"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.

Monday, February 22, 2010

Ina May's 2 Cents Worth

Let’s be honest. The decision to take away the option for women to have a midwife-attended birth at St. John’s Pleasant Valley Hospital in Camarillo as of February 8 had nothing to do with concerns for the safety of women or babies. If it had, the hospital would not have cancelled privileges for midwives Lynn Olson and Joyce Weckl. There is plenty of evidence that indicates that putting midwives in charge of caring for healthy women during pregnancy and birth actually produces better results for mothers and babies with fewer interventions at lower costs than having an obstetrician (who is trained to deal with pathologies of birth, not with normal birth) be the sole caregiver for healthy women. There is no evidence that newborns or mothers at St. John’s were put at any increased risk because of midwifery care. CEO T. Michael Murray knew this, I suspect, or he would have presented some with his cowardly statement that rescinded the midwives’ privileges.

A recent U. S. study showed that nurse-midwives spend an average of 24 minutes with a woman during each prenatal visit, compared with obstetricians, who spend only 10 minutes per visit on average. Another study of more than 4 million U. S. births found that midwife-attended low-risk births had 33 percent fewer newborn deaths and 31 percent fewer babies born too small, which means fewer brain-damaged babies. It is well known that midwife-assisted births are far less likely to be induced or to result in a cesarean. No wonder approximately 60 women in the Camarillo area per year took advantage of this option last year. But that’s over now—at least in Camarillo. This bullying of pregnant women and midwives is outrageous; it is especially insulting to explain it as a “safety” measure.

Without exception, the European nations in which 75 percent of births are attended principally by midwives (usually with no obstetrician in the birth room) have lower rates of newborn and maternal deaths than we have in the U. S. None of these countries spends nearly as much money per capita on maternity care as we spend, and in none of these countries are licensed midwives kept from working in hospitals providing maternity care. The U. S. is the only country among the highly industrialized nations that even has the concept of midwives who must beg for privileges, which can later be summarily withdrawn without any right of appeal.

It’s ironic that the St. John’s decision against midwifery took place only days after Californians learned that maternal death rates in California had nearly tripled between 1996 and 2006. Some have suggested that this rise in due to better reporting, which is unlikely, because California has so far done very little to improve the accuracy and completeness of maternal death reporting. Even if it were due to better reporting, it is about 5 times the maternal death rate set as our national goal for 2010 (3.3 deaths per 100,000 live births).

Some might expect that such a shocking news report would have been accompanied by a systematic analysis of the causes for such a quick increase in maternal death—a problem that most people think was solved long ago by high-tech obstetrical care. That has not yet happened. In fact, the state Department of Public Health has so far refused to issue a report on this trend that could help people learn the reasons for the sudden increase in this worst of maternity care outcomes. Surely, California’s women of childbearing age deserve better than this.

For over a decade, I have been tracking the problem of poor reporting of maternal deaths in the U. S., because I was so shocked to find out that the Centers for Disease Control (CDC) is unable to fix the problem they first stated in 1998—that the true maternal death rate in this country could be three times what is officially reported. I began collecting the names of U. S. women who died from pregnancy-related causes since 1982, the year of our lowest reported maternal death rate. I recently learned that by using Google and taking reports from family members or friends of women who have died, I have a considerably larger database of maternal deaths than the Joint Commission, the closest thing we have in this country to a certifying organization for hospitals and other health organizations. (It is suggested, but not mandatory, for hospitals to report maternal deaths to the Joint Commission). Judging by the stories of maternal deaths in my database, the rise in the death rate has much to do with the rising rates of cesarean and induced labors.

There are also similar sounding stories of women dying in hospitals of hemorrhages following birth, suggesting that some hospitals may not be employing enough nurses to provide the kind of watchful care that is necessary in the hours following birth. Making a greater use of midwives is an obvious way to begin reducing high rates of cesareans and induced births.

Ina May Gaskin, PhD (Hon.), CPM, MA
Speaker/Author: Ina May's Guide to Breastfeeding, Ina May's Guide to Childbirth, Spiritual Midwifery
Founding member of The White Ribbon Alliance for Safe Motherhood
Curator: The Safe Motherhood Quilt Project
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Summertown, Tennessee 38483
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The opinion of Ina May was reproduced with her permission. Comments welcome. Dr F

1 comment:

  1. DONA International, a leading organization of birth and postpartum doulas, supports choices in childbirth and holds in high regard the caregivers, organizations and institutions that support this premise.

    Pregnant and birthing women’s autonomy is increasingly being limited, or even denied, based on the special interests of a select few or the policies and practices of organizations or institutions that do not take into consideration evidence-based care practices.

    The Midwifery Model of Care has been proven to result in greater satisfaction in childbirth and better maternal-child outcomes. To deny women access to midwifery care is to deny them and their babies the best possible care, putting them at increased risk.

    DONA International applauds and upholds Dr. Stuart J. Fischbein, his support of midwives and all he stands for as exemplary obstetrical care.

    DONA International