly difficult I'll leave to your imagination........

Furthermore, most of the medical "heroics" which lead to these
iatrogenic outcomes are a product of legal pressures
and medical culture and incentives rather than responses
to actual medical crises. For instance:

1) "The majority of hospitals and obstetricians in this country (still)
insist on a birthing position that quite literally makes the baby,
following the curve of the birth canal, be born heading upwards.
States Williams: "The most widely used and often the most satisfactory
(position for delivery) is the dorsal lithotomy position on a
delivery table with leg supports" (Cunningham et al. 1989:315). No
reasons why this position is "the most satisfactory" are given, but
a strong clue is provided in an earlier text:

The lithotomy position is the best. Here the patient lies with
her legs in stirrups and her buttocks close to the lower edge
of the table. The patient is in the ideal position for the
attendant to deal with any complications which may arise (Oxorn
and Foote 1975:110)

"This position, in other words, is the easiest for performing obstetric
interventions, including maintaining sterility, monitoring fetal
heart rate, administering anesthetics, and performing and repairing
episiotomies (McKay and Mahan 1984:111).........

2) "Immediate clamping of the umbilical cord at birth has become a
standard procedure during the past two decades. This merits
investigation as the cause of increased incidence of autism. Clamping
of the umbilical cord before the lungs function induces a period
of total asphyxia and produces severe hypovolemia by preventing
placental transfusion - a 30% to 50% loss of blood volume - resulting
in a hypoxic, ischemic neonate at risk for brain damage.
As in circulatory arrest and other factors that disrupt aerobic
metabolism, damage of brainstem nuclei and the cerebellum can result.
Visible damage seen in some cases of autism also involves brainstem
nuclei and the cerebellum. The brainstem auditory pathway is
especially vulnerable to brief total asphyxia. Impairment of the
auditory system can be linked to verbal auditory agnosia, which
underlies the language disorder in some children with autism.
Due to blood loss into the placenta, the immediately clamped neonate
is very prone to develop infant anemia that has been widely correlated
with mental deficiency and learning / behavior disorders that become
evident in grade school.
We propose that increased incidence of autism, infant anemia,
childhood mental disorders and hypoxic ischemic brain damage, all
originate at birth from one cause - immediate umbilical cord clamping.
This deserves to be investigated as extensively as genetics or
exposure to toxic substances as an etiological factor for autism.
Normal cord closure, with placental oxygenation and transfusion,
prevents asphyxia and ischemia. Allowing physiological cord closure
at every delivery could at least reduce the incidence of birth brain
injuries."

... "Immediate clamping of the umbilical cord before the child has
breathed (ICC) has been condemned in obstetrical literature for
over 200 years. [1] [2] In the 1970s, primate research [A][3][4]
using ICC to produce neonatal asphyxia resulted in brain lesions
similar to those of human neonatal asphyxia.".........

The trauma of being asphyxiated at birth after losing half your
blood to the placenta can only be imagined.

3) "In 1975, the College Entrance Examination Board commissioned an
advisory panel to examine the possible reasons for an alarming
continuing decline in the scores of high school students on the
Scholastic Aptitude Tests or, "SAT's," a decline which had started
with the 18-year-olds born in 1945 and thereafter. From 1963 to
1977, the score average on the verbal part of the SAT's fell 49
points. The mathematical scores declined 31 points. (1) (...)

"The SAT is designed to be an unchanging measurement. Considerable
effort has been made to keep the test a sufficiently constant measure
so that any particular score received on a current test indicates
the same level of ability to do college work that the same score
did 36 or 20 or 5 or 2 years ago. The SAT measures individual
students' capacities not only in comparison with their peers in the
particular group but also in comparison with those who took the
test in earlier years .... The SAT score decline does not result
from changes in the test or in the methods of scoring it." (2) (...)

"What happened around 1945 that might have contributed to declining
academic performance in the United States in the years that followed?
Consider this brief history: According to figures from the National
Center for Health Statistics, hospitals were the setting for only
36.9% of American births in 1936. By 1945 that figure had more than
doubled to 78.8%. In 1950, 88% of Americans were born in hospitals.
In 1960 the figure was 96.6% and in 1970, 99.4%. (...)

"A reading of the obstetric literature indicates that there had
always been philosophic differences among doctors regarding normal
childbirth. There were those who felt it was best to allow nature
to take its course and there were those who felt that intervention
was better. In the years following the 40s and under the stresses
of the population explosion, there was a tremendous acceleration
of intervention in obstetric care. Instead of adapting to the
time-consuming demands of normal childbirth, the obstetric community
(with very few exceptions) changed normal childbirth to conform to
the comfort of the mothers and the convenience of the doctors,
hospital staffs and hospital routines -- all at the expense of the
fetus and newborn."........

4) "ABSTRACT: Twenty years of clinical and behavioral observation
indicate that cesarean births cause considerable trauma to babies.
The physical and psychological effects are subtle and powerful,
occurring at the unconscious level of the infant psyche. Negative
impacts include excessive crying, feeding difficulties, sleeping
difficulties, colic, and tactile defensiveness. There also may be
long-term psychological effects such as rescue complexes, inferiority
complexes, poor self-esteem, and other dysfunctional behaviors and
feelings."

http://www.eheart.com/cesarean/emerson.html

"Prima Non Nocere: Iatrogenic Cesareans

"When used inappropriately, medical interventions interfere with the
normal process of birth and increase the risk of complications and
cesarean deliveries.28, 29 A US national survey of birth practices
revealed that 93 percent of women had electronic fetal monitoring,
86 percent had intravenous fluids administered through a blood
vessel in their arm (an IV), 55 percent had their amniotic sac
membranes artificially ruptured, 53 percent had oxytocin to strengthen
contractions, and 63 percent had epidurals for pain relief. More
than a third of labors were artificially induced. Almost three
quarters of the women were restricted to bed, and three out of four
were on their backs while pushing their babies out.30

Personal accounts from women who have had a cesarean, as well as
emerging research, suggest that despite a healthy baby and a timely
physical recovery, some women experience cesarean birth as a
traumatic event. An unanticipated cesarean is more likely to
increase the risk for postpartum depression and post-traumatic
stress disorder (PTSD). As in other traumatic human experiences,
the symptoms of birth-related PTSD may emerge weeks, months, or years
after the event.9,11 Women re-experience the birth and the emotions
associated with it in dreams or thought intrusions. They avoid
places or people that remind them of the event. Some mothers have
difficulty relating to their infants, and some will avoid sexual
contact that may result in pregnancy. They will also exhibit
symptoms of hyperarousal, such as difficulty sleeping or concentrating,
irritability, and an excessive startle response. Untreated
post-traumatic stress often leads to clinical depression.12".......

