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

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

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

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

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

Explaining the Cause

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

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

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

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

Tuesday, January 25, 2011

Response to ACOG Committee Opinion #476

The American College of Obstetrics & Gynecology has released a new opinion paper on the "dangers" of home birth and the questionable qualifications of those that attend them. Just writing these words leaves me speechless....or keyboard frozen....or whatever! If you have a chance to get a copy of this document please read it critically. It is proprietary so I cannot copy it here but I have written a letter to ACOG president, Richard Waldman, responding to this embarassing, biased, unscientific and inconsistent opinion piece. (see below)
It has been 2 1/2 years since my first letter to ACOG on the subject of home birth. Sadly, they have learned nothing.

January 22, 2011

Richard N. Waldman, MD, President
The American Congress of Obstetricians and Gynecologists
Department of Executive Board Affairs
409 12th Street, SW
PO Box 96920
Washington, DC 20090-6920

Re: Committee Opinion Number 476

Dear Dr. Waldman,

I am an obstetrician who has collaborated with both certified nurse midwives (CNM) and licensed midwives (LM/CPM) in California for more than 25 years and I am a Fellow of the American College of Obstetrics & Gynecology. I, myself, also attend home deliveries. I use my knowledge and experience to make safe, evidenced based decisions and provide true informed consent to my patients. I feel qualified and obligated to, once again, comment on the position taken by ACOG against home birthing in Committee Opinion #476 and on the data from which it seems to be based. It seems from the very outset to be a document biased against home birth choices and those who provide support for them. This paper prefaces its conclusions with claims to support a woman’s right to make a medically informed decision about her birth path but evidently has an agenda to obstruct that right.

In the text of this paper it clearly states that in every measurable parameter of morbidity, except neonatal death, home birth is superior to hospital birth (page 2, paragraph 1) in comparable low risk women. Yet, in the abstract, this conceded fact is minimized in the words, “Specifically, they should be informed that although the absolute risk may be low…” No, the absolute benefits are, indeed, well documented as every reputable study shows. The college does not recommend informing patients that these are hard facts yet goes out of its way to say that “Specifically, they should be informed that…….planned home birth is associated with a twofold to threefold increased risk of neonatal death...” which is an assumption based on very controversial data.

It seems the College relied heavily on a paper by Joseph R Wax, MD in formulating its opinions. I have written the college before regarding the use of level C evidence (consensus opinion) to dictate policy and recommendations. Those of us who truly support a woman’s right to choose her own path based on true, not skewed, informed consent know the damage that can be done by a legitimate organization like ours when it puts out an opinion. The paper by Wax and colleagues is an extremely flawed article. It has been reviewed extensively by many who express legitimate criticisms. None of which ACOG chooses to address. This study demands a critical reading. The meta-analysis of Wax, et al is the weakest type of data and should never be used as an exclusive measure of a topic. The fact that the authors cherry picked this data, including the use of one tiny study with 11 women, to prove its point while ignoring the largest studies from North America and Europe on planned homebirth demonstrates the clear bias. His paper compares apples to oranges. He goes back 40 years, mixes matched cohorts with prospective cohorts and record reviews, mixes urban and rural statistics and admits to many difficulties in interpreting this information including whether an attendant was even present and excludes many legitimate studies that do not fit his theory. His bias is evident throughout his comment section and it seems his sole negative conclusion, of a higher neonatal death rate, from this flawed study is simply mirrored and emphasized by ACOG in Committee Opinion number 476.

Oddly, it seems that combining data from more than 40 years ago to the present time is accepted for the purpose of denigrating midwives and home birth. Would you be so eager to accept that sort of chronology for a conclusion on hospital obstetric practice? Wasn’t it just 25 years ago that ACOG was pushing VBAC so much that their influence led the insurance industry to mandate trials of labor for every woman? And didn’t that lead to an increase in morbidity for mothers and babies resulting in the more draconian ACOG endorsed (but NIH Consensus Statement of March, 2010 refuted) policies that so many hospitals have now embraced to ban VBAC? Would we consider including all those years of ignorance in formulating a consensus opinion paper today to be good science? Let’s be honest here. Of course not! So why is ACOG wedded to the controversial Wax article? In it he also quotes a transfer rate of 25-37% for nulliparous women. This, with modern day selection protocols, is simply untrue. In my extensive experience as a backup physician I can state it is far closer to 10% and only a tiny fraction of those are for anything close to an emergency.

In the ACOG opinion paper the limitations of any meaningful data interpretation are outlined (page 1, paragraph 2). Yet, it seems this awareness is totally disregarded when one analyzes the language of certainty used against home birth in the text. When facts favor homebirth it is written off as “selection bias”. From my decades in the role of a physician backup to Licensed Midwives here in Southern California I can tell you of the excellence of this group of professionals. These midwives go through an extensive training program and apprenticeship, have ongoing education and regular peer review and do wonderful work. Patient satisfaction from the midwifery model of care is consistently rated higher than from care given under the obstetric model. In California, they are licensed by the State Medical Board. This is the same body that licenses physicians. It is simply wrong and rather malicious to state that for “quality and safety” reasons ACOG does not support care given by licensed midwives or certified professional midwives. They deserve far more respect than our organization grants them. I think you know this.

