"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.

Wednesday, March 10, 2010

Draft summary of NIH VBAC position

Very good news and reassuring that at least at the academic level evidenced based reasoning and common sense have prevailed. Please read the initial statement from the National Institute of Health on VBAC:


The conference was a worthwhile experience and I believe the panel members have the most honest of intentions. I am so glad I went. I hope some of you followed the webcast and if not, it will be up soon through the NIH website. My take on the conference was that it is clear from the presentations and the panelist conclusions that there is no convincing evidence that VBAC is inherantly unsafe nor is it ethically a choice that should be denied to any informed woman. While I do not think there is a snowball's chance in hell it will cause any immediate effect on hospital policy, I do believe if disseminated to patients they can make a convincing argument to their local hospitals that they cannot be forced into surgery and have the right of informed refusal.

One of the most compelling points of the conference to me was the following. ACOG's 1999 statement No.5 changing the word readily to immediately available was not based on any evidence. It was likely done to give ACOG members legal cover in cases where compliance was maintained and still a bad outcome ensued. The result was no real protection against the fear or reality of a disastrous law suit and only fed the fear which led to VBAC bans at more than 30% of American hospitals. Amazingly, neither before ACOG came out with the "immediate" guideline or in the ten years since has there been any studies undertaken that have ever shown that having emergency help immediately available has done anything to lower the incidence of cerebral palsy, neonatal death or maternal morbidity over the "readily" available (30 minutes decision to incision) standard! It is horrifying for me to actually learn that so many of these repeat c/sections were inflicted on women based on nothing but fear and economics. My profession should be ashamed of our cowardice.

I will post a link to the final NIH consensus statement when it appears. The BAC website and VBACfacts are also a great resource to follow the story. Spread the word!


  1. Thank you for being brave enough to say it like it is, Dr. Fishbein. YOU (and a rare few others) make the profession of Obstetrics proud.

  2. If only evidence would convince policy makers. Thank you for continuing to shed light.