"Flat earth obstetrics is a 21st century version of a medical Dark
Ages, in which contemporary medicine has forgotten or ignored the
traditional knowledge base and physiological principles necessary
for normal labor and safe, spontaneous birth. Flat Earth Obstetrics
is the belief that medical and surgical interventions are necessary
in every normal childbirth, despite evidence that such a policy is
harmful. The term is derived from the insistence by religious and
political leaders during the Dark Ages that the earth was flat
despite evidence to the contrary.

"The problem with the current form of obstetrical care in the United
States is the uncritical acceptance of an unscientific method --
the routine use of interventionist obstetrics for healthy women
with normal pregnancies.

"Medicalizing normal childbearing in healthy women makes childbirth
unnecessarily and artificially dangerous."

"Obstetrics has been rated as the least scientifically-based specialty
in medicine" [Dr. Ian Chalmers 1987........

A letter from Leilah McCracken
http://www.birthlove.com

Early organized medicine saw midwifery was successfully competing
with them in terms of safety and affordability while undermining their
claims to scientific authority, so they mounted a campaign to
force them out of the birthing business in the early 20th century
http://www.collegeofmidwives.org/safety_issues01/rosenbl1.htm

The next thing our altruistic medical profession did, after eliminating
one of the few professional opportunities available to women at the
time, was to discard their accumulated wisdom and pathologize and
try to control the whole process, rather than let nature take its
course. The results have been disasterous.

It seems medicine's appreciation for its own level of ignorance and
incentives to interfere is inspired by the chemical industry's
approach to the safety of its own products: innocent until
proven guilty. But while the economically conflicted medical
research establishment is busy catching up with monkeys and dogs
in its understanding of birth and child care, children are being
hurt, with often life-long consequences.

I urge you to investigate this issue. Once you crack open this
pandora's box, I guarantee your life will never be the same. But
you will have many allies, and as public awareness is raised, this
country will experience a time of self-reflection that will profoundly
change it for the better.

Thank you.

Rich Winkel


I have been temporarily reschedule to appear on "Thought Crime Radio" on December 28th, 2009. Will keep you posted. Stu

A new type of birthing facility

Seems like my idea for a full service maternity center is spreading. My friend Alan Huber recently noted this in his blog at: www.birthissues.blogspot.com (see italics below)

I presented this idea 2 weeks ago at my talk at the international breech conference in Ottawa. It was well received and I have blogged about it on this site previously. Does not matter to me whose idea it is. Just so we are working towards this goal and all would welcome communication and idea sharing with others. Many contributing to the learning curve is better than one. It is an idea whose time has come. It would bypass all the silliness and politics regarding VBAC and Breech delivery. Market forces and competition would eventually force hospitals to meet patient demand and satisfaction or give up on low risk OB. My current hospital has been run by a closed "cartel" of doctors that have no desire to perform VBAC or Breech and because they don't want to do them they have blocked the few of us who do from offering.


Friday, October 30, 2009
Why Are Pregnant Women Forced to Choose between X and Y?
Before reading today's posting, please read Wednesday's and Thursday's (October 28 and 29th) posts.

Yesterday, I made the point that whichever choice a woman makes to have her baby, it is not the safest possible choice, BECAUSE the safest choice does not exist.

When I ask obstetricians: “Under what circumstances would you consider performing out of hospital birth?” the usual response is: "If they could have an epidural and have an operating room right there!"

I already hear the out-of-hospital chorus screaming, "The reason for out-of-hospital birth is to AVOID epidurals and operating rooms!"

To which the obstetrician might respond, "Why does a woman's choice have to be: in- hospital without pain or out-of-hospital with pain?"

I can tell you how the out-of-hospital and normal birth community would respond, but instead, let's all take a very long, deep breath, and examine this. As a person that has run birth centers and has had tons of face-to-face interaction with pregnant women seeking alternatives, I would like to tell you what I heard the pregnant women say when they came into the birth center:

"Can I get something for the pain?"… "Is there a doctor available in the event of an emergency?"….. "What if the baby crashes, and I need an emergency cesarean?"

Myself and my staff were thoroughly trained in how to respond to these questions. We extolled the virtues of natural birth, the benefits for the baby, the fact that we monitor and can usually pick up problems before the emergencies and that we get to the hospital. relatively quickly.

Obstetricians are not happy with the current constraints placed upon their practices, especially by hospitals and insurers. But what is their option? A natural birth center, with no cesarean capability? They are not trained to practice like this. More importantly, they don't believe that the pregnant women that they come in contact with really want a natural birth, without pain meds. They believe that they are meeting the demands of the vast majority of their patients.

So why can't a woman choose an out-of-hospital birth with pain medication and emergency cesarean section capability? I'm sure that many of you will start sending me all the reasons that this is bad. I ask you to hold off on that, and bring the list to the Controversies in Childbirth Conference, where this topic will receive a major airing, with all the goods the bads and the uglies.

I want to examine this a bit from a free-market perspective. Assume that physicians are able to open some type of out-of- hospital facility, where epidurals can be given and emergency cesareans can be performed. This will put the physician in the place of the hospital, the same way that midwife-run birth centers replace the hospital. The physician-owner will look for ways of driving business to his birth facility and lowering costs.

Should market research show that women would prefer midwives in this facility, he/she would undoubtedly hire midwives. If a woman has a vaginal birth, she could go home earlier, thereby saving the facility money and thus the facility might work to keep a low cesarean rate. The physician-owner would be very attuned to what his patients are saying on the Internet about him and would probably become more customer- centric, in the same ways that hotels work to avoid negative comments from appearing on TripAdvisor and other comparison sites.

It's estimated that ONLY 27% to 32% of U.S. OB/GYNs are still delivering babies. That means the competition has been severely reduced. Giving physicians a reason to go back to delivering babies will spur competition and give women more choices. How many women do you know have had to choose a new OB because the obstetrician that they loved has stopped delivering babies?

Birth advocacy is about giving women what they want. If obstetricians believe that women want a different experience than the hospital, but will not buy in to homebirth or natural birth centers, why shouldn't they be free to pursue a model that they believe is what patients want?

BUT- the devil is in the details!! There will be much discussion about what you could or should do and not do in one of these facilities. I'm inviting this discussion to be held February 19-21, 2010 at the Controversies in Childbirth Conference in Tampa, Florida. The plan is to have one session with an obstetrician who is experienced in both hospital- and birth center births to discuss from a clinical standpoint what he believes obstetricians and patients want and what could safely be made available to them in this setting. We also hope to have an obstetrician who has a birthing facility in another country, very much like the I am proposing.

The next day, there will be a panel session with representatives of obstetricians midwives. consumer advocates etc. to discuss all the intricate details and to see if people would come together to make this work or oppose it and what the trade-offs would be.

Full conference information is available at: www.birthconference.org.

I myself had a paradigm shift when this model was first described to me. I'm not sure I agree with it! Nor do I think I disagree with it! I do know that I want to discuss it.