In a letter I wrote to your predecessor in 2008 I asked for an explanation as to the actual experience with regards to home birthing of those who make up the opinion committee. For it defies common sense to believe that anyone on this panel who has actually spent a lifetime supporting or attending home births could condone this paper. In respectful correspondence with Dr. Ralph Hale I received no answer to my question about that nor about why the College felt obliged to so vehemently pursue or support potential legislation against the informed choice option of about 0.6% of pregnant women. It is not that ACOG puts out an opinion that matters to me. It is that this opinion lacks any foundation of solid evidenced based medicine. Truth is our most important value. ACOG should never lower its standards of excellence in research to accept evidence against home birth, HBAC and selected twin or breech vaginal delivery simply because they may disagree with these choices. And where can a woman turn to when her local hospital bans these options and then defends its position citing ACOG opinions and recommendations?

These sorts of opinion documents are biased and self-serving. Physicians and midwives share the same noble goals. The College’s continuing crusade against home birth only serves to hurt its reputation amongst our colleagues in the midwifery, nursing and alternative medicine professions and damages the confidence of the patients we are avowed to care for. It is divisive, unnecessary and fear based. It is especially so when those positions taken are based on flawed data and the motives for doing so remain unexplained. If it looks suspicious it probably is. The College often hides behind the canard of “safety” in its reasoning. It is a bit arrogant to think that only ACOG considers safety a virtue. Albert Camus said,” The welfare of humanity is always the alibi of tyrants”. Ironically, the modern experience and majority of current literature does not support your safety argument when low risk women choose home birth with qualified professionals. There is so much damage being done to women in the hospital setting through interventions that we know to be harmful all in the name of safety and, yet, there you remain silent. Separating mothers from babies, policies prohibiting VBAC and breech, continuous fetal monitoring, immediate cord clamping and unnecessary inductions of labor are but a few. Cesarean section rates of 35-40% are an abomination and inflicting, as yet, untold physical and emotional damage on an entire generation of women and babies.

ACOG committee opinions such as number 476 are misguided at best and will only further restrict options and choice and lead some low risk pregnant women to forced hospital based birthing and its tendencies toward interventions and morbidity that even ACOG agrees often occurs unnecessarily. It may also force informed mothers committed to experiencing their birth plan to have no option but an out of hospital birth. Is this really where our organization’s energy is needed? I consider it my professional, moral and ethical responsibility to write to you in adamant opposition to the questionable conclusions stated in committee opinion 476. For they do not serve us or our patients well and should be reconsidered. I would hope to have the courtesy of a personal response and to an honest dialogue with you.

Sincerely and with respect,

Stuart James Fischbein, MD FACOG


  1. Amen!!! Thank you for writing this and I hope they listen!

    -HBAC mom

  2. I love you. That is all. Thank you for this wonderful letter to ACOG.

  3. "Write On" Dr. Fischbein.

    Add my name to your letter. How many members does ACOG have? I wonder how many condone opinions based on faulty evidence (as you point out)? What would it cost to send this letter to every member of ACOG? Just pondering.
    Hugs, Kim

  4. Wow. Wish you were in MS. CNMs can't even do home births here bc of the insurance companies dropping supportive back up physicians. So we are left ONLY with licensed midwives with no hospital privileges to follow us to the hospital if a transfer is necessary. I support the licensed midwives, too, however. I am a CNM. Fortunately, my midwife was able to go with me to the hospital bc of a very supportive physician who "accidentally" missed the birth on purpose...twice! Thank you for speaking out!

  5. Wow! Amazing words. And so true. It's a catch-22. The ACOG wants women to birth in hospitals and not at home with a midwife, but then allow hospitals to implement practices based on the beliefs of the ACOG that dramatically decrease a woman's options in her own birth. This runs the risk of women resorting to birthing at home while unattended by a licensed professional. Who wins there? Sure, most women will be fine since most pregnancies and births are low-risk, but a few could require the aid of an attendant and what's wrong with having to option to have one?

  6. Bravo, Dr. Fischbein! I'll spread this word as far as I can.

    Ina May Gaskin, CPM

  7. Wonderful letter! Thank you for writing and for supporting this safe and beautiful way of birthing.

    Megan Linn, mom of homebirths

  8. Thank you! We'll keep educating and advocating!

  9. Thanks for your support.

    I would like to see the next opinion on home birth focus on women's rights and informed consent, and the role of ACOG's members attitudes and choices in making home birth transfers safe.

    Let's see ACOG urging members to treat women who present in the hospital from a home birth with respect, giving full consideration to their wishes for the lowest level of intervention that is appropriate, and sensitivity to the families beliefs about the importance of treating the newborn with gentleness. There are many things about home birth ACOG has little influence over, but they could have a significant influence on their members attitudes about how women and babies are treated during a transfer. I hear too many stories of women encountering punitive attitudes and practices as a result of the physicians having negative judgments about their choice of birth location or caregiver.

