Blog Talk Radio with Gena Kirby

Last Monday I had the privilege of being interviewed by Internet Radio personality, Gena Kirby. We met in person last month at the premiere of "More Business of Being Born" in Santa Monica. Gena, who resides in Texas, asked if I would come on her weekly program to discuss the reality of breech birthing in America. We had a great 90 minute chat on this subject and, of course, many others and took a couple of questions from listeners. You can find the full podcast at: http://www.blogtalkradio.com/progressive-parenting/2011/12/20/breech-birth-a-reality-a-conversation-with-dr-fischbein
Listening will not be time wasted and comments here or on Gena's site would be appreciated. Merry Christmas to all. Dr. F

We can all learn something from Ibu Robin

Inspired! One cannot spend time with midwife Robin Lim and not come away with a sense of peace and inspiration. For over 20 years Robin has cared for women at her clinics in Bali, Indonesia. Providing health and maternity services to all women regardless of economic status in a country in desperate need. For her tireless efforts she was awarded the CNN Hero of the Year award this past week.

http://www.cnn.com/video/?/video/bestoftv/2011/12/11/heroes-hero-of-the-year.cnn#/video/bestoftv/2011/12/11/heroes-hero-of-the-year.cnn

I was fortunate enough to have a few minutes with her last evening at a gathering in Montecito, CA. What wonderful, and sometimes tragic, stories she has to tell. So much love and nurturing affection in the room full of people eager for such sanity in the world of birthing. In the midst of all the deserved attention and accolades that Robin is receiving I read an article written by Stacia Guzzo titled, "The Paradoxical Perception of Midwifery in American Culture". The contrast it presents is startling and disturbing and speaks for itself. Please take a moment to read.


http://feminismandreligion.com/2011/12/13/1722/

Thank you Robin and Wil and Mary Jackson and all my colleagues and friends who, by example, bring peace, common sense and respect for the individual back to birth. Dr F

Breech Birth, a Reality

I was watching the brilliant movie "Inception" for the umpteenth time and saw a parallel for what those of us who believe that breech birth is just a variation of normal are up against. Like a virus, an idea, once implanted, is very hard to eradicate. Whether true or false, if this idea takes hold it changes the participant and the playing field and, thus, the world we live in.

Up until the early 90's delivering selective vaginal breech babies was taught in residency programs and practiced by obstetricians in the real world. When I trained there were studies supporting this idea including the pivotal work of Martin Gimovsky, MD in the early '80s.

Obstet Gynecol. 1980 Dec ;56 (6):687-91 7443110 Cit:22 Neonatal performance of the selected term vaginal breech delivery.
[My paper] M L Gimovsky, R H Petrie, W D Todd

Several authorities have recommended cesarean section for all intrapartum breech presentations. The present study documents that judiciously selected fetuses at term in breech presentation may be safely delivered vaginally by a selective management protocol that requires cesarean section when mandated criteria are not met. The outcome and performance of 6 years of vaginal breech deliveries were evaluated. Those in the control groups were delivered by spontaneous vertex vaginal and elective repeat cesarean section procedures. Morbidity was not different in the protocol breech vaginal delivery group and in the controls. Mortality was found only in the nonprotocol-managed breech vaginal delivery group, which also had a morbidity 5 times greater than that of controls. Approximately half the term breech presentations that are properly selected and managed may be safely delivered vaginally, thereby avoiding a significant number of cesarean sections and subsequent inherent risks.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1021563/?page=1

As residents we were eager to learn and excited for the opportunity to practice this skilled art and at Cedars-Sinai Medical Center in Los Angeles selective vaginal breech deliveries were the norm.

But in the 1990's the idea began to grow that maybe delivering breeches vaginally was risky. This thought culminated with the publication of the "Term Breech Trial" by Mary Hannah, MD in 2000.


Lancet. 2000 Oct 21;356(9239):1375-83.
Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group.
Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR.
SourceDepartment of Obstetrics and Gynaecology, Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario, Canada. mary.hannah@utoronto.ca

Abstract
BACKGROUND: For 3-4% of pregnancies, the fetus will be in the breech presentation at term. For most of these women, the approach to delivery is controversial. We did a randomised trial to compare a policy of planned caesarean section with a policy of planned vaginal birth for selected breech-presentation pregnancies.

METHODS: At 121 centres in 26 countries, 2088 women with a singleton fetus in a frank or complete breech presentation were randomly assigned planned caesarean section or planned vaginal birth. Women having a vaginal breech delivery had an experienced clinician at the birth. Mothers and infants were followed-up to 6 weeks post partum. The primary outcomes were perinatal mortality, neonatal mortality, or serious neonatal morbidity; and maternal mortality or serious maternal morbidity. Analysis was by intention to treat.

FINDINGS: Data were received for 2083 women. Of the 1041 women assigned planned caesarean section, 941 (90.4%) were delivered by caesarean section. Of the 1042 women assigned planned vaginal birth, 591 (56.7%) delivered vaginally. Perinatal mortality, neonatal mortality, or serious neonatal morbidity was significantly lower for the planned caesarean section group than for the planned vaginal birth group (17 of 1039 [1.6%] vs 52 of 1039 [5.0%]; relative risk 0.33 [95% CI 0.19-0.56]; p<0>

INTERPRETATION: Planned caesarean section is better than planned vaginal birth for the term fetus in the breech presentation; serious maternal complications are similar between the groups.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(00)02840-3/abstract

Finally, those that were against teaching or performing term vaginal breech deliveries and did not want to investigate further had their evidence. Never mind, that within 2 years after the paper was published there were a slew of articles and papers critical of and refuting Dr. Hannah's research and conclusions.

Well summarized here: http://www.breechbaby.info/termbreechtrial.pdf

Too late! The seeds of the IDEA that breech vaginal birth is dangerous had been planted. And this idea was rooted in welcoming fertile ground as it justified the easier, less time consuming, more lucrative and thought to be less liability ridden c/section as standard of care for frank or complete breech at term. An idea, regardless of its validity, is made all the more powerful when it fits the current trend in the medicalization of birth and the fear based model that restricts individual choice. It infects the population and the profession to the core and has led to a stoppage of even teaching the knowledge and technique of vaginal breech delivery to future practitioners. Our halls of higher learning have no shame in denying future mothers this option due to a simple idea based in fear.

Fortunately, some forces are beginning to wake up from the nightmare and realize that "inception" has taken place. Maybe they have a "totem" of their own or just maybe common sense is an antidote to the viral model of a long festering idea. The Royal College of Ob/Gyn in England and The Society of Ob/Gyn of Canada have issued statements in the last couple of years in support of retraining new doctors in the methods of vaginal breech delivery. Even the American College of Ob/Gyn has a clinical guideline paper in support of selective vaginal breech delivery as a reasonable choice for the skilled practitioner and the informed woman.

Those of you who know of my work are aware that I have supported true informed consent and birth choices including the option of vaginal breech delivery. I have been ostracized in my former local community for many of my views and this has led me to choose the path of supporting women's choices in the home and birthing center setting where I do believe that common sense, individuality and evidenced based medical practice can freely occur. With the help of social networking, celebrity advocates and a growing number of devoted maternal care givers an old idea, that normal birth is not a disease and that selected vaginal breech is just a variation of normal, is being re-sown. I believe we can awaken my colleagues and the American populace from "limbo" even if it is one person at a time. A good idea need not be a virus. It may awaken us, as in Christopher Nolan's incredible movie, to the sanity and reality of the beauty of home and family and natural birth.

It is with these comforting feelings that I and my birthing Instincts team of Beth and Jaclyn and doula Robin announce the successful home breech birth on 12/5/11 of an 8 pound baby boy to glowing parents Hallie & Michael. Planning a home birth with the great midwives of South Coast Midwifery they found themselves in the not uncommon dilemma of persistent frank breech at term. Having no success with the usual measures to turn the baby they looked for options. Sadly, they could not find a single facility in Orange county willing to allow them a natural birth. C/section only! Lorri from South Coast knew of my practice and my philosophy and referred them for a consult only last week. We spoke several times for several hours and really connected. They had the right stuff and met all the criteria for a selective breech delivery. The very next day labor began and in less than 7 hours Hallie gave birth at home in their bed with grandma present. Congratulations to them on this blessed event and for their conviction.

I do believe that term breech presentation should be treated as just a variation of normal. And if selection criteria are met then informed consent and choice belong to the woman and her loved ones. While a hospital that respects autonomy would be an ideal place for these women to give birth that is not the current reality we live in.
Choices are so extremely limited. That is just one of the most compelling reasons why another birthing option is so needed in America. Under the current medico-legal and economic climate I do not foresee hospitals and physicians currently in practice changing from the "breech is dangerous" idea. The dream of the Sanctuary Birth & Family Wellness Center and I and a few of my colleagues, too, is to build our own maternity facility where individuality and common sense and respect for birthing are, once again, the norm. Dr. F

My response to another rant by Dr. Tuteur

In the November 7th, 2011 online edition of “Time Ideas” internet blogger Amy Tuteur attacks Ricki Lake and Abby Epstein’s sequel to the popular “Business of Being Born” and continues her rant against home birth and the midwives who support this option. Had Dr. Tuteur actually viewed the 4 part DVD, “More Business of Being Born”, she would find that the film was not an advertisement for home birthing but rather a documentary that presented evidenced based medicine and real life experiences in hopes of educating the viewers on their options for birthing in America. In her zeal to critique anything that has to do with the movement she argues, disingenuously, four major points.
As to point #1:
As a board certified and practicing obstetrician who has worked with both CNMs (certified nurse midwives) and LMs (licensed midwives, also called certified professional midwives CPMs), my experience is that they are both consummate professionals in their area of expertise. Licensed midwives in California are licensed by the Medical Board of California, the same agency that licenses physicians. This consumer protection agency sees fit to certify these professionals to care for low risk pregnant women. In my extensive experience spanning 30 years of collaboration with them in California I have direct knowledge of their work. They have extensive didactic education with accredited institutions and are trained in the care of normal birth through the mentoring and supervision process. The model of care they provide is based on prevention and nurturing and the trust that birthing a baby is a normal bodily function.
Dr. Tuteur believes that having a university degree and extensive in-hospital training is required to care for normal pregnant women. I would state without reservation that midwives do normal birth better than most obstetricians who are trained in surgical birth and rarely experience a normal labor from start to finish. By labeling licensed midwives second class, Dr. Tuteur demonstrates for us her pejorative style that is her reputation when confronted with facts and issue she disdains. In other developed nations the model of care of collaboration between midwife and doctor is the norm. Whether to choose a CNM or an LM is a matter of preference for the informed woman.