Please register today for the conference (http://www.birthconference.org/)

Have a GREAT weekend
Alan


We are trying to figure out a good name for this type of facility. Sort of a full service, nurture and nature maternity center. It is good to hear the distant rumblings growing stronger. Please feel free to submit ideas. Thanks, Stu

Words have meanings

The words "urgent" and "cooperation" seem to have different meanings depending on who utters them. When spoken by a bully one had better heed but when spoken by a small voice they can be ignored. Almost 2 weeks ago I sent certified letters to the OB committee chairman and the Chief of Staff asking for cooperation and clarification on breech deliveries at the Oxnard hospital. Since I am credentialed to perform breech deliveries I politely requested an urgent answer to my question regarding their restricting my ability to perform such an approved privilege. As of today, still no word and so 2 patients sit on the fence not knowing their fate.

Again, there is no supportive data or policy that says a woman must be forced into a c/section by the random fate of having a breech baby. Yet they do it anyway. I would encourage anyone to call the medical staff office at 805 988 2500 and leave a respectful message for the OB chairman to please call back and explain his position.

Update on Breech Conference and the status of Breech Deliveries at The Woman's Place

Hi all, it has been quiet for a few weeks while I wait for clarification on the status of elective breech deliveries here in Ventura County. I was intially told in writing in no uncertain terms that this was not allowed at either of the CHW hospitals. After posting this fact on my blog it seems that the administration says I was misleading you. In a letter from last week they wrote that, in fact, elective breech deliveries are allowed at St. John's Regional Medical Center in Oxnard. While this is welcome news the contradiction is puzzling. I have written a certified letter asking for clarification. I will keep you posted.

I returned Monday from The Coalition for Breech Birth's conference with much insight, information and optimism. We were treated to a lecture by Dr. Louwen from Frankfurt, Germany which included some marvelous videos of natural breech birthing in the upright/all fours position. Topics included evidence why vaginal breech birth in selected cases is safe. Concerns all around regarding how future practitioners are to be trained. One idea is the model of Dr. Louwen where he runs a referral center for breech deliveries. Putting them in one place provides the volume and may just give us an idea of how we can give future doctors and midwives the experience they need to feel comfortable doing breech deliveries again.

The next group of speakers moved us all with their stories of birth options no longer available to them that led to birth stories and memories that were troubling to them even years later. It was very emotional and these strong women were inspiring in their desire to make changes so that others will not suffer their fate. I was honored to speak on a panel with Dr. Michael Hall of Denver, CO and three insightful doctors from Canada. Our topic was "The challenges and solutions to offering the choice of vaginal breech birth in the hospital." It stimulated much conversation afterwards. Finally, Ina May Gaskin gave a talk on breech with anecdotes and stories that kept us all enthralled. She also solemnly talked about women who have been lost due to complications of c/sections. Thanks to Robin Guy and all the supportive staff for putting together such a passionate and informative program.

Excerpt on Patient's Rights from "Fearless Pregnancy...." 2nd Edition

When you come to see or consult a health professional it is most reasonable to expect that you will be given the best information based solely on the knowledge and experience of that practitioner. You have the right to expect the information to be discussed in a manner that you can understand. You should be educated about the diagnosis and presented with all options for treatment. Ideally, this information should be given to you free from the bias of the health professional providing it. Only in this way can you and your family make the decision that best suits you. This is called the right of self-determination and belongs to each of us as patients. Along with this right comes the responsibility to accept the outcomes of your decision.
The free flow of unbiased information between you and your caregiver is called “informed consent.” You have the right to know all the significant risks, benefits and treatment options for the problem you are confronted with. It is inappropriate for your practitioner to purposely leave out or skew this information in order to direct you toward the option he or she prefers. The best way to know your options is to do some of your own research on the Internet and come prepared with good questions when you sit down to talk to your caregiver. We at Fearless Pregnancy hope that you will take full advantage of your right to choose. Once you have been given this information it is perfectly appropriate to ask your expert caregiver what he or she might do in your particular situation. But remember, we each have different philosophies and experiences in life that make us unique.
Now that you have gathered and considered all the information and the recommendations proffered, you have the right to agree to those recommendation or choose a different path. The right to decline an offered treatment is called “informed refusal.” A common example: your doctor recommends you have a repeat c-section but you choose to try for a vaginal birth. Your wishes should be respected and you cannot be forced into a decision against your will. Realize that some caregivers may refuse to treat you if they are uncomfortable with your decision. As we say so often throughout this book, a good bond between patient and practitioner makes a world of difference. When you have this mutual respect, there is already existing common sense and trust that makes these situations very rare. It is important that each of us take responsibility for our own health and knowing your rights of informed consent and refusal is a big step in that direction.

Note: Hopeful release date of my book "Fearless Pregnancy...." 2nd edition is Spring 2010

Breech Forum - Afternoon session

Heard from Dr. Savas Menticoglou, one of the principle authors of the recent SOGC (Society of Ob/Gyn Canada) guideline paper. He went through how and why the Canadian society has changed its position from its rigid stance against breech birth to a more tolerant, although not enthusiastic support of, this option for selected women. I am optimistic that he represents a growing wave in academia that agrees with the basic right of informed consent and allowing women the dignity of choosing their own course. Change will only come slowly, however. He pointed out some significant flaws in the 2004 Term Breech Trial paper and affirmed that the 2006 two year followup showed no difference in outcomes for breech babies born by vaginal vs. cesarian section.

We also heard from Jane Evans, a midwife practicing breech birth in England. She gave a talk on the mechanics of the breech baby as it comes through the pelvis and expoused the virtues of the kneeling position in facilitating the unassisted delivery of breech babies.

Tomorrow, Dr Louwen and Dr. Reitter will be showing us some amazing footage of this practice in action as done successfully at a center in Frankfurt, Germany. I will be speaking on the challenges of offering Breech birth in the Hospital. When I listen to these knowledgeable people talk with such energy and common sense it does give me hope that positive change for women will come. Probably agonizingly slowly but come it will.

Patricia Grube asked me if I think things will ever change here in the U.S. Here is what I wrote to her earlier today:
"Practically, I believe change will only come when market forces make it a necessity for hospitals to alter their economic approach. In other words, if patients demand choice and can find it elsewhere and start leaving hospital settings for more deisrable delivery options it might change. That is why we are going to try to get a birthing center up and running by next year. Not that it will be for everyone but women deserve options. I think the free market competition model will be the only way to give choice back to women. My experience with the hospitals I deal with is that they do not like to be challenged, they dig in their heels and they try to silence any opposition. Besides, unless we retrain practitioners to do breeches they can always argue that a c/section is all they know. So how to encourage programs to train them and how to get enough cases for future doctors and midwives to feel comfortable is another barrier. I would hope if we can get a center running and be a referral for breeches from all over the SoCal area then we can offer training, too."

