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

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

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

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

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

Explaining the Cause

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

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

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

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

Friday, October 30, 2009

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

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

Wednesday, October 28, 2009

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.

Wednesday, October 21, 2009

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

Thursday, October 15, 2009

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

Sunday, October 11, 2009

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

Thursday, October 8, 2009

Protecting Reproductive Rights at Delivery

Please take a moment to link and read.


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.

Friday, October 2, 2009

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

Thursday, October 1, 2009

You must read this!


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