As to point #2:
Dr. Tuteur says “All the existing scientific studies…show that American planned home has triple the risk of neonatal death”. This is a stance she consistently takes on her blog site and when quoted in articles and is patently false. The use of hyperbole is also a trademark of Dr. Tuteur and strains further her credibility on this subject. Does any reader really believe that “All” the studies of any topic are on one side only? The American College of Obstetrics & Gynecology (ACOG), of which I am a member and Dr. Tuteur is not, has consistently taken a position against home birthing and the basis for their recent opinion relies almost entirely on a meta-analysis of his selection of 11 out of more than 50 studies encompassing several decades by Wax, et al. The criticisms of his conclusions are numerous in the literature and even include some by the authors he has cited. There is certainly no consensus. Dr. Tuteur seems to assume that her statistics end the discussion. Even Wax, himself, admits that if you accept his data as indisputable the overall increased risk of a fetal death at homebirth is 1 in 1,133. While every loss is significant the evaluation of this risk is a personal decision. No pregnancy is without risk and hospital birthing is no exception. Parents must be allowed to weigh the much greater risk of intervention and surgical birth and the multitude of complications that can arise from them in context with their own life experiences. True informed consent and respect for patient autonomy is not a virtue that Dr. Tuteur seems to value.

As to point #3:
Dr. Tuteur cites a Netherlands study in the 2010 British Medical Journal which had the surprising finding of a higher fetal death rate in low risk women cared for by midwives than for high risk women cared for by obstetricians. The analysis of scientific articles is not a simple task, often comparing apples to oranges and that is the case here. Recall that Dr. Tuteur states that the Netherlands does not allow licensure of CPMs therefore one must conclude that the midwives caring for Dutch women are the equivalent of CNMs, a category of midwife that Dr. Tuteur approves of. Secondly, the study does not clearly define location of labor as a factor, only the care provider. Also, as tragic as a fetal loss is, again, it cannot be used in isolation as the only endpoint when determining models of care. The use of this study as a condemnation of home birthing is, again, disingenuous. The authors’ conclusions are not the condemnation of the midwifery model but that a reevaluation of the Netherlands care system is warranted.

As to point #4:
I agree that if the Midwives Alliance of North America (MANA) has meaningful data they should consider publishing it. Supporters of the midwifery model want the best for their patients and would be accepting of criticism if that is what the statistics showed. For those interested in seeking their data there is a legitimate application process that provides access. Dr. Tuteur seems to be eager to attribute sinister motives to MANA while bathing herself in righteous indignation. Those who know of her antics see her for the internet provocateur she is. One who calls for informed decisions but skews her information, refuses offers to debate opposing views publically, obfuscates her own background and motivation and seems to take pleasure in demeaning those with whom she disagrees. Unlike Dr. Tuteur, I applaud Ms. Lake and Ms. Epstein for bringing the issue of how American women give birth to the forefront. Honest dialogue, true informed consent and individual autonomy in life’s most precious moments are the business for us all.

Stuart J. Fischbein MD, FACOG
www.birthinginstincts.com

(This essay was submitted to the op-ed editors of online Time/Ideas more than a week past. Since I have yet to hear any response from them I have elected to post it here. Dr. F)

You can find the original article by Dr. Tuteur at:
http://ideas.time.com/2011/11/07/what-ricki-lake-doesnt-tell-you-about-homebirth/

Time Ideas did eventually publish an edited version of my comment to Dr. Tuteur. Read it at:
http://ideas.time.com/letters/the-home-birth-debate-continues/?iid=op-main-lettereditor

More hypocrisy from Dr. Stephen Carter

I have not blogged in a while as I have been involved with some other great projects. "More Business of Being Born" premiered a couple weeks ago. I highly recommend this 4-part DVD as an adjunct to Ricki and Abby's BOBB for those who wish to educate themselves in birthing options. It was such a fun gathering of good souls. Great to see my colleagues Glen Elrod from Wasilla, Alaska and Robert Biter up from San Diego along with so many nurturing people who trust birth. I must say I did not know what to expect as we previewed the Celebrity Birth Segment. But I was pleasantly surprised as I found it both entertaining and informative. I have yet to see part 4 on VBAC but colleagues tell me I am in it and did not make a fool of myself so thats reassuring.

My co-author, Victoria Clayton and I were at the Ventura County Book Fair a couple weeks ago promoting "Fearless Pregnancy". I was honored to teach a suturing class to more than 25 birth professionals at the Santa Clarita Birth Center. And of course there is that birthing thing. In the past week I have had my first failed VBAC and another beautiful home delivery of twins. Please check out my summary in the news section of www.birthinginstincts.com

On a very sad note, my friend, mentor and colleague of 30 years passed away early Monday morning. Irwin Frankel was a wonderful physician, very hands on and old school. He was a passionate teacher with knowledge and patience and a calming influence and everyone adored him, patients and colleagues alike. They do not make them like him anymore and his passing signals the end of an era. I will miss him very much.

The contrast between an honorable man like Dr. Frankel and Pleasant Valley Hospital's own Dr. Carter could not be more stark. Some people actually fool themselves into believing what they say and some are just fools. I do not pretend to know the motivation of Dr. Carter and will leave that up to the reader. For those who have followed the antics of the obstetric committee and administration at PVH and St. John's in Oxnard in this blog and in the Ventura County Star towards midwifery you will know what I am talking about. In a recent article regarding the debate over closure of the maternity ward at PVH Dr. Carter, once again, stepped in it. Please take a moment to read the recent article "St John's Pleasant Valley Hospital Postpones Decisionon Closing OB Unit"

I commented on the article as follows:

Dr. Carter says, "I've worked here since '98 and I've never felt the lack of an NICU was a big deal. It's nine miles away." Yet Dr. Carter was an integral part of the OB committee that agreed on a year long ban of midwives for just that reason. Former CEO, Mike Murray, echoed Dr. Carter's position in a story in this paper at the time. Citing "safety" as the reason for the midwife ban. It would seem from Dr. Carter's words here that safety was never the issue. Which we all really knew anyway. The motivation for keeping or closing the unit will remain economics. Also, the reporter should try to see how much the anesthesia and pediatric departments have brought pressure to bear for closure. It is hypocritical to argue safety then but not now. The policies in place at that hospital over that past several years are what have destroyed the census. I agree with Ms. Graf that closure of the woman's unit at Pleasant Valley would be a blow to the community. Sadly, with the unexplained departure of the supportive Mr. Bibby and the current economic forces in the medical industry it would be surprising to see our little haven survive.

.

The health care system is set up to create and protect the Dr. Carters of the world while what is really needed are the Dr. Frankels. Irwin held himself to such high standards that he did not need administrators and lawyers and confidential peer review committees and investigative journalists to inspire him to do the right thing. While those at Pleasant Valley Hospital impersonally debate the future of the women's unit surrounded by syncophants and protected from liability let's not pretend you and I don't really know what is going on there. Dr F

More thoughts on the "Affordable" Heathcare Act

Last April I gave a speech at a tax day rally here in Thousand Oaks, CA expressing my opinions on some of the chilling effects of the government getting into the healthcare business. The text of that speech can be found in the April 2011 archives on this blog. On October 12th I will be a member of a panel speaking on this same subject at a dinner in North Ranch, CA. I will post the details here as the date draws closer for anyone locally who would like to attend.

One of my biggest criticisms of the health care bill is the intrusion of immense government into the realm of the very personal issues of healthcare and the expansion of the administrative state well beyond its scope granted by the U.S. Constitution. Taking a closer look at what this legislation is about reveals it has almost nothing to do with the distribution of medical care and is simply about control and bean-counting of our lives and enrichment of some favored groups.

Writing in the September 2011 publication, "Imprimus", of Hillsdale College, author Edward J. Erler has this to say:

"The administrative state, of course, always seeks to extend its reach and power. This is an intrinsic feature of a system where administration and regulation replace politics as the ordinary means of making policy....This is tantamount to denying that legitimate government derives from the consent of the governed...(taken from The Declaration of Independence). Obamacare certainly fits the description of the activities denounced in the Declaration. The number of regulations and the horde of administrators (not to mention lawyers) necessary to execute the scheme are staggering. We have only to think here of the Independent Payment Advisory Board. It is commission of 15 members appointed by the President, charged with the task of reducing Medicare spending. This commission has rule-making power which carries the force of law. The Senate, it is true, will have the power to override its decisions--but only with a three-fifths majority. There are no procedures that allow citizens or doctors to appeal the Board's decision. The administrative state--here in the guise of providing health care for all--will surely reduce the people under a kind of tyranny that will insinuate itself into all aspects of American life, destroying liberty by stages until liberty itself becomes only a distant memory."