I am hopeful that the day will come where others care to learn these skills that are being maintained by vigilant and honest practitioners. For the loss of the knowledge to perform breech deliveries will inevitably lead to preventable tragedies. Dr. F

Update From Ottawa

OK, So we are on lunch break at the Coalition for Breech Birth's International Breech Conference. Very good lecture by Dr. Glezerman from Tel Aviv. Pointed out the reasoning and flaws behind the conclusions of the 2004 "Term Breech Trial" that has caused so much consternation. Much emphasis on what I have been saying about the obstacles to choice and the restrictions on practitioners in the hospital based model. So jazzed about the direction we are heading with a birth center in SoCal designed for supportive nurturing birthing. Whenever I go to one of these meetings surrounded by supportive, logical and caring people I feel like my gas tank gets filled up with super premium fuel. I know it is a leap from a small birthing center to one that serves more as full maternity center with the option of an operating room on the premises. You know that has been my vision for a while and I am convinced we can get there. For once we have such a set up then we can promote an environment that is accepted and nurturing to all appropriate women including breech and VBAC. Midwives may have to lead the way back for breech deliveries since the numbers of breeches out there are probably going to remain too low to retrain doctors unless we have some sort of referral center for breeches. Someday, maybe our place could be a model for allowing patients the dignity of choice while having the numbers to be a training facility for future deliverers of breech babies. Thus, removing some of the monopoly on obstetrics and the hospital model which is based mainly on fear and what can go wrong. Sacrificing the beauty and satisfaction of the majority of births that go right. More to follow. S

Dr. F at International Breech Conference

FYI, I will be speaking as part of a panel discussion at this conference this coming Thursday and Friday in Ottawa, Canada. I am honored and exciting to learn and share ideas with leaders from the Canadian Health Care system. As you may know, recently the Canadian Ob/Gyn Society reversed its position on c/sections for all breech deliveries and now, once again, supports the evidenced based position of encouraging selected breech vaginal births. I will post much of what on learn on this site in the coming days. Dr. F

Protecting Reproductive Rights at Delivery

Please take a moment to link and read.


http://www.rhrealitycheck.org/commonground/2009/10/07/protecting-right-give-birth-safely#comment-30834

Here is my comment to the article by Jill Alliman


Thank you for this truthful and factual article. While birthing center births are not for everyone in America, I believe that choice still is. The assault on out of hospital birthing by the organized medical industrial lobby is not evidenced based nor does it value the basic rights of self determination and true informed consent. My conclusion, therefore, is that those against this option can only be motivated by economics, expediency or ignorance. I am hopeful that your organization and supporters will gradually spread the word about birthing options to the women of America and those that care about them. We may yet see the eventual shift to choice and a free market that responds by making home birth and birthing center birth a viable option. Possibly even leading to little specialty free standing maternity centers that support natural childbirth and midwifery while having a functioning operating room for that 5-10%. Just maybe a natural process like birth can be removed from large hospitals that treat pregnancy as a disease. The demise of the hospital based model of labor and delivery in America would not be a bad thing.

Health Care Forum a success

Last night in Newbury Park, CA about 200 people attended a health care forum. The panel consisted of 8 physicians and one insurance executive. Each panelist got to speak about a topic of their choice for about 10 minutes and then questions from the audience were addressed. Many different points of view were presented in an atmosphere of respect. Problems with the current system and the proposals in Congress along with offers of solutions were all discussed. The consensus from all is that there is no reason to rush into a decision that will affect every American. Health care is not a commodity like "oil" that can be regulated and bartered. Health care is people. This issue needs to be treated with respect and transparency. We all agreed that health insurance is different from health care and that without personal responsibility and choice no solution will be successful. The event was videotaped and I am trying to see if it will be posted anywhere. SJF

You must read this!

http://www.lakepowellchronicle.com/v2_news_articles.php?heading=0&story_id=1849&page=77

Seems all too familiar............and sad. This will only stop when our voices get too numerous and loud for them to be ignored. Please write to the hospital or the paper in support of the woman. Thanks to Janel for pointing this out. SJF

International Breech Conference Coming Up

Just to let you all know I have been asked and am honored to speak at a panel discussion on breech delivery at the International Breech Conference in Ottawa, Canada on October 15-16th.

I think Ina May is also schedule to appear there. The full schedule of events can be found at the website below. Hope you will spread the word and please let me know if you or any of your colleagues plan to attend. I hope to share ideas about bringing back the option of selected breech delivery to America as the Canadian Ob/Gyn Society has recently endorsed. Would be great to see youthere, Stuart


Breech Conference http://www.breechbirth.ca/Conference.html

International Breech Conference

The Bronson Centre

Ottawa, Canada - October 15-16, 2009

Programme
Conference Registration
Pre-Conference Workshop
Evening Event: Birth, a play by Karen Brody
Sponsorships, Exhibitors
Visiting Ottawa

The International Breech Conference is a forum where birth professionals and parents alike can share their knowledge and experience with breech birth, creating a community which can work together towards breech delivery practices and protocols which respect the individual needs of each family and each birth.

PROGRAMME
NEWS!
We are delighted to announce that Dr. Marek Glezerman will be joining us from Tel Aviv. Dr. Glezerman published important early criticism of the Term Breech Trial and will be speaking from the perspective of a centre that participated in the contraversial TBT.

The programme features prominent doctors, midwives, and researchers from around the world, including Germany, Australia, the UK, and the United States, as well as speakers from Ottawa and across Canada. Topics range from varying techniques and protocols of breech delivery, to education of mothers and informed choice issues, to methods of assisting breech babies to turn to vertex.
click here to view the programme

CONFERENCE REGISTRATION DETAILS
Registration fees are on a sliding scale. Registering as an Obstetrician or Professional (a category including family doctors, nurses, midwives, naturopaths, chiropractors, and doulas) may include CME or CEU credits.

Click here to register for the International Breech Conference!

PRE-CONFERENCE WORKSHOP (PROFESSIONALS)
Doctors, Midwives, and Nurses may register separately for "A Day at the Breech", a hands-on workshop featuring Jane Evans, UK Midwife and internationally acknowledged expert in breech birth, as well as Dr. Frank Louwen and Dr. Anke Reitter of Frankfurt, Germany, whose work in the last five years delivering breeches with the mother in the upright position has eliminated the need for forceps rescues.

Registration is limited. To register or to get on the waiting list for A Day at the Breech, please send an email to breechbirth@gmail.com.

Contact us: breechbirth@gmail.com

Dr. F on Health Care Debate Panel

I N V I T A T I O N

What: Forum on Health Care
When: Oct. 1, 7:00 p.m.
Where: Calvary Chapel, 2697 Lavery Court, Suite 10, Newbury Park, CA 91320
Who: Conejo Coalition for Responsible Government.
Contact: 805-262-2477, cguillot@roadrunner.com


This Forum on Health Care will consist of a panel of medical professionals and others on both sides of the Health Care reform debate. The purpose is to exchange real ideas for reasonable reform that preserves liberty and choice for the individual.

Seats on the panel may still be available for professionals favoring government-run health care; suggestions are welcome.

