"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, November 24, 2010

Cal State Northridge Jounalism Student Project

By Andrew Lopez

It was 3:00 p.m. on June 23, 2007, when Emory Rivas, 27, arrived at St. Joseph Hospital in Orange, CA, to give birth to her first child, Davian. Throughout her pregnancy, Rivas, a Costa Mesa resident, has had a clear idea of how she wants her birthing experience to unfold, yet over the course of the next several hours, nothing works out quite like she wanted. First, the doctor she has put all her trust into delivering her child is not available because it’s the weekend. Secondly, she is talked into both an epidural to decrease pain and Pitocin to speed up her contractions, though she had planned all along not to take any medication during labor. Finally, at 6:00 a.m. the next day, her hope to give birth vaginally is no longer possible. The nurses tell her that she is failing to progress and starting to develop a fever. Feeling the decision was never truly in her hands, Rivas agreed to give birth by C-section.

At 6:34 a.m., Davian Rivas is born. Instead of being able to spend time with her newborn, Emory holds him for only a few minutes before he is taken to the nursery while she is taken to a recovery room. The anesthesia is causing her to vomit and she is crying for her baby. Though she was glad that the surgery was successful, the experience of having a C-section and the hospital policies that kept her from Davian was deeply upsetting.

“It was the worst feeling ever,” Rivas said. “They didn’t respect my birthing plan. I felt like I was by myself. It was horrible.”

Rivas is not alone. According to the CDC National Center for Health Statistics, 32.3 percent of babies born in the United States were by cesarean delivery in 2008. This number is at odds with a 1965 analysis of births in the United States, when just 4.5 percent of babies were born by cesarean. These rising numbers are alarming to those who advocate against unnecessary C-sections.

“The healthy rate (of C-sections) is between 8-15 percent for industrialized nations,” Chelsea Shure, chapter leader of the International Cesarean Awareness Network, West Los Angeles, said.

While critics of unnecessary C-sections point to a hospital’s bottom line as the primary reason for such high rates, those closest to the trend believe that it’s much more complex than that.

“There are many legs to this,” Dr. Stuart Fischbein, who practices in Southern California, said. “The big three are expediency, economics and malpractice.”

Dr. Gary Nishida, whose office is located in Oxnard, CA, lists “failure to progress” as the most common reason for first time C-sections. The term itself means that the laboring process has come to a standstill. There are a variety of reasons for this, including the woman’s pelvis being too small for the baby, according to Nishida. Nishida points to the one and a half lb. increase in baby weight since the 1950s and the unchanged size of an average woman’s pelvis.

However, certified birth doula (a trained person in childbirth who provides non-medical support before, during and after labor), Patricia Grube, believes that there is more to it than just that. “Failure to progress?” Grube asked rhetorically. “Doctors just don’t want to wait around.”

Shure believes that more than a failure to progress, C-sections are increasing due to a lack waiting by medical professionals. She believes that the unpredictable nature of vaginal births cause doctors to act quicker than necessary.

“A normal vaginal birth is so wildly inconvenient,” Shure said. “Doctors won’t sit on their hands. They can’t wait.” Shure also believes that obstetricians opt for C-sections because they haven’t been properly exposed to unmedicated births in their training. Fischbein agrees. “Obstetricians are high-risk surgeons,” he said. The medical model is that of intervention, he explained. Fischbein believes that the fear of a lawsuit rather than finances, dictates how obstetricians are taught.

Nishida disagrees that the bigger bills generated by C-sections is the primary reason they occur. “It has nothing to do with finances,” Nishida said. “I’m getting paid one-third what we got paid 15 years ago,” he said. It is the fear of a malpractice suit that facilitates swift action. “None of us (doctors) get sued for doing a C-section, we get sued for not doing a C-section,” Nishida said. “If they (those who oppose the high C-section rates) want to pay my malpractice suit, they can go ahead.” Fischbein also points to the fear of a malpractice suit as a driving force for unnecessary C-sections. “No one wants to work with an anvil over their head,” Fischbein said. “It’s a huge burden.”