As a concrete example it has been announced that diagnosis coding, required by Medicare and all insurance companies, will be changed in 2013. Currently, ICD-9 coding has about 12,000 diagnoses. The new ICD-10 coding to go along with the mandated electronic medical records provision of the bill will have 140,000 diagnosis codes. Is this for the betterment of health care or will it be used for micromanaging and regulation and eventual rationing of health care resources? What do you think? You know what I think! Dr. F

Junk Science or an Inconvenient Truth?

In a recent article published in the Green Journal, ACOG's monthly academic publication, and much their credit, it was revealed that many guidelines used as "gospel" to counsel patients on OB/Gyn matters are not based on good science. In an article by Christie Haskell on the CafeMom web site she notes the following:

According to Professor of Medicine, Dr. Andrew D. Auerbach, "more than two thirds" of recommendations are based on anecdotal evidence or even just expert opinions, which are wrought with personal biases. While opinion can be helpful where we don't know things, it doesn't always translate into what's best for the patients.

In the new study, Dr. Jason D. Wright of Columbia University in New York and colleagues went through 717 practice recommendations from ACOG, the nation's leading group of ob-gyns.

They found 30 percent of those were based on top-notch evidence, so-called randomized controlled trials. About 38 percent came from observational studies, whose value is limited, and 32 percent were purely expert opinion.

Awareness of this information is crucial in the informed consent process. Asking questions of your doctor about the veracity of the evidence for his/her recommmendation is a good idea and should be greeted with respect by your practitioner. Remember, ACOG guidelines are meant to be just that, guidelines, and yet once published they become the basis for strict hospital policies and fodder for trial lawyers. Again, I give credit to the editors and the author for pubishing this article. Hopefully, it is based on good scientific method. Dr F

Trip to Israel

Every now and then it is beneficial and theraputic to take a mental and physical break from our routine. We all need a refresher course on what are the really meaningful things in life and a change of perspective that comes with traveling can be just the thing. Such was my experience in my first trip to the holy land. My daughter and I, along with 168 other Dennis Prager listeners, enjoyed 10 fantastic days touring Israel. From Tel Aviv to the Golan Heights, Ceasaria to Kfar Blum, Nazareth, Bethlehem, Masada, floating in the Dead Sea and, finally, Jerusalem we experienced history, religion and the co-existence of a vibrant working society. After a visit to these places it is unlikely that one can ever look at the world the same again. We had the opportunity to hear interviews and lectures from a cross section of ideas including the Palestinian Mayor of Bethlehem, a member of the Israeli defense forces and an amazing woman at Yad Vashem to a former ambassador along with the wisdom of Mr. Prager. As he always says, "Prefer clarity over agreement". Seems pretty clear to me that any real peace in the Middle East will not occur in my lifetime. Nonetheless, one must continue to try and it begins with open dialogue and free access to information for the children of the Arab world. For freely educated children are the only hope that old enmities will die out.

As I return to Los Angeles and the work that I love I am hopeful that some of the lessons I learned in Israel can be applied to my profession. I believe more than ever that my profession has been going in the wrong direction. Widening the divide between caregivers for birth by hardened rhetoric does not benefit those we wish to serve. We have a duty to educate the future generations of obstetricians in the skills needed for vaginal birthing and encourage them to reach out to our midwife colleagues in a way that organized medicine has vehemently resisted in my professional life. Collaboration benefits everyone and honored co-existence makes for a more peaceful world for children like my daughter to inherit. That would leave a beautiful legacy for the Middle East and for the birthing world. Dr. F

Ventura County Star op-ed: complete essay

In the August 27, 2011 online edition of the Ventura County Star I had an opinion piece published. Due to length constraints it had to be edited. The complete essay is as follows:


The Medical Model of Obstetrics has Gone too Far

Two weeks ago Maria saw me for a consult near term with her fifth baby. Her first baby was a C-section, followed by three uncomplicated vaginal births in Mexico. Though a vaginal birth would be safer and healthier, Maria was told by the local community hospital that she must have a scheduled C-section. They didn’t tell her she could go elsewhere. They didn’t tell her she had the right to refuse surgery.
Hospital birthing remains the right choice for many and certainly the best choice for some. But it must be realized from the moment a women leaves her home in labor until she puts the baby in the car seat to drive home everything that happens is counterintuitive with nature’s design. The hospital model is illness, not wellness. You leave your nest to arrive at an emergency room. You are placed in a hospital gown with monitors around your belly and a blood pressure cuff strapped to your arm. An IV is inserted. You need permission to go to the bathroom. You are not free to walk around and move and you are not allowed to eat. You are asked to sign consent forms and are constantly interrupted. And you are on the clock. All these policies lead to interventions that disturb the process of labor and contribute greatly to the rise in surgical birth.

If women are nurtured and left to their own natural instincts the birthing process works quite well. Home birthing respects normal physiology. When other mammals labor they go off to some safe, quiet place, shut down their higher cognitive brain, and allow their primitive instincts to come forth. When accidentally disturbed or frightened, labor stops and they get up and run away. There is no place like home for many to feel safe and nurtured and uninhibited.

At home women can move about freely, rest in their own bed, eat their own food and shower and bathe as desired. They can labor silently or cry out without concern for who is listening in the next room. The mother and baby need not be separated and the cord is left alone. There is no timetable.

Families that choose home birth are often some of the most well-informed. Often the choice is made because, like with Maria, the local hospital and medical community do not support reasonable medical choices such as vaginal birth after cesarean section (VBAC) or breech delivery. These women trust their birth team and the process and they have mastered their fear allowing labor to progress as nature intended.

Yet the medical organizations that represent doctors like me actively oppose home birth. In 2007, 2008 and again in 2010 ACOG issued statements against home birth, criticizing midwives who aren’t Certified Nurse Midwives.
The sad truth is that for most Americans birth remains shrouded in mystique and fear. Hospitals and the medical model of obstetrics have gone too far. They have taken something beautiful and natural and convinced us it is an illness.
We now have three generations who have grown up with hospital birthing as the norm. Doctors rarely—if ever—see unmedicated births, and very few—if any—have attended home births. The ones who trust birth—who want to give breech babies or twins a chance to be born vaginally—often face ostracism and ridicule from their peers.
We are told that modern medical interventions for all pregnant women are our savior. Albert Camus said, “The welfare of humanity is always the alibi of tyrants.” The safety net a hospital provides for those that truly need it is wonderful. But safety is often used as a canard for control. There is nothing safe about a surgical birth rate of 33%.
Partly because of the rising C-section rates and the antagonism that exists between doctors and midwives, birth in America is much less safe than in more than 40 other industrialized countries, where collaboration of midwife and doctor provides a much better model of care. The safety problems in America are not because a tiny percentage of women are giving birth at home. They are because we are interfering technologically with the natural process of birth to the detriment of American mothers and their newborns.
In a country founded on personal liberty the choice of how to give birth belongs to the individual woman. She is entitled to true, not skewed, informed consent and the right of self-determination. The medical profession has the duty to respect that right. The American Medical Association (AMA) code of ethics states, “Rational, informed patients should not be expected to act uniformly, even under similar circumstances, in agreeing to or refusing treatment.” The refusal to grant Maria her choice of a vaginal birth was neither medically indicated nor ethical.

The women of America deserve better than what the medical model of obstetrics has provided. The strength of a woman has no better champion than Margaret Thatcher who said, “Choice is the essence of ethics: if there is no choice there would be no ethics, no good, no evil; good and evil have meaning only insofar as man is free to choose.”

Stuart J. Fischbein, MD

Sanctuary gets some press

My colleagues, Heather and Aleks, were featured in todays Daily Breeze. I liked the article because of the clarity it provides. Reading the comments of Aleks and Dr. Rosenthal could not make the difference in birth approaches more clear. One based on trust, the other on fear. One respecting the process, the other concerned about blame. Yes, both are realities. In which one would you like to live? Dr. F

http://www.dailybreeze.com/lifeandculture/ci_18749525

Who Speaks for Maria?

The hospitals in Ventura County where I used to admit patients continue their de facto ban on vaginal birth after c/section. There is no appealing to the clinical evidence, ACOG and NIH recommendations or even their sense of fairness. Today I saw a patient whose story must be told.

Maria R. is a Gravida 5, Para 4 hispanic female. Speaking to her via an interpreter today convinces me she is educated and well informed of her birthing options. For you see, she had a c/section in Mexico with her first baby and has had 3 successful VBACs all in Mexico since. I saw her early in pregnancy as a consult and reviewed her options including her right to have a vaginal birth at the hospital of her choice. No one can force her to have surgery. She does not want a c/section. She knows the risks to her are much greater with a repeat c/section that with a vaginal birth. She knows the likelihood of a successful VBAC for her is greater than 90%.

Maria is now 39 weeks. She is schedule for a "unelective" repeat c/section in 6 days. She came in today thinking she might be in early labor. She was concerned about having to have surgery against her wishes but is not the type to raise a stink. My associate, much to her credit, has contacted the hospital and anesthesia department on Maria's behalf and has been told that a planned VBAC is not an option. If she were to arrive at the hospital without time to wheel her into the operating room she would then be "allowed" to deliver vaginally. My associate, who is currently on vacation, is afraid to stand up for this patient's safety and rights because she is aware of my story and the hospital's history of how they deal with conscientious dissenters. Her last labor was so fast she barely made it to the hospital. I told her that she has the right to refuse surgery should she show up too early. She would be a great candidate for a home birth but her family lacks the means and her insurance does not cover that option.