This forum is open to the public at no charge. It is a non-partisan event; no signs or clothing displaying a point of view will be admitted. Security will be provided.

It would be great to see you there! SF

The Coalition for Improving Maternity Services Responds to The Today Show’s Biased Reporting of Midwifery Care and Home Birth

Sept. 22, 2009

Dear Producers of The Today Show,

The Coalition for Improving Maternity Services (CIMS) and the undersigned organizations are disappointed with The Today Show’s misrepresentation of midwives and home birth that aired on Sept. 11, in a segment titled “The Perils of Midwifery,” later changed to “The Perils of Home Birth.” This biased and sensational segment inaccurately implied that hospitals are the safest place to give birth even for low-risk women and mischaracterized women who choose a home birth with a midwife as "hedonistic," going so far as to suggest that these women are putting their birth experiences above the safety of their babies. Neither could be further from the truth.

Unfortunately, The Today Show did not do its homework on the evidence regarding the safety of home birth and midwifery care. The segment featured an obstetrician who presented only the American College of Obstetricians and Gynecologists’ (ACOG) position in opposition to home birth, but it did not make any attempt to present the different viewpoints held by the many organizations that are committed to improving the quality of maternity care in the US. We are deeply saddened that the show did not take the opportunity to note that both CIMS and The National Perinatal Association respect the rights of women to choose home births and midwifery care, and that the respected Cochrane Collaboration recommends midwifery care because it results in excellent outcomes.

There is no evidence to support the ACOG position that hospital birth for low-risk women is safer than giving birth with midwives at home. What the research does show is that the routine use of medical interventions in childbirth without medical necessity can cause more harm than good, while also inflating the cost of childbirth. However, the current health system design offers little incentive for physicians and hospitals to improve access to maternity care practices that have been proven to maximize maternal and infant health.

“Birth is safest when midwives and doctors work together respectfully, communicate well, and when a transfer from home to hospital is needed, it is appropriately handled,” says Ruth Wilf, CNM, PhD, a member of the CIMS Leadership Team.

That is why the national health services of countries such as Britain, Ireland, Canada, and the Netherlands support home birth. In those countries, midwives are respected and integrated into the maternity care system. They work collaboratively with physicians in or out of the hospital, and they are not the target of modern day witch hunts. These countries have better outcomes for mothers and babies than the US.

Childbirth is the leading reason for admission to US hospitals, and hospitalization is the most costly health care component. Combined hospital charges for birthing women and newborns ($75,187,000,000 in 2004) far exceed charges for any other condition. In 2004, fully 27% of hospital charges to Medicaid and 16% of charges to private insurance were for birthing women and newborns, the most expensive conditions for both payers. The burden on public budgets, taxpayers and employers is considerable.

As US birth outcomes continue to worsen, it should come as no surprise to The Today Show that childbearing women are seeking alternatives to standard maternity care. After all, American women and babies are paying the highest price of all—their health—for these unnecessary interventions, which include increasing rates of elective inductions of labor and cesarean sections without medical indication.

To the detriment of childbearing families, the segment “The Perils of Midwifery” totally disregarded the evidence. Although the reporters acknowledged that research shows home birth for low-risk women is safe, that message was overshadowed by many negative messages, leaving viewers with a biased perception of midwifery care and home birth. CIMS makes these points not to promote the interests of any particular profession, but rather to raise a strong voice in support of maternity care practices that promote the health and well-being of mothers and babies.

One of the ten Institute of Medicine recommendations for improving health care is to provide consumers with evidence-based information in order to help them make informed decisions. The Institute recommends that decisions be made by consumers, not solely by health care providers. The Institute maintains that transparency and true choice are essential to improving health care. We remain hopeful that the medical community will soon recognize the rights of childbearing women when it comes to their choices in childbirth and will respect and support these choices in the interest of the best possible continuity and coordination of care for all.

We urge The Today Show to provide childbearing women with fair and accurate coverage of this important issue by giving equal time to midwives, public health professionals, researchers of evidence- based maternity care, and especially to parents who have made choices about different models of care and places of birth.

Sincerely,
Coalition for Improving Maternity Services
Academy of Certified Birth Educators
Alaska Birth Network
Alaska Family Health and Birth Center
American Association of Birth Centers
American College of Community Midwives
American College of Nurse-Midwives
Bay Area Birth Information
Birth Network of Santa Cruz County
Birth Works International
Birthing From Within, LLC
BirthNet
BirthNetwork National
BirthNetwork of Idaho Falls
BirthNetwork of NW Arkansas
Choices in Childbirth
Citizens for Midwifery
DONA International
Doulas Association of Southern California
Evansville BirthNetwork
Harmony Birth & Family
Idaho Midwifery Council
Idahoans for Midwives
InJoy Birth and Parenting Education
International Childbirth Education Association
International MotherBaby Childbirth Organization
Lamaze International
Madison Birth Center
Midwives Alliance of North America
Motherbaby International Film Festival
Nashville BirthNetwork
National Association of Certified Professional Midwives
North American Registry of Midwives
Oklahoma BirthNetwork
Perinatal Education Associates, Inc.
Reading Birth & Women's Center
Rochester Area Birth Network
Sage Femme
The Big Push for Midwives Campaign
The Tatia Oden French Memorial Foundation
Triangle Birth Network
Truckee Meadows BirthNetwork

About Us
The Coalition for Improving Maternity Services (CIMS) is a coalition of individuals and national organizations with concern for the care and wellbeing of mothers, babies, and families. Our mission is to promote a wellness model of maternity care that will improve birth outcomes and substantially reduce costs. The CIMS Mother-Friendly Childbirth Initiative is an evidence-based mother-, baby-, and family- friendly model of care which focuses on prevention and wellness as the alternatives to high-cost screening, diagnosis, and treatment programs.

Cord Clamping and philosophy

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

Taken from the original "Common Sense" written around 1776. The wisdom of these amazing men is still inspiring today. We must remember to challenge things that do not make sense. Just because something has been done a certain way for a long time does not make it right. Often there are ulterior motives, sometimes faulty logic, but all the more reason to never stop thinking and speaking out. SJF

Remember to ask "Why?" when something does not seem sensical.

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

A quote from "Common Sense" written around 1776. The wisdom of these men is inspiring. To not question why we do some things routinely

Just an Update

Hi all, Very little news to report this week on my interactions with my hospital. Seems as long as I "behave" to their liking and, as such, ignore certain patients rights issues and give consent and admit patients per their recommendations all is well. Except that I have had to refer 5 patients this past month to other doctors or institutions so that they could have a chance at a vaginal birth. I have also had 2 patients reluctantly agree to a repeat c/section because they would prefer to remain with The Woman's Place and my care. I am waiting for my attorney to review some of their letters to see if we can at least challenge the taking of my credentialed privilege to do vaginal breech deliveries. I have long been approved to do them and there is no official policy against vaginal breech delivery at the hospital and yet they have told me if I allow another scheduled breech delivery they will suspend my obstetric privileges. Your support through all this has been uplifting but the process of trying to do what seems right to me is so tedious and slow. I have been invited to speak at a health care forum in Westlake Village on October 1st at the Calvary Church. Open to the public. I am hoping to attend the international breech conference in Ottawa next month. I have also offered to attend a Catholic Healthcare West seminar in Sacramento, October 9th, on obstetric policies in the CHW system to provide an alternative voice. I need approval from the chairman of the OB committee at St. John's in order to go so I am not holding my breath. Its been more than a week since I sent my written request. Will keep you posted.