In 2008, Rivas found out she was pregnant once again. This time she did research on VBAC’s (vaginal birth after cesarean) and switched hospitals and doctors, hoping to fulfill her wish of giving birth naturally. To her dismay, her new doctor thought it best not to try for a vaginal birth. He explained to Rivas that her body shape wasn’t ideal for a VBAC. “He was basically saying I wasn’t fit for it,” she said. Not until she was seven-and-a-half months pregnant did she decide to once again go with a surgical birth for her first daughter, Daya. Once again, she felt pressured and regretted her choice. “With Daya I felt I made the wrong decision,” she said. “I kind of got screwed over.”

Nishida points to the strict guidelines that must be met to perform a VBAC as the reason so few actually take place. Not only must a doctor be on-call throughout the process, an anesthesiologist and a team of nurses must also be waiting around the clock as labor takes its course. Nishida finds these guidelines to be unrealistic, as neither he nor the anesthesiologist would be getting paid to wait for the laboring process. “There are cost issues and practical issues,” he said. “If someone wants to pay me to sit around they can go ahead,” he said. Nishida also cites the American College of Obstetricians and Gynecologists (ACOG) stance on VBAC’s, which states the risk of uterine rupture that could take place during labor might be catastrophic. Once again, Nishida fears a lawsuit if something were to go wrong in performing a VBAC. “You’d lose everything you got,” he said.

Shure doesn’t agree that the risks of a VBAC are any more dangerous than performing multiple C-sections on a healthy woman. “The risks of major complications from a second C-section is one-in-23,” she said. “That’s a huge problem,” she said. Shure does agree with Nishida that the strict guidelines for VBAC’s are unpractical and in place so no one can blame the hospital for an unsuccessful attempt at a vaginal birth. “It’s not fueled by doctors. Hospitals have policies that make it hard for vaginal births,” she said. “They’re covering their ass,” she said. Shure believes that the prohibition on VBAC’s reflects a combination of hospital policy, unnecessary inductions fueled by poor information to obstetricians and simple impatience.

Fischbein looks to the executives of insurance companies to explain why these contentious policies exist. Politics and bureaucracy, according to Fischbein, are the motivating factors behind many of the problems he sees in the healthcare system.

“None of these decisions are health-based,” said Fischbein, who summed up his distrust of those with the most authority in the healthcare system by quoting French philosopher, Albert Camus: “The welfare of humanity is always the alibi of tyrants.”

Just as Fischbein attributed three causes for the increase in C-sections, he sees three solutions as being the only ways those rates will decrease. First, he suggests that the cost of vaginal births go up to account for the high cost it takes to staff the delivery process. Secondly, he proposes some kind of tort-reform to limit the damages that may be sought in malpractice suits. Thirdly, Fischbein envisions a freestanding maternity center run by midwives, free of the bureaucracy that rule hospitals. He doesn’t see a reason for low-risk pregnancies to end up in a hospital at all.

“Hospitals are for sick people,” he said. “Pregnancy is not a disease. Labor is not an illness,” Fischbein said. “Midwives do regular births better than obstetricians.” Grube agrees. “For non-complicated pregnancies, a midwife should be the model,” she said. “Midwifes deliver babies naturally and healthily. They are very patient.”

Rivas is visiting her parents’ home in Fillmore as she sits on the front porch on a warm, Sunday afternoon. She looks out onto the quiet street as Daya rests against her chest, nodding off. She smiles from time to time during the interview, but there is an unmistakable air of regret that surrounds her as she revisits the past.

“I feel like I missed out,” she said. “I was robbed.” She doesn’t rule out the possibility of another baby in the future, and if she does, she plans on looking into the issue much closer. “I’m going to definitely prepare myself,” she said. She plans to look into hospitals and their C-section rates, as well as doctors’ tendencies to perform surgical births. She also plans on looking into the possibility of having a midwife deliver her baby. As she weighs her options for the future, Rivas becomes more at ease. It’s as though she realizes for the very first time that her desire to give birth naturally need not be tangled up in the problems of a defensive, bureaucratic healthcare system.

.....Hope this story struck a nerve. I would appreciate feedback which I will forward to the student writer. Happy Thanksgiving, Dr. F

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