Maria and I spoke for a while during her visit. When she left, my nurse and I shared our feelings. A combination of anger and frustration would best describe them. Why should this woman be forced into such a situation? Clearly, there is no one who can argue on clinical grounds that she is not the ideal VBAC candidate. Clearly it is safer for her to deliver vaginally. Clearly it should be her informed choice. And I wonder, should she suffer a complication from an unnecessary surgery who is responsible? Will hospital administrators, OB and anesthesia committees stand up and say its their fault?

ACOG and other organizations have written much about the ethics of home birthing. Dr. Nicholas Fogelson and I had a letter to the editor published in the August 2011 Green Journal responding to Dr. Chevernak's rigid stance against it. Where do the ethicists stand on this one? Who speaks for Maria? The silence is deafening! Dr. F

http://journals.lww.com/greenjournal/Fulltext/2011/08000/Obstetric_Ethics__An_Essential_Dimension_in.24.aspx

Fighting for a Breech Birth

Karin Ecker is a mother, artist and filmmaker in Byron Bay, Australia. I get the impression she never saw herself in the role of activist but circumstances often dictate a different path. She has produced and directed a wonderful documentary that follows her story of trying to achieve a birth of her choice against a system that is not accommodating. I highly recommend her film "A Breech in the System" for everyone who supports a woman's right to be informed and choose. Her video would make a thoughtful gift for those faced with a decision such as Karin's. Please check out her site at: www.abreechinthesystem.com
I hope to sponsor a screening sometime this fall in the SoCal area once the bussle of summer calms down.

You can also view Sara & Doug's Breech home delivery on my site at: www.birthinginstincts.com
I find it moving every time I watch. Dr F

LA Times chimes in on rise in Home Birth

July 11, 2011: Writer Olga Khazan highlights the usual pros and cons of home vs. hospital birthing. Some of the usual suspects appear, including some quotes from me.

http://www.latimes.com/health/la-he-home-births-20110711,0,7182324.story?page=1

I did comment to the writer on the story as follows:

Olga, I saw your article today. I think it was objective but there are some clear disputes to some of the statements and facts presented. Risk of uterine rupture is 0.5 % and of those only a small fraction actually end up as disasters. This risk is similar to the risk of requiring an emergency in any mother having her 1st baby according to the NIH study. I am not sure why someone thinks that over 35 is a risk factor for home birth. Your 2 pro-hospital experts continue to espouse the anti-CPM biased position of ACOG but I do not know where else the USC doctor gets his information. As for Dr. Tuteur, did you actually check out her current credentials or did she just tell you her background? I do not believe she is a Fellow of ACOG nor is she practicing. When was the last time she was actually seeing patients? What do you really know about her? She has her web following but is a provocateur who oftens throws vitriol publically at home birth parents and advocates. I have had many encounters with her and have asked her on several occasions to debate. She has never responded even when asked through an academic intermediary. You quote her as saying "all the existing scientific evidence...that home birth increases the risk of death" but then go on to point out a major study that does not. Also, even if you accept ACOGs conclusion of a 2-3 fold increase risk of neonatal death it is still far less than 1 in 1000! You also point out a single tragic outcome from a homebirth but fail to describe multiple similar tragedies occuring in hospitals despite all that technology and often caused by the interventions that push the uterus and baby beyond normal. After our discussions about these issues I am disappointed that you decided to use an anecdote as something against home birth when clearly these things happen in hospitals as well. Just ask my partner. I know you are limited by the number of words you can write so I do understand your position. I hope you understand mine. Maybe someday you can sponsor a public forum where Drs. Ouzounian and I can debate. All the best to you, Dr. Fischbein

I think the recent increase in stories and publicity about home birth is a sign that the public interest is rising. Watch for those opposed to raise the canard of safety and push back with fear based rhetoric. Dr.F

On Informed Consent by Dr. Fogelson

Another good essay by my friend and colleague, Nick Fogelson, MD on the pitfalls of the current surgical informed consent process. I encourage you to check it out at:

http://academicobgyn.com/2011/06/20/on-the-surgical-consent-process/#comment-2850

Bottom line: Doctors and patients should maintain a good professional relationship which, much to the chagrine of the "boundary" fanatics, must cross into the realm of personal insomuch as trust and nurturing and a sense that there is real caring are the best legal protection against an unforseen outcome. As you know, I believe that the continued march toward shift medicine, hospitalists and electronic medicine will only magnify the inevitable errors that will occur and there will be no face of responsibility. Sadly, the "impersonal" model is a much better formula for patient dissatisfaction and inevitable law suit. Until some miracle happens I will continue to preach the path to government endorsed managed healthcare is bad for patients and health care providers but good for lawyers. I do hope I am wrong. Dr. F

HBAC in Water

June 16, 2011: Her first birth story was a nightmare filled with fear, unprofessionalism and coldness that is one I hear all to often. Ending in an "emergency" c/section in the pushing phase with little humanity or respect for family wishes was not what this woman had envisioned. What a difference from the events of today. Desirous of a nurturing environment for her VBAC and with a trust in the process that comes from education and faith, this marvelous woman delivered at home in water in her own living room held and surrounded by husband, family and the Birthing Instincts birth team.
www.birthinginstincts.com

There is another way to give birth that respects both woman and process. Individual demand is the catalyst that will lead to a change in the system. It has to be. Congratulations to all who witnessed this blessed event. It was an honor to be accepted as a part of your family. Dr. F

SOGC Understands

In celebration of the International Day of the Midwife on May 4th, 2011, the Society of Obstetrics & Gynecology of Canada (SOGC) has put out a news release calling for more collaborative care for pregnant women. The president of SOGC has this to say:

“The SOGC acknowledges that it is the mother’s decision to decide where she would like to give birth,” stated Dr. André Lalonde, executive vice-president of the SOGC. “Most babies are born without serious complications. As ob/gyns, our specialized training allows us to address the unique requirements of high-risk situations. What matters is that all professions acknowledge each other’s competencies and work together to provide mother and baby with the quality care they need, when they need it, where they want it.”

See the entire press release at:

http://www.sogc.org/documents/medInternationalDayOfTheMidwifeENG110504%20(2).pdf

Long Distance VBAC

On June 4th, just after sunrise, I was honored to particpate in the birth of a beautiful baby boy to a delighted couple who traveled down from Oregon to have their baby at the Sanctuary Birth Suite. Mom had a c/section with her first child and when it was difficult to bring the baby through a low transverse incision her physician had to "T" the incision to accomplish the delivery. Because of this incision her operative report stated that a repeat c/section should be recommended. She had a midwife in Oregon but could find no doctor willing to back up her desire for a VBAC. The couple researched her options and found me through the internet. After corresponding for a bit they decided to travel down and meet the team. We all hit it off and upon reviewing the records I did not see a reason she should be forced to have a repeat c/section and felt an attempt at VBAC was reasonable. In my training we often allowed women with low vertical c/sections to have a trial of labor with good success. This is not the same as a classical c/section. At 36 weeks she moved the family down to Los Angeles and just 2 days after her due date went into labor. Less than 12 hours later she gave birth to an 8 pound, 7 ounce baby brother.

We were honored that she chose to educate herself in the risks and benefits of all her birth options. This is a right that belongs to all pregnant women. That there was no one she could find in the entire state of Oregon to support her is tragic. This is a trend that I hope can be reversed by truth and example and loud word of mouth. Dr. F

You must watch this!

Andrew Laming, MP attacks Labor's sneaky attempt to snuff out home births in Australia. The liberal party in Australia wants to outlaw home birth. Yes, the liberal party. The one that favors abortion rights but decries home birth rights. Three cheers for Mr. Laming who makes a compelling argument for choice.

http://www.youtube.com/watch?v=zNJA4k-2OkI&feature=share

How headlines are often deceiving!

In the April 2011 edition of the American Journal of OB/GYN Dr. Wax responds to many of his critics in the letters to the editor section. Hope you can find it at www.AJOG.org

My comments to this were part of a conversation I had with my colleague Nick Fogelson in South Carolina and were as follows:

So much to say but will summarize. Everyone has bias. I do feel comfortable, however, with Wax's contention that he had none when setting out to do his study. His last point, that most criticism comes from birth choice advocates, is a bit silly as not much criticism would be expected from hospital birth advocates in a paper that is not critical of hospital births. That Wax concludes there is an increased risk of neonatal mortality of 1 in 1,333 in home vs. hospital birthing does not seem worthy of all the hullabaloo. Most people would not consider this number to be a reason to or not to have a home birth. So, even if we were to accept his paper as flawless, is this number so substantial as to base an entire ACOG committee opinion on? Not being adept in statistics I cannot comment on the science of his calculations. But if we give Wax credit for being truthful we do have to put some credence in the knowledge and science of those authors of some of the papers he uses who disagree with him as well.
When a headline says a 2-3 fold increase in neonatal death it looks scary. When you see the increased risk is really less than 1 in 1000 its not so bad to many. when I counsel patients on interpreting statistics I often use the example of disease X. Say it has a frequency of 1:1,000,000 last year and this year there were 2 cases or 1:500.000. Both very small numbers. However, advocates for funding of research into disease X can say the rate doubled. Very misleading.
Do you agree that the increased risk is still very small and, if so, why do you think organized medicine is so vehemently against informed choice? The risk of c/section in hospitals surpasses 1 in 3 and yet does not draw close to this much finger pointing from ACOG.