More Thoughts About Early Cord Clamping

Thanks to my Facebook Friends for this article:

Cord Clamping Danger to BabiesShare
Wednesday, July 1, 2009 at 5:11pm
By Lucy Johnston HEALTH EDITOR, Daily Express Weekend – Dec, 16, 2007

CLAMPING a newborn baby's umbilical cord too soon after birth can lead to oxygen deprivation and may explain the dramatic rise in autism, scientists have warned.

Groundbreaking research suggests the routine practice of cutting the cord quickly after delivery may reduce an infant's supplies of oxygen and nutrient rich blood in the crucial minutes before they start breathing.

Specialists now believe that in vulnerable infants this is leading to brain hemorrhaging, iron deficiencies and mental impairment, including autism, a mental condition characterized by extreme loneliness and a desire for sameness. Experts say this now affects up to one in 100 children … a sevenfold rise over the past decade.

Last night. David Hutchon, consultant obstetrician at Darlington Memorial Hospital who has studied the effects of cord clamping said: "Babies are being put at risk by clamping the cord too quickly.

"The blood and oxygen supplies in the baby are rapidly decreasing during the minutes after birth. Infants need an increased blood volume to till their lungs and the rest of their organs that are coming into use.

He added: "In susceptible infants, early cord clamping and the lack of blood to the baby increases the risk of brain hemorrhage and breathing problems. This could help explain the rise in autism. Why are we doing it?"

He added that he considered the modern practice of early cord c1amping to be "criminal" in particularly vulnerable and undernourished infants. And he said, "Obstetricians are more likely to clamp early than midwives. It is perhaps significant that autism seems to be more prevalent in babies who were delivered by an obstetrician.”

Umbilical cords are now clamped almost immediately ... before 30 seconds in many hospitals because over the last 20 years doctors have increasingly believed this could reduce the risk of mothers bleeding to death.

However: a growing number of experts, including Mr Hutchon, believe the risks to the baby outweigh the potential harm to the mother. They say at least three minutes should elapse before the cord is cut to allow the mother's blood from the placenta to continue to flow into the baby until its breathing is more established.

Their theory is borne out by recent research. In one major study, involving more than 1,900 newborns and published in the Journal of the American Medical Association, delaying cord clamping for two minutes reduced the risk of anemia by half and low iron levels in the blood by a third.

Eileen Hutton, assistant dean of midwifery at McMaster University in Hamilton, Canada, who carried out the research, said: "These benefits extend beyond the early neonatal period."

Another study carried out by Andrew Weeks, and published in the British Medical .Journal had similar findings: Dr Weeks, senior lecturer in Obstetrics at the University of Liverpool and practicing obstetrician at Liverpool Women's Hospital, told the Sunday Express: "I delay the cutting of the cord. This is especially important for premature babies who have fragile blood vessels. The lack of blood supply could theoretically lead to autism.

"There is evidence to show it [immediate clamping] can damage a baby but none to show it can benefit."

Patrick O'Brien, spokesman for the Royal College of Obstetricians and Gynecologists said: “The latest research does suggest parents should be given a choice and it should be discussed routinely in antenatal classes.”

Birth injuries caused by immediate clamping of the umbilical cord are explained and discussed fully at the following web sites:

www.autism-end-it-now.org
www.birth-brain-injury.org
www.cordclamp.com

G. M. Morley MD FACOG

Email obgmmorley@aol.com

I gave a PowerPoint presentation on cord clamping injuries at Darlington
Memorial Hospital on September 24, 2007.

GMM.

Dispelling a Myth About the Umbilical Cord

The umbilical cord around the fetus’ neck cannot strangle your baby! There, I said it. Now, let’s discuss the logic behind this truth. Nature has devised a system to nourish the developing baby inside the womb of all mammals. The placenta and umbilical cord are an amazing creation of both form and function. The placenta acts as a factory for hormones to support the pregnancy, a filter that among a myriad of tasks acts to bring in good things and remove waste and provides a reserve of blood and oxygen to support the baby through labor. The umbilical cord is the conduit by which nutrients such as sugar and oxygen help feed the baby via its two veins while through its one artery passes the waste by-products of growth.
Understanding how a baby gets its oxygen allows us to understand why a baby cannot strangle or “choke” on its cord. In order to choke, one must be using its trachea to breath air. Clearly, there is no air in the uterus, the baby does not breathe through its throat and, therefore, cannot choke. When an ultrasound reveals the cord around the neck it is a normal human response to anthropormorphasize the intrauterine baby to our extrauterine experience. But this is not the case and there is no reason to have fear. So, let’s dispel once and for all the rumor that a cord around the neck (nuchal cord) is more dangerous than any other situation. About 35-40% of normal term babies are born with the cord around the neck at least once. It can also be wrapped around the body or legs or even at times have a true knot. None of which are usually significant as the cord is designed to deal with this.
Cord compression can occur anytime during pregnancy. The cord is well equipped to handle temporary squeezing as the 3 vessels are cushioned by a matrix called Wharton’s jelly and the surrounding amniotic fluid. In labor, sometimes after the bag of waters breaks and fluid leaks out, the cord can be repeatedly compressed with contractions. This is not uncommon and is not, by itself, a sign of distress. Your practitioner or nurse can listen to or interpret the fetal heart rate pattern to know whether any intervention is necessary. And the compression of the cord almost never is an emergency or a cause for the tragic death of a baby inside the womb. When that tragedy occurs we all want to know why and often, mistakenly, we are told it was a “cord accident”. Compared to the number of times I have heard this mentioned by patients or news stories the real truth is that this is a very rare event.
Please be reassured that your baby will not strangle on its cord because it is not breathing through its neck like you and I. If you hear someone repeat this rumor you would be doing a great service to pregnant women everywhere by logically explaining to them the reasons why.

Perspective on the Rights of a Fetus

ACOG has clearly come out against home birthing and last year made a formal statement that the safest place for giving birth is the hospital or a birthing center attached to a hospital. In a recent Today show interview, ACOG spokesperson, Dr. Erin Tracy, stated that in rare circumstances a home birth can go awry resulting in injury or death to the fetus and used this reasoning to argue against supporting a woman's right to informed consent and choice. So, my understanding from this is that ACOG has deep concern over the rights of the unborn baby and puts those rights above the mother's.

In July of 2007, ACOG reaffirmed their statement of policy regarding abortion. Paragraph #3 states: "Termination of pregnancy before viability is a medical matter between the patient and physician, subject to the physician's clinical judgement, the patient's informed consent and the availability of appropriate facilities."

Paragraph #5 states: "Informed consent is an expression of respect for the patient as a person. It particularly respects a patient's moral right to bodily integrity, to self-determination regarding sexuality and reproductive capacities, and to the support of the patient's freedom within caring relationships. A pregnant woman should be fully informed in a balanced manner about all options.....The professional should make every effort to avoid introducing personal bias."

"The College continues to affirm the legal right of a woman to obtain an abortion prior to fetal viability. ACOG is opposed to abortion of the healthy fetus that has attained viability in a healthy woman (Dilitation and Extraction or late term abortion). Viability is the capacity of the fetus to survive outside the mother's uterus." Although against this procedure, they do acknowledge that a late term abortion may be the most appropriate procedure in a particular circumstance to save the life or preserve the health of a woman and only the doctor, in consultation with the patient, can make this decision. ACOG also states that a select panel they convened could identify no circumstances under which this procedure would be the only option to save the life or preserve the health of the woman.

I was sort of confused by this last paragraph so don't feel bad if you have to reread it, too. Anyway, their statement of policy on abortion concludes in bold print: "The intervention of legislative bodies into medical decision making is inappropriate, ill advised, and dangerous."

So, realizing that I am editorializing here a bit let me see. Hmmmm, they are on a lobbying campaign to discourage or eliminate a woman's choice of home birth because it can very rarely cause damage to a fetus but they are against legislation to prevent a woman's choice of a late term abortion which kills viable fetuses. Am I missing something here? Am I comparing apples to apples? Is this an amazing bit of ACOG hypocrisy? Please comment as I would love clarity here. Thanks, Dr. F

9/12 Rally in Thousand Oaks

Here are the details:

What: "912 Protest Against Socialized Health Care and Government Spending."
Where: Hillcrest & Lynn Rd., NE corner, across from the Oaks Mall parking lot.
When: Speakers: 12:30 - 2:00 p.m. ----- Protest: 11:00 - 3:00 p.m.
M.C.: Trevor Woolley
Organizer: Carolyn Guillot -- 805-262-2477

Hope you can attend. We are all individuals with life experiences that make us unique and shape our decisions. We are not identical, our lives should not be relegated to an RVS code and one size fits all medical guidelines set by faceless panels. Having been a practicing physician for more than a quarter century I have seen the demise of personal liberty to the detriment of the individual. Whether it is big business or big government, we should not trust our lives to those motivated by economics. Surrendering personal choices and responsibility to the false god of "equality" will lead only to enslavement. Never a good thing.

You all know the issues that I stand for. Birth choices and personal responsibility. My belief is that this can best be achieved through changes in the current system and not a government run system. While dealing with insurance companies is all too often maddening beyond reason, it is so much worse trying to care for patients under the current government programs of MediAid and MediCare. Doctors cannot make a living, run a business and do what is right by their patients under this immense regulatory burden, poor reimbursement and the fear of a guilty until proven innocent audit and legal system. If an insurance company wrongs a patient or a practitioner there are avenues of recompense. And as burdensome as they might be one can sometimes prevail. You can appeal to their medical reviewers, the insurance commissioner or even sue. But who can you appeal to when the government run insurance company harms you?

So, this among many reasons is why I support the private sector with oversight. Oversight, not over regulation. Government is the problem! The reason there is no competition from out of state insurers is government regulation. The reason that the few remaining in state insurers offer one size fits all policies is government mandate. You have heard this before but here is what government can do, and within weeks, to show they mean what they say.
1) Remove blocks to interstate commerce. If you can buy your TV from Ohio why not your health insurance?
2) Remove employers as the purchasers of health insurance and thus make it portable. Would you let your employer dictate the one model of car you can have?
3) Stop insurers from cherry picking healthy patients and excluding ones with prexisting conditions. Here is where a government pool supported by charitable organizations supported by citizens freed from high tax burdens could contribute to those truly unfortunate.
4) Allow decisions to return to the patients and their practitioners who know them as individuals. I support use of outcomes data and evidenced based decision making. No panels or guidelines that dictate one size fits all policies.
And 5) The greatest restriction to meaningful reform in all areas of our lives, not just health care, is the American tort system. Fear of being sued drives up costs everywhere. you cannot have meaningful, cost saving health reform without tort reform. Liberals must capitulate on this or all other reforms, government or private, will not work. How can anyone support a system that holds a health care worker or institution responsible for an adverse outcome when the diagnosis or treatment is delayed because of bureaucratic inefficiencies?

Imagine you have a new headache. Your physician examines you and thinks an MRI is necessary. He orders one but there is a delay of 4 months before you are allowed to get it. In the meantime you have a stroke. Is the doctor at fault? In the currently proposed healthcare bill, without tort reform, he/she would be. A career destroyed. What doctor would want to practice under such a system. Even more worrisome is who is going to want to go into medical school knowing this is what awaits them. A life of living under the microscope of Monday morning quarterbacks holding a legal axe over your head. The President and Congress want to rush through a bill that few have read, almost no one understands and spend trillions of dollars faster than I could get you that MRI. Now I have a headache!! How much for a couple aspirin?

Dr. F at Health Care Rally

I have been asked to appear and speak at a rally on 9/12 in Thousand Oaks. The main theme is against a government take over of health care and indiscriminate spending. So much has been said already pro and con that there is little I can add. My hope is that I can say a few words about cost savings in maternity care using the midwifery model. And back it up by giving a real face to the issue from one with expertise who is actually doing the work. I am hoping that on one subject left and right can agree. That being that the ultimate decisions in any health care proposal need to belong to the patient. On another note, my daughter and I will take a moment on the morning of 9/11 to pause and remember the tragedy of 8 years ago. God bless the memory of those lost on that day.

Please check out my interview from Stand and Deliver. Soon to be posted on my web page as well. Thanks to Rixa for doing this.

http://rixarixa.blogspot.com/2009/08/interview-with-dr-stuart-j-fischbein.html

Stand and Deliver (formerly The True Face of Birth): Interview with Dr. Stuart J. Fischbein

Source: rixarixa.blogspot.com

Baby flips after visit to Berlin Wellness Group

On a nice positive note, I saw a patient today, September 4th, at 40 weeks gestation upon the kind referral from Elliot Berlin, DC. She thinks she might have been in breech position for several weeks but was only confirmed by her doctor in Pomona 2 days ago. This left little time for interventions that might help turn the baby. She was also concerned because there was no practitioner in her area she could find to take her on at this late date let alone offer a breech vaginal delivery.