I thought it very important to point out the manipulation of statistics by ACOG to make a point and another way to look at the numbers it deems so impressive in its argument against home birth. Lies, damn lies and statistics! Dr. F

Board Recertification Abuse

When the chains of bureaucracy obstruct the physician’s ability

to care for patients appropriately, the physician has an ethical duty to

discard the chains and escape, to be free to practice according to the

physician’s best clinical judgment, as opposed to the substituted

judgment and whims of arrogant bureaucrats.

Lawrence R. Huntoon, M.D., Ph.D.

The American Association of Physicians & Surgeons has taken a stand on the ridiculous burden of annual Board recertification. The onerous and tedious requirement of annual board certification is without evidence to support its efficacy. It has long gone past the goal of quality maintenance and taken on the life of a self sustaining monster with the apparent self-interest of monetary gain and power. Here are some comments by my longtime associate and friend, Howard Mandel, MD FACOG as well as Dr. L.R. Huntoon that expose another view of annual MOC (Maintenance of Certification).

Dear Dr. Huntoon:

I thank the editors of the Journal of American Physicians and Surgeons for their publication of Dr. Dubravic's insightful article regarding board certification and recertification. As an obstetrician/gynecologist who finished my residency in 1985, I was required to take my boards and earned a 10 year certificate. If I would have graduated in 1984, I would have been boarded for life. The ABOG, requires a two part exam, the first written and the second a three hour oral examination, part of which is based on the first entire list of all the physician's hospitalized patients plus a significant number of representative outpatient visits. I passed both examinations the first time and was reboarded 10 years later. Since that time, my speciality board has changed the requirements to six years and now a yearly exam as well as the MOC. In Los Angeles where I practice, we have observed the erosion of younger physicians partaking in our local speciality meetings. The LA OB/Gyn Society is a skeleton of what it once was. The LA OB/GYN Annual Assembly, which was once world renown, with upwards of 700 participants attending, barely has 150 attendees, many of which are retirees. I hypothesize that the numerous hours and costs required to maintain our certification have added to the demise of these once impressive meetings and organizations. Another unfortunate outcome is the destruction of the collegial relationships developed by OB/GYNs in our region. I would scientifically study my theory, yet I am too busy preparing for yet another annual examination. Perhaps, the ABMS or any of the individual sub specialities can spend some of their resources on why comradery, collegiality and membership in local organized medicine has plummeted since the introduction of reboarding.

Respectfully,
Howard C. Mandel M.D., FACOG
10309 Santa Monica Boulevard
Los Angeles, California 90025
310-556-1427

And another message from Dr Huntoon, The Editor-in chief of the Journal of American Physicians & Surgeons:


Subject: Re: MOC article from the Journal of American Physicians and Surgeons

This is not unlike what happened with the AMA.

When the AMA made the "secret" agreement with the
government for exclusive use of the CPT coding system (in 1983),
the AMA made a huge leap in the direction of no longer being
financially dependent on membership dues for survival.

Once an organization gets in a position of no longer depending
on membership dues for survival, they are no longer accountable
to the membership and the needs of the membership.

In the current MOC environment, our specialty organizations see the
potential for huge windfall profits as the specialty organizations will be providing
the CME and practice evaluation tools needed to comply with MOC.
Once the specialty organizations start down this road, there will be no turning back.
The specialty organizations, like the AMA, will no longer be dependent on membership
dues for survival and accountability to the membership will be severely eroded or lost.

The leadership of specialty organizations, many of whom are in academic medicine and
who may see a significant financial benefit by providing compliant CME/evaluation tools,
are not likely going to lobby to stop this trend.

It is likely that the grassroots membership is the only hope for stopping it.
Alas, physician apathy and reluctance to "get involved" or "speak out against"
the trend are significant barriers to overcome.

Those who believe in exerting ever increasing control over medicine (like implementing
onerous MOC and MOL requirements), fail to appreciate the adverse consequences
of their actions.

A significant percentage of physicians in this country are over the age of 55.
As physicians get closer to retirement, many will simply refuse to jump through
all of the nonsensical, non-evidence-based bureaucratic hoops, just to remain in
practice in an environment where they can be expected to be paid less and less
which each passing year. They will retire or do something else.
The shortage of physicians, which will occur, cannot be replaced over night.
Many patients will suffer with increased waiting times and decreased access to care.
The MOC/MOL bureaucrats who engineered this debacle cannot provide the care.

Ultimately, we need to educate patients about these predictable adverse consequences
of MOC/MOL.

As a start, feel free to copy the articles our journal has published on MOC and
place them in your waiting rooms for patients and distribute them to your colleagues.
AAPS has published a White Paper on our recertification survey. You can find all of the
articles we have published by searching the Cumulative Index on our website under the terms
"maintenance of certification" and "maintenance of licensure."
Our journal website is www.jpands.org
And, as I have said before, we would be happy to accept more commentaries
on this topic.

L.R. Huntoon, M.D., Ph.D., F.A.A.N.
Editor-in-Chief
Journal of American Physicians and Surgeons
Editor@jpands.org

Welcome Taj

For those in the obstetric profession who have not experienced the joy and peace and marvel of a home birth, whatever their reason may be, I would suggest they stop and think a second time. Last evening Karni and I were once again privileged to assist in the home birth of baby Taj and the rebirth of a woman and her family unit. That is all there is to say. Home birth is filled with wonderful stories that never make a headline and yesterday was one of those moments. There is so much more to giving birth than just giving birth and the home environment absolutely enhances the experience for informed women who freely choose that option. There is room in the birthing debate for more open mindedness and a respect for the process. Congratulations to Amara & Mike and thank you for the privilege. Dr. F

Panel discussion at Bini Birth on June 1st, 2011

Check out what Bini Birth and Ana Paula Markel are up to on June 1st. After an all day workshop with Naoli Vinaver there will be a panel discussion with Naoli, Dr. Elliot Berlin, Dr. Suzanne Gilbert-Lenz, Davi Kaur Khalsa and me on Breech and Other Variations of Normal. June 1st from 7-9 PM at Bini Birth, 5355 Cartwright Ave, Unit 313, North Hollywood, CA 91601. Hope to see you there.

http://us2.campaign-archive1.com/?u=d2f5c0d977688cdd08f0b431c&id=96a87fdf44&e=3f8f30c19b

Another sign of the times.

I had the great fortune to attend my stepson's graduation ceremony from NYU Film School this past Wednesday in New York City. A time honored tradition that the NYU faculty did a fantastic job with. About 35,000 people attended the ceremonies at Yankee Stadium and mother nature was kind as we had dry skies in an otherwise rainy week. Even the sun poked out for a moment while former President Bill Clinton gave the keynote speech to the graduates and happy families. Then each college dean recognized their respective graduating class. What was most telling for me was that the NYU Law School graduated 1020 new lawyers while the Medical School produced only 178 physicians. Almost a 6:1 ratio of lawyers to doctors. Shouldn't it be the other way around?

A sad statistic on an otherwise glorious day.

More on Breech and Informed Consent

http://www.breechbirth.org.uk/birthchoices.html


For those interested, the Royal College of Obstetrics & Gynecology has put out revised parameters supporting an option of vaginal breech delivery. Based on research that debunked a lot of the information in the earlier Term Breech Trial that organized medicine originally jumped on to recommend c/section for all breeches. The RCOG is way ahead of ACOG in the strength of their statement and the commitment to try to reeducate practitoners in the art of breech delivery. If you are breech or have a client who is breech at 35-36 weeks this would be an excellent educational, calm reasonable website to refer to families who want to know more. Might keep them from surfing the interent in unfiltered and sometimes hysterical sites.

When considering a home breech delivery, as that may be the only option left in many areas, it is important to give true informed consent. The most significant difference in a home birth with a skilled practitioner is the lack of ability to use Piper forceps for my midwife colleagues since this is out of their scope of practice. Trained physicians can use these helpful aids and I carry them in my birth supplies. Once again, showing the collaborative approach of midwife and doctor teaming up can provide optimal care. Of course, we all know how few doctors there are willing to collaborate with the midwife community and the pressure those few are under from their peers. Also, the diminishing number of doctors skilled in breech delivery is concerning. Lastly, home birthing also lacks the immediate availability of general anesthesia in the extremely rare case where complete uterine relaxation is necessary to assist in delivery of an entrapped head. Women need to know these things but they must be presented in the light of the reality that the likelihood of this frightening problem is extremely rare when proper selection criteria labor management for breech delivery are used. In my opinion, the risks of a complication that is life threatening is more common from a surgical birth and these should be discussed as well. Then, whatever decision is accepted by the family should be respected. Where vaginal breech delivery is the preference but not an option, an ethical practitioner should refer that patient to someone who can honor her request.

From the AMA's Code of Ethics:
The patient should make his or her own determination on treatment. The physician's obligation is to present the medical facts accurately to the patient ... and to make recommendations for management in accordance with good medical practice ... Rational, informed patients should not be expected to act uniformly, even under similar circumstances, in agreeing to or refusing treatment

Dr. F

Bad news has decibels.

There is a lot of buzz when a homebirth goes awry. No one should relish in the misfortune of another. Bad things happen in birth sometimes. No matter what the location. Yet there does seem to be some piling on when a homebirth is involved. Below are a couple of links to stories or blogs in the aftermath of a midwife who pled guilty to two felonies in a home breech delivery case in Maryland. I added my thoughts to the comments section on both of them. Dr. F


http://abcnews.go.com/Health/midwife-karen-carr-pleads-guilty-felonies-babys-death/story?id=13583237

http://blogs.babble.com/being-pregnant/2011/05/12/take-back-the-night-mentality-not-so-much/

Tragic ending to a tragic story.

Not much I can add to this well written story in Slate. I thought the writer did an excellent job of reporting on this sad tale. Please read and comment here. Thanks, Dr. F

http://www.slate.com/id/2293389/pagenum/all/#p2

What is.....Breech delivery at home?