She underwent chiropractic manipulations yesterday and last night reports a lot of fetal movement. Upon presenting to my Camarillo office today ( a very long drive from Pomona!) I am happy to report the baby had spontaneously flipped to vertex. Ultrasound confirmed the findings on Leopold's maneuver and the environment around this 8 pound baby looked great. She was sent home with a binder and hopes renewed for a natural birth back in Pomona. Kudos to the wonderful doctors at the Berlin Wellness Group and to the dedication of such marvelous parents who endured the drive through the infamous LA traffic to keep the dream of their desired birth experience alive. Dr. F

Comment on Huffington Post

As a newly trained physician just out of residency back in the 80s I remember inviting my parents to Las Vegas for my formal acceptance ceremony into the fellowship of ACOG. I was so proud to be a part of what I thought was the pinnacle of my profession. Fast forward 20 years and now I wonder what has happened. Did they change or did I? ACOG does many good things and their continuing education and promotion of some research and programs have been a benefit. But, all too often of late, they have done some really stupid things. ACOG has released several Committee Opinions that defy evidenced based research, common sense and even the the very foundation of their organization that purports to respect a woman's autonomy and choice. I have written them for an explanation as to who decided and on what evidence and received only anecdotal hogwash from their executive vice president. Whether they or their blind supporters and shills like Amy agree with out of hospital birth is not the real question. To make statements based on "consensus opinion" that are purposely designed to remove choice is unscientific, unprofessional and belittles their organization. Those that are behind these pronouncements know what they are doing will influence policy, insurers and hospital administrators. It is an abuse of power and wholly unhypocratic. Patient autonomy and choice as well as honesty are the issue here. Whether readers, shills or ACOG are supportive of home birth and midwifery or not we should all strive for respect of the patient's intelligence, dignity and liberty. ACOG comes out last year with a statement against out of hospital birthing and now puts out a call for stories to back up their opinion? Isn't that sort of backwards, insulting and poor research technique? Simply embarassing. Not the pinnacle anymore.

http://www.huffingtonpost.com/louise-marie-roth/acog-up-to-dirty-tricks_b_274372.html#postComment

Midwives Reinstated !!

Hi All, Well, a big thank you to Terry Cole, MD, a long time supporter of midwifery, who stepped up and agreed to be our backup. This should satisfy the ever changing rules of the MEC for now. I had to switch days to cover my Century City office from Mondays to Tuesdays because we could not find any physician willing to back me backing the midwives on Mondays. I spoke to 5 of the members of the OB committee and a total of 8 members of the attending staff and all refused. The reasons went from reasonable to absurd but not surprising. At least now our patients can get the care they desire while we continue to work for their rights to choose the manner by which they give birth.

Supportive Organization Brings up Important Issue

Received this e-mail today. Points out another rarely mentioned consequence of lack of true informed consent. I was unaware of the extent of this problem and want to thank Jennifer Zimmerman for her good work. Check out her link in the supporters column.

Hello, I am from the non-profit organization Solace for Mothers: Healing After Traumatic Childbirth (http://www.solaceformothers.org/). I am very interested in your case because we have identified a lack of informed consent and the ability to refuse care as a major risk factor in developing traumatic stress (or PTSD) symptoms after childbirth. Women are unable to get a lawyer if their legal rights to informed consent and refusal were violated and caused them PTSD. Lawyers simply will not take these cases, which means that providers are free to trample over women's rights with no punishment for their illegal actions. Having a lack of true informed consent is leading to more and more women suffering from postpartum PTSD, which is often misdiagnosed and treated as postpartum depression. Our organization will soon launch a letter writing campaign to Lynn Rosenthal, the newly appointed Presidential Advisor on Violence Against Women (an office within the Department of Justice). We intend to inform her of the violence that is happening against women in maternity care, and the effect it has on these women. If you would like to add your voice to this campaign, I will inform you of when we begin.

Jennifer Zimmerman
Project Coordinator
Solace for Mothers, Inc.
www.solaceformothers.org

Always question motives.

From: Patricia Sent: Thursday, August 27, 2009 8:57:34 AM

Subject: Re: Couple of things about ACOG

Thanks, Dr. Fischbein, for this recent notice from ACOG. It does seem like we are going back to the Dark Ages! Well, at least, they are putting out a statement that it is "okay" from women to have more than icechips in labor. Really? Who are these people?!

Re: reporting of unsuccessful homebirths. It is curious that there is a need for data collection on numbers. I am suspicious as to the motive for data collection. But I hope that along with collecting the numbers, there is an assessment for the reasons for hospital transfer (i.e. emergency vs. nonemergency).

Have a great day!
Patricia

Dear Patricia, You should be suspicious. Last year they came out and made a statement against homebirth based on Level C evidence (consensus opinion). Now, it seems, they are out to find out if they were correct. This is ass backwards thinking and reeks of bad research technique. "Here is what I think now we will try to find evidence to prove it!!" By the way, if they don't, you will never be told. Completely lacking in objectivity and, as I said before, what do the anecdotal stories mean without comparison to successes? Also, I do not see them asking members to report data on bad outcomes in hospital births as they have already concluded that hospitals or birthing centers attached to hospitals are the safest place to give birth. This is just such a witch hunt. Thanks, Dr.F

What about Successful home Births?

ACOG is asking its members to report failed home births. Maybe I am biased but what good is this registry if there is no registry on successes?

Reporting of Unsuccessful Attempts at Home Delivery with or without Adverse Consequences
In 2006 there were 24,970 home deliveries reported in the United States[1]. Obstetrician-gynecologists and other members of the medical community may be faced with the presentation of an obstetrical patient who has attempted home delivery unsuccessfully. The need exists to quantitate the frequency and information of these events. The goal of this registry is to attempt to quantitate when home delivery is unsuccessful and what the outcomes are. To be HIPPA-compliant, no identifying information will be requested. Data points include the state of occurrence, as well as the month and year of delivery, maternal and gestation age, gravidity and parity and obstetric or neonatal complications. An attempt to identify the home attendant type if known will also be useful data.

ACOG appreciates your recognition of this issue and your utilization of this registry to assist us in data collection.

No progress on Midwive's Privileges

My take: As of today, the hospital's legal counsel is still playing a childish game of semantics which is hurtful to both midwife and patient. We have honored their request for physicians willing to back them on days when I am in my other office. One of the physicians has not been approved because she requires proctoring for obstetric admissions. While this may sound reasonable it is really absurd. Her proctoring requirements have been in place since July of 2008 and have not changed. From July 2008 until January 2009 the midwives and I shared call with her and several other physicians. No one complained then. Since January she has covered several physicians in a call group without restriction. She has also covered me and the midwives when I had to go out of town. And no one complained then. When asked to explain this situation today, the chief of staff told me he would have to discuss this with legal counsel and get back to me tomorrow. It seems clear to me that these decisions are coming from a lawyer who benefits financially each time he can be obstructive and is in no hurry to respond or resolve this dilemma. Meanwhile it has now been 2 weeks since they abruptly restricted the midwives from caring for inpatients. Lets see if they follow through tomorrow and what they will think of next. Thanks for reading. Comments welcome. Dr. F