If I were playing Jeopardy and the answer was: "The only option left in SoCal to a woman whose baby is butt first", the question would be.......(see title).

Proud to announce the delivery of little Andrew this morning, bruised bottom and all, to excited first time parents, Eva & Jared. When faced with no other option but forced, not elective, cesarean section they chose, instead, the unlikely option of a home breech delivery. Informed of options, risks and benefits and knowing they would like to have many children they felt that c/section was a bad choice for them. Hospital vaginal birth with the one doctor who still accepts primip breeches was financially nonviable due the limitations of their HMO policy. The Sanctuary Birth and Family Wellness Center midwives and I were delighted to help this couple achieve their goal in the comfort and privacy of their own bedroom. Using the skills I learned in training and adhering to specific guidelines for the safety of breech vaginal birth made this choice possible. Respecting the right of true informed consent and all birth options made it a wonderful day for all involved. Thanks Molly and Heather Anne. Dr. F

First Tranport

5/07/2011: Birthing at home can be a miracle and a blessing. On rare occasions even the best laid plans can fall short. Sometimes exhaustion sets in when too little sleep and nourishment occur over the course of a 29 hour labor. After 9 months of assisting in home birthing I finally had my first need to transport a family in labor. Thank God for backup physicians like Dr. David Kline and the judicious use of epidurals and pitocin. They do have their place. With his patience and skill a beautiful baby girl was born vaginally early Saturday morning. Mom, dad and baby were home again inless than 6 hours. This family was delighted and had the satisfaction of knowing that these interventions were necessary and what was needed by their sweet baby girl to enter this world.

Happy mother's day to them and to all of you. Big hugs all around. Relish in them as there is an emptiness when your mother is no longer with you to hold.

As for me, this was a watershed moment. It was the first time I can recall in my 25 years in private practice that I had to relinquish the care of a woman to another colleague. This felt very strange for me as I am a healthy bit obsessive about completing tasks to which I have committed. I have shared this feeling with some of my midwife colleagues today and want to thank them for their awesome support. A big hug to my friend and colleague for 29 years, Dr. David Kline, too. Thanks, Dave.
Dr. F

Only 2 state-licensed birthing centers in Central Indiana close

Citing problems with insurance coverage and insurers reluctance to pay for birthing center births despite the savings of about 50% from the cost of a hospital birth these 2 centers were forced to close. The midwife running the 2 centers, Barbara Bechtel, also stated that the insurers demanded an obstetrician be her backup rather than the family medicine doctor she had been relying on. She could not find cooperation from the local obstetric community and so this option for mothers is no longer available. There was no mention of problems with bad outcomes to justify the noncooperation. But is it hard to figure out why? See the full article at the link below. Dr. F



http://www.indystar.com/article/20110430/LOCAL1804/104300333/Only-2-state-licensed-birthing-centers-Central-Indiana-close?odyssey=nav%7Chead

Ethics in the eyes of the beholder!

In this months Green Journal, the ACOG publication, were 3 articles concerning the ethics of home birth. If anyone is interested in reading them please send me your email and I can send them to you. They are proprietary and password protected and cannot be linked here. One nearly brought me to tears called "An Obstetrician's Lament". The writer eloquently painted a picture of a somewhat professionally self inflicted dilemma. One took an honest look at relative vs. absolute risk and true informed consent. The third, surprisingly, upset me more than I thought. Dogmatically labeling obstetricians who participate in home birth as lacking integrity and suggesting that educated patients who refuse hospital birth should be given "respectful persuasion". In response to this article I wrote the following letter to the president of ACOG.

Dear Dr. Waldman, I just was reading the articles in this months Green Journal and came across one in particular that I found very troubling. I think you know that I am an advocate for true, not skewed, informed consent and a supporter of midwives and the option of out of hospital birthing for well informed low risk women. Dr. Chervenak and colleagues in an article titled, "Obstetric Ethics" seems to continue the College's selective bias against home birth and those who support it.

In the abstract he says this," ...Obstetricians have an ethical obligation to disclose the increased risks of perinatal and neonatal mortality and morbidity from planned home birth in the context of American healthcare and should recommend against it. Obstetricians should recommend hospital-based delivery and respond to refusal of these recommendations with "respectful persuasion". As a matter of beneficence-based professional integrity, obstetricians should not participate in planned home birth."

As my president I have to ask you if you believe this statement to be true.

As for myself, I find so much wrong with this in the context of known hospital based risks which the college does not seem as eager to recommend disclosure of. Also, the restrictions on choice occuring because of ACOG opinions and the legal and economic climate in which hospital policies restricting those choices are made. I find it repulsive that the authors, and I suspect the editors of the journal, condone respectful persuasion which seems to be just another nicer name for skewing informed consent. Am I and other obstetricians who support patients who desire an out of hospital birth acting without integrity and unethically as Dr. Chervenak proposes?

The demand by a better educated populace for a say in how and where they give birth is coming. The current trend in c/section statistics and interventions do not speak well for the medical model in low risk birth when compared to the midwifery model of pregnancy as wellness not illness. The obstetric profession is not preparing its doctors in training in the art of medicine any longer. Skills of breech birth, forcep and vacuum deliveries and twin vaginal birthing have disappeared from the training programs under our watch. Fear has replaced trust in that most natural of life's events. The authors and ACOG are running with a strawman argument that home birth is unsafe and building upon that questionable foundation. There is far more evidence based medicine that supports the safety of selective home birth. Certainly enough that should give pause to reasonable people labeling those that have a different view as unethical or lacking in professional integrity.

I am very concerned that we now have articles endorsed by our college that dogmatically define ethics and integrity to fit their definitions of what normal pregnancy should look like. Personally, I resent the implication. Just as the authors seem certain they know what is better for individual patients and have taken it upon themselves to label those who differ unethical, I am certain their hubris and possibly well-meaning paternalistic views are a violation of our oath and mission statement.

Again, as my president, I need to know if you agree with the finality of Dr. Chervenak's definitive statement.

Sincerely, Stuart J. Fischbein, MD

Kim Rivers responds to PV midwife ban

Thanks to Kim Rivers for writing a response the the Ventura County Star article on the midwife ban at Pleasant Valley hospital. And congratulations to Kim on getting the Star to post her op-ed piece in yesterday's edition. You can find her article at:

http://www.vcstar.com/news/2011/apr/25/rivers-why-are-midwives-being-targeted/

I encourage you to read and comment. It is a rare chance for small voices to be heard. Dr. F

Another Home VBAC

Why do babies so often come in the wee hours of the morning? Does seem disproportionate but makes the driving easier. I had the privilege of assisting a wonderful couple with their HBAC this morning in their bedroom in Santa Barbara. Well informed and also aware of the hostility towards VBAC in their local hospital they made a choice to birth at home. From the spontaneous rupture of membranes to the birth of the beautiful little boy took only 4 1/2 hours. Assisted by dad with grandparents hovering about we welcomed Lucas's little brother Matias Esteban into the world. Dr. F

I guess "When" is this Monday

The Headline in the Ventura County Star reads:

Midwife restrictions at St. John's Pleasant Valley Hospital will be lifted next week

http://www.vcstar.com/news/2011/apr/18/midwife-restrictions-will-be-lifted-next-week/

While good news is always nice to pass along, midwife Lynn Olson says it best. This (ban) should never have happened in the first place. So 14 months after they were inexplicably removed to the canard of "safety issues" per the former CEO, midwives are set to return on Monday. Oddly, seems that Lynn and Joyce, the only 2 CNMs working there, need to be recredentialed. Sort of unusual since they have maintained their credentials at the sister hospital, St Johns, all this time. This would seem to be a new policy or legal barrier placed on them and only them as it has always been that credentialing at one of the 2 campuses gave you privileges at both. Lastly, the administration has supposedly used these 14 months to create new policies to ensure safety of midwife patients. Yet they do not detail what those policies are nor why doctors working there throughout the midwife ban could function without them. I have the belief that these decisons will someday be looked at under a microscope and those most involved held responsible for their unrepentant and inexplicable actions against these devoted CNMs. For now, good news for the women of Camarillo. Dr F

Where we are likely headed....

Jason Fodeman, MD wrote an article on Townhall.com today that is worthy of mention. It is titled: "The New Heath Law: Bad for Doctors, Awful for Patients". You can find it at:

http://townhall.com/columnists/jasonfodeman/2011/04/16/the_new_health_law_bad_for_doctors,_awful_for_patients

The article is taken from a White Paper analyzing the PPACA (better known as ObamaCare) authored by Dr. Fodeman for the Galen Insitute. It is certainly worth reading no matter where you fall in the debate. I happen to agree with him and am not optimistic about the long term health of our health care system. Please take the time to read the full link below.

http://www.galen.org/fileuploads/NewHealthLaw_BadForDoctors_AwfulForPatients.pdf

Thanks, Dr. F

Text of Dr. F's 2011 Tax Day Rally Speech

For the second year in a row I was asked to speak at the Tax Day Tea Party Rally at the Thousand Oaks post office. This is the text of my address:

I have been asked to give a practicing doctor’s perspective on what is happening to our health care system.

I would like to begin by telling a brief parable about the farmer and his horse:

The Farmer & His Horse

There once was a farmer who had a beautiful farm and a devoted horse. The horse worked long hours, never complained and loved his work. Twice a day the farmer would feed the horse and all was right in the world.

But then the farming business went into a slump and the farmer asked the horse to work longer days and plow more fields just to make ends meet. The horse never complained and loved his work. Once a day the farmer would feed the horse and all was still ok in the world.

Soon the farmer was told that the cost of hay was increasing. There were no more hours left in the day to work harder to pay the increasing costs. So he decided he would just feed the horse a little less hay each day. The horse never complained about his hunger, did his work as best he could but the world was not so good anymore.

This went on for some time. The farmer continued to work his horse really hard, had to lay off his workers and spend less on hay for his horse in order to keep his farm running. The farmer noticed his fields were looking a bit shabby. His harvest was the worst he ever had. He was baffled. Why was this happening?

Finally, he woke one morning before dawn. Dragged himself out to the barn and there was his devoted horse, lying in his stall. Starved to death!

Medical professionals and the patients they serve cannot be squeezed indefinitely. Like the poor farmer and his horse, the story will not end well.

Healthcare is not an inanimate commodity to be treated and bartered like oil or water or even hay, for that matter. It is us! And each and every one is unique.

Centralization is a bad idea and a terrible one for medicine.
What we will see as government and insurance companies continue to micromanage our lives are mandates based on ideological, nanny state one size fits all ideals. You will begin to see laws and commercials and public service announcements, paid for by government stimulus money, really, our tax dollars, which entice you by reward or punishment to follow their advice. Advice based most often on emotion and not science. You will see more brainwashing type curriculum in public schools with the purpose of indoctrinating our children early on towards the “correct” way to think.

Really, this extends far beyond just the healthcare law. What we have now unleashed in our country is a hostage situation to the American legal system. Whether it’s the local restaurateur, the small businessman, the ski resort, your family doctor or your local hospital or school we are all intimidated by a lack of restraint on our legal tort system. Quite frankly, my biased opinion thinks that the biggest obstacle to American values and common sense returning to us is the American civil legal system which promotes victimhood and extortion. If any industry was in need of reform it is that one. Where are the future leaders who are willing to take on the trial lawyers? Now that would show real bravery. Dennis Prager has rightly labeled ObamaCare, “The trial lawyers of America stimulus package”.

Recently, a midwife friendly hospital serving the needy in Greenwich Village closed its doors due to its inability to stay financially solvent while trying to comply with all the mandates, regulations and legal protections required. Many doctors are already at the point where they cannot afford malpractice insurance or continue to take on more patients for ever decreasing reimbursement. As costs inevitably go up reimbursement to providers will be decreased or care will be rationed. MediCal and medicare patients are going to find it harder to make appointments and are going to be waiting longer. Lowering reimbursement further will just devalue the doctor-patient relationship. It will push small community hospitals out of business, as it has in Greenwich Village, and lead to rationing by default. How much more work can you squeeze from a starving horse. Most doctors love our profession but hate what the business of medicine has become.

As for my practice: Carolyn asks whether I would consider giving it up and retiring early. The question is actually can I afford to keep going? This year I will turn 55. I love my work. I could continue to practice for another 20 years. The real question is “Would I be a fool for doing so”? Not only will doctors able to quit consider doing so but who in their right mind will become the future doctors in our country. Years of training and sacrifice of social life lead to a loss of a decade of fun and earning power and massive debt. Only to come out and see your expenses rising and uncontrolled but your earning power capped and regulated. The devastating threat of a career ending law suit hanging over your head like the sword of Damocles is no way to live. Having the authorization for a test or procedure denied by some non-medically trained faceless cubicle worker who can’t spell the diagnosis is maddening to those of us who care. Your medical decisions weighed and scrutinized by faceless utilization review boards, government agencies and hospital committees. None of whom will ever bother to get to know the patient you are advocating for. How many of you would want to live like this? How many of you want your children to live like this?

And I have yet to mention the looming specter of Electronic Medical Records coming by 2014. Every detail of your medical history and that of your children will be mandated to be online for bean counters of all shapes and motivations to see. Do you trust that it will remain confidential and used wisely? I don’t! And there will be a large cost of installing the hardware and mandated annual updates that will not be reimbursable to the practitioner. Adding another undo burden on the small, independent practice of doctor, midwife, chiropractor and therapist. Another not so subtle hammer to force solo doctors like me out of business or submit to joining large impersonal multispecialty groups where the individuality and art of medicine I love will disappear.

Solving this will be a complicated process. Remember, healthcare is not the problem. We have the best in the world. It is more accurate to call this dilemma a problem of healthcare access. I know it sounds radical and probably too late but I don't believe the government has any business being in the business of health care. Evidence based medicine is a simple premise that supposes that medical decisions are based on scientifically proven studies What is most scary to me in an era where we are supposed to rely on evidenced based medicine is this. All these regulations that are being instituted and forced upon us have never, I repeat, never been studied to show that they have actually improved healthcare delivery and outcomes. If anything, other countries that have tried this are backing away from it. These edicts are being rammed down out throats with no science to back them up. They are theoretical only, and the motivation is financial and control, not betterment of health and not individualized care. The canard that is always used is "safety". Albert Camus, the French philosopher, said, "The welfare of humanity is always the alibi of tyrants."

How can the Tea Party help? In my perfect world, first, repeal Obama-care entirely and end the fraud that has been played on America. Then insist on tort reform and insurance reform and demand our elected leaders “Read the Bills”! Stop having insurance companies, lawyers, politicians and hospital administrators dictate medical decision making that belongs by right to patients and their practitioners. Also, encourage states that limit competition from allied health professionals such as midwives, naturopaths and alternative medical practitioners to lessen their restrictions on these caring men and women. Leave pharmaceutical companies alone. They are not the villain. And reign in the FDA and its draconian restrictions on new drug development and patient choice. Let the free market loose and trust the educated consumer to make their own life decisions and accept the consequences of those decisions.

Most doctors are excellent caring professionals. Go after fraud and bad doctors but do not lump us all together. Do not micromanage all of us who mostly want to do good work for those we serve. Confident knowledgeable people do not need micromanagement. I would like to know that when I am sick I am being cared for by someone who is a leader and not a follower.


So, we have come to a place where we have to decide who we trust. No longer can we be passive when it comes to something as important as our family’s health care. We have to take a stand. I trust the relationship I have with my personal physician. I trust my ability to judge him by his actions. I trust that she has my welfare as her primary concern. I encourage you all to educate yourselves and ask questions. You have the right to be truly informed. I trust that if he does not serve me well I can go someplace else. I do not trust big government or big business to have my back. I do not trust the nanny state to make decisions that are in my family’s best interest. I will do that and I want a country that allows me the freedom to succeed or fail. One size does not fit all. We must get away from that mentality. The best and the brightest should be going into noble professions like medicine. Sadly, unless we continue to elect leaders who repeal this horrible health care legislation, medicine will no longer remain an appealing avocation and the best and brightest will seek other interests. Possibly wasting their talents as lawyers or government workers because that’s where the money and lifestyle remain.

Finally, the government should not have the right to take my hard earned skills and demand of me to give them away for what they determine they are worth. I am not a horse to be fed ever decreasing amounts of hay. And, I never dreamed I would be before you all today making empassioned speeches. All I wanted to do was to practice my profession as I was trained to do and love my family. I am lucky. I have the good fortune of collaborating with midwives and the honor of assisting families who desire home birthing. Working outside many of the pressures and restrictions I have discussed today. But, I cannot sit idly by and watch this happen to the profession I love. I want my children to know that their dad stood up for self determination and personal responsibility.

Royal College of Ob/Gyn Supports Delayed Cord Clamping

The RCOG recommends that the time at which the cord is clamped should be recorded. Early cord clamping is defined as immediately or within the first 30 seconds. The cord should not be clamped earlier than is necessary, based on the clinical assessment of the situation. Evidence suggests that delayed cord clamping (more than 30 seconds) may benefit the neonate in reducing anaemia and particularly the preterm neonate, by allowing time for transfusion of placental blood to the new born infant which can provide an additional 30% blood volume. In the preterm infant (less than 37 +0 weeks) this may reduce the need for transfusion and reduce intraventricular haemorrhage. Delayed cord clamping does not appear to increase the risk of PPH. The timing of cord clamping needs to be made by the doctor or other attendant in the light of the clinical situation. Early clamping may be required if there is postpartum haemorrhage, placenta or vasa praevia, there is a tight nuchal cord, or the baby is asphyxiated and requires immediate resuscitation

. April 2011

The International Federation of Obstetrics and Gynecology and the World Health Organization no longer recommend immediate cord clamping as a component of active management. Dr. F

HBAC in Water

Spreading the word and announcing another beautiful home birth in water this past week. I was honored to attend the home birth after c/section of a wonderful family in Simi Valley. In a county that for all intents and purposes has banned the choice of vaginal birth after a c/section in the hospital I am happy to offer this option to families in the comfort of their own home. I will continue to advocate for reason and the respect for choices in childbirth that belongs to mothers.
Dr. F

ACOG silence remains deafening

MEDSCAPE: Planned Home vs Hospital Birth: A Meta-Analysis Gone Wrong: A Flawed Analysis

This is potentially very significant. The authors of the British Columbia and Netherlands home birth studies that were allegedly included in the Wax Paper have published a devastating attack on that study on Medscape:

http://www.medscape.com/viewarticle/739987

Thanks to Susan Jenkins and Linda Bennett for forwarding me this link. My respect goes out to the authors of this rebuttal to the Wax, et al paper. These men and women did the honorable and tedious work of breaking down the data and critically analyzing Wax's methods and conclusions. I forwarded this information to the President of ACOG, Richard Waldman, MD. It is very difficult these days for anyone to admit they made a mistake. There is no shame in doing so, I know, and it is time for ACOG to do the same regarding Committee Opinion #476. Dr. F

Questioning Veracity

After some prodding by me and others, finally, last week the Ventura County Star and writer Tom Kisken finally reported on the status of the longstanding midwife ban at Pleasant Valley Hospital in Camarillo, CA. I found the headline to be misleading, the article to be very milk toast and Mr Kisken's investigative effort into the veracity of the hospital administration to be lax at best. Those that have followed me for the past year and a half know of the issues to which I am referring. Please read and add your comment to the story at:

Midwives ban to be lifted at Camarillo hospital; question is when

http://www.vcstar.com/news/2011/mar/31/midwives-ban-to-be-lifted-at-camarillo-hospital/

I have sent Mr. Kisken the following e-mail after returning home from a fun filled weekend with my daughter and her Westlake High School choir class at the Heritage Music Festival in Anaheim. Hoarse and exhausted from chaperoning 160 kids through the event and long, good days at Disneyland and California Adventure.


Dear Tom, I just read your article is last weeks Star. I found it very disappointing. Once again you failed to get anyone to explain anything. You allowed administration to avoid answering the obvious question. "Why Certified midwives banned and not doctors?" Laurie Eberst was not even here when this happened. What could she possibly know about the truth other than what she had been fed? Where are the quotes from Ann Kelley or Eugene Fussell? If no one is talking doesn't that bother you? You quoted anonymous sources but did not say why anyone would need to remain anonymous here. How about explaining that your sources were reprimanded last time for talking to you? How about some investigative journalism into why anesthesia is and has been obstructing the midwives return? Did you speak with Dr. Kalcic? How can it possibly take more than a year to implement any policy change if they really want to change? Good investigative reporting would have asked those questions and not allowed a non-answer. Also, since I was a major part of their reasoning for the ban, why not approach me for information? Was not I the one who gave you the "push" in the first place? And what is that headline supposed to mean? It seemed almost tongue in cheek and very inappropriate. Was that story really your best work?

Sincerely, Stuart Fischbein, MD

I will patiently await his reponse and happily report any error in my facts should he wish to clarify. My colleague, Kim Rivers, has written a letter to the editor in reponse to the article. With her permission, I will post it if the Star refuses to.
Dr.F

Confirmation of ACOG damage

For the umpteenth time since release of ACOG's Committee Opinion #476 I have seen the propagation of its misinformation. I use Google Alerts to help me review stories around the world on home birth. In story after story having to do with this subject, other "experts", reporters and sources quote its conclusions of a 3-fold increase in neonatal death blindly and as definitive fact. Funny, how it is almost verbatim and the virtues of home birth quoted by ACOG are never equally extolled. I can only assume it is because an organization such as ACOG has a built in gravitas that writers will rely solely on its statement without doing any further research. I have spoken about this to ACOG leaders as a consequence of its standing in the medical community. With great power comes great responsibility. ACOG and Dr. Wax have much to answer for but almost certainly will not.

So, for the umpteenth time I have written to to the writer or posted a thought in the comment section to at least give another perspective. I encourage readers to take a moment to respectfully do the same when they come across a reporter quoting an expert who categorically uses the "3-fold" line. Dr. F

Here is what I wrote this morning in repsonse to an article in The Herald, an Australian newspaper:

Dear Ms. Hadfield, For the record, Dr. Andrew Pence is quoting data that is well known to be incorrect. It is from one flawed study by a researcher named Wax who cherry picked his meta-analysis data to reach his conclusion on the perils of home birth. Dr. Wax's motives for doing so are unclear. The truth is far different. He excluded the largest studies from North America and the Netherlands which showed no such risk and, in fact, in comparable low risk patients showed far less intervention and c/section rates and greater satisfaction in women who had home births. Dr. Pence makes a common mistake in relying on data that is supportive of the established medical position rather than looking critically as a scientist should. Then relaying this misinformation as if it is undisputed fact. Reporters often go to academic sources with a blind trust that they are objective and their advice is evidenced based. Sadly, neither is often true. Home birth in low risk women is a safe alternative and a choice that belongs to them when given true, not skewed, informed consent. I would be happy to discuss this further if you are interested. Warmest regards, Dr. Stuart Fischbein, MD FACOG

Stand & Deliver Offers Breech Skills Workshop

www.rixafreeze.com/pdf/breechflyer.pdf.

I received this e-mail from my colleague, Rixa Freeze, of the great web site Stand & Deliver. Please pass on this info to anyone you know who might be interested in learning or relearning these skills. Good stuff! Dr. F

Hi Dr. Fischbein,

I am thrilled to announce a vaginal breech skills workshop coming to Indianapolis this July! Participants will perform and observe simulated vaginal breech deliveries with Canadian obstetrician J. Peter O'Neill and learn upright (hands & knees) breech techniques from Canadian midwife Betty-Anne Daviss. She will also be giving a free public lecture about upright breech birth on Saturday, July 16th.

I have attached the flyer & registration form (PDF). You may also access it at www.rixafreeze.com/pdf/breechflyer.pdf.

Please circulate this to other physicians or midwives who might be interested in updating their vaginal breech skills. Don't forget to take advantage of the early registration discount before April 15th.

I hope to see you there!

Rixa Freeze, PhD

Rainy Day Philosophy

Living in Southern California has many advantages. One is the absence of snow days and another is the rarity of rainy days. Life slows down for me on a rainy Sunday morning. No place to run to. Horseback riding cancelled. Cat asleep at my feet. The sound of the wind and rain on the roof all cozy in bed with my book momentarily unhooked from the world. It is wonderful to slow down in today’s buzzing world of instantaneous information overload and short attention spans.

Then I open my computer to read the amazing notes of my midwife colleagues at Sanctuary attending 4 separate births in the last 24 hours. Maybe there is something to the super moon thing! They post on the board of the natural progress of labor that comes in so many different forms. With calmness born of wisdom they describe what the families are doing at home. Some resting quietly while others are up walking and talking. Some sit or stand in water while others forage in the kitchen for the perfect nourishment to suit their craving. Fathers and doulas and midwives and apprentices and hypnosis experts and children and pets all are choreographing this dance of life. I was speaking to my great friend and colleague, Heather, in the comfort of The Sanctuary Birth & Family Wellness Center, this past week and the following realization just flowed forth.

I have now attended more than a dozen home births and have noticed many differences from my 28 years of attending hospital births. But none is more striking than how the environment affects the traditions and attitudes of the practitioners. In a hospital based birth the primary care giver is almost always a nurse or possibly a CNM. They are bound by policies and procedures that limit individualization. No matter what the desire of the family dictates there is pressure on the staff to complete forms and data entry. They must document “progress” and even encourage intervention when it does not conform to some standardized norm. To not push the process along can bring the scorn of their supervisor. Nurses are encouraged to monitor all sorts of bodily functions and even the most caring have to deny food and interrupt the primordial place a woman should be for the sake of documentation.

Documenting what and for whom? When and why then? Likely for administrative policy, litigation mitigation for that worst case scenario fear, for the next nurse and doctor coming on in the shift practice model or just one of those long habits of not thinking a thing wrong, thus making it seem right. But that is all the consequence of the dominant trend to look at pregnancy and labor as illness, not wellness.

In this model there is rarely a doctor present until called by the nurse to come in. From experience I think many nurses fear this for woe be unto them for calling the doctor too soon or too late. From my past experience I vividly recall arriving to the labor room from home or office. Invariably, all eyes would now focus on me and I would be expected to do something. Many doctors would feel as if they must do something because they are now there. And so there would be vaginal exams and commands to push when no urge was felt. The nurse would receive orders for pitocin and pressure catheters because labor was not following the curve fast enough. Discomfort is difficult for doctors to observe so the wonders of an epidural would be lauded.

It would almost be inconceivable for the doctor to arrive, sit quietly in the corner observing for a while, whisper a few words of encouragement and then quietly leave the woman and her partner alone. The “I am here now so I must do something” mentality is pervasive. It may be the rescuer in us, the fixer or it could just be an impatience born of long hours, frustration, poor rewards and fear. Whatever the reason it is pervasive and is a startling contrast to the calm, nurturing approach of my experiences with home birth.

When I arrive at a home birth after a gentle knock on the door I quietly enter the space with a whispered greeting to the father or other caregivers. I observe the room, listen to the sounds and look at the faces of those present. There is so much vital information there that no machine can tell me. There is an honoring of the process and the woman in labor is on a pedestal. She is a person not an object. The goal of all those around her is to keep her feeling safe and nurtured and in whatever zone will keep her focused on the primitive, instinctual processes of labor. There is no timetable and no hustle and bustle of disturbances. There are only the sounds of nature and family linking us to all those that came before. We are calmly waiting for another generation to enter the world.

The conversation with Heather clarified what had been just a feeling since joining the home birth community and made it a revelation to me. My midwife colleagues have heard me say that no matter how I am feeling before I enter that sacred space of the nurturing birth world I always leave feeling better then when I came in. That was almost never the case when entering even the parking lot at a hospital. It is a striking difference to enter the world of the laboring woman and not feel like I am obligated or entitled to do something. Trusting birth makes it a better world for everyone involved and returns the joy to my work.

We have all created a safe and cozy space for ourselves. We call it home. On this windy, rainy Sunday there is no place better to be. I am surrounded by familiar sounds, sights and smells and it feels wonderful. It is a metaphor for life and certainly for birth. Building a secure, nurturing support system is good for your life and better for your birth. There is much to be said for returning to the pleasures of sociability and being intentionally unproductive. I would encourage my fellow practitioners to take a deep breath, look about them, walk more slowly and rethink the model which has become so normal and yet so detrimental to the enjoyment of their lives.

Warm Greetings To You All, Dr.F