    Something along these lines of recognizing the importance of adhering to the professional code of ethics when presented with home birth transfers would be nice. I like the UK midwives ethics code. http://www.nmc-uk.org/Nurses-and-midwives/The-code/The-code-in-full/

    When it comes to health matters, I want an honest assessment of my personal circumstances, complete, honest information and about the choices I have and the associated risks and benefits. I would like to see an neutral body generate informed consent materials along the lines of I am not that interested in ACOG's opinion of what is best for me. I feel pretty qualified to decide for myself, thanks. I think MIDIRS in the UK produces a very nice objective series of brochures for OB care. http://www.infochoice.org/

    Lets see ACOG move towards the position of honoring human rights in the birth room as Europe is doing with the recent European Court of Human Rights decision December 14th 2010 that determined 'Legal uncertainty prevented mother from giving birth at home' and that this 'is a violation of Article 8 (right to respect for private and family life) of the European Convention on Human Rights'. Here is the original decision:

    Keep up the good fight, women everywhere appreciate that you are sticking out your neck for what is good and true.

  10. You rock! and so does Ina May (comment above)!!!

  11. We, in the birthing community, are blessed to have you represent us in such an accurate and articulate way. As a midwife in Texas, I am getting more and more clients who want home births just because it seems the only way they are going to have their wishes heard, such as, delayed cord clamping, and instant contact with their babies. They quickly learn that there are MANY more benefits to having their babies at home with a midwife. I get many who are unable to find a doctor who will even consider a VBAC. My back up doctor once asked me why I would take the risks of doing VBAC's. I simply said, "because you won't".
    This is all about choice. Women are often treated like idiots in the hospital, as if, they don't have a clue as to what is best for them. Midwives go out of their way to educate their clients so they can make informed decisions.
    I remember the medical revolt it took in the 70's by women who wanted to take back control of their bodies and birth their babies how they chose. It might be time for another revolt!

  12. Thank you Dr. Fischbein! I appreciate your efforts to help Midwives get some respect from the medical community. I wish there were many more (or even a few) like you.
    Quincy Bates, LM

  13. This comment has been removed by the author.

  14. Thank you so much, Dr. Fischbein. I'm planning my secondary VBAC at home in April, and the main reason is that I know I cannot expect to be treated fairly in any of my local hospitals (and I've seen the insides first hand as a doula.) My hospital VBAC experience was sabotaged at every stage, and I was bullied and threatened by the very people who insisted they were trying to keep me "safe." Thankfully I had a birth team that respected my need for a vaginal birth and that's what I got in the end, but the road to get there was rough. This time I know the safer experience for both me AND my baby is to avoid that system all together and birth at home with my highly experienced homebirth midwife whose watchful eyes and evidenced-based practices I trust fully. It's a shame that the ACOG insists that this is a reckless choice, but if not for the reckless choices of the OB and hospital staff in my last two labors, I wouldn't even be sitting here with a cesarean scar and emotional trauma from those experiences.

    Thank you for everything you're doing to speak out.

  15. Thank you, Dr Fischbein. I have had 2 babies at home, under the watchful eyes of two experienced and wonderful midwives. I cannot thank you enough for speaking out on behalf of parents.

  16. Thank you so much for writing this letter. It's so important to have physicians such as yourself supporting a woman's right to a safe and satisfying birth experience, at home, birth centers, and hospitals across our nation. Sir, your efforts are much appreciated and respected, and I sincerely thank you from the bottom of my heart.
    --Jen Huston, mother and doula, planning a future HBAC

  17. Thank you, thank you, thank you.

    homebirth mother & homebirth midwife

  18. You are my newest hero! Thank you, so much for your blog! I will follow it from now on. Hope you will also follow mine:


    Kim Mosny, CPM
    Home Birth Midwifery Service
    Midlothian, VA

  19. Well said, Stuart !!!

    Happy New Year !!

    I just returned from opening day of the General Assembly in the Tar Heel state and can tell you that the legislators are listening. For women who would choose midwifery care and the home setting for birth, it is essential that every state cultivate a safe and caring environment for them by licensing and regulating Certified Professional Midwives and enabling any Certified Nurse Midwife who would opt for this service to do so. It is a management problem, and a simple problem to solve.

    Wax Paper is junk science and ACOG knows it. I am shocked that the AJOG saw the paper, did their happy dance, and gave it their Editor’s Choice Award and fast tracked it to the media. I am optimistic that things will change and we will live to see it. I hope that future generations who lead ACOG will look upon this episode and learn from it.

    I will definitely inform your colleague, and my good friend, Henry Dorn (www.ncdocsformidwives.org) of the good work you are doing.

    Be well, my friend.


    Russ Fawcett
    Vice President & Legislative Co-Chair
    North Carolina Friends of Midwives

  20. If only there were more OBs out there like you! And I agree--Ina Mae is awesome!

    I'll be delivering my 2nd baby with a CNM in a hospital any day now. If she did homebirths I'd do it at home, but I'm very attached to my midwife and was lucky to have great nurses at the hospital.

  21. Thank you for taking the time and effort to write that letter to ACOG. And thank you for everything else. May you be the light in this darkness.

  22. Way to speak truth to power Dr. Fischbein! Thank you! Thank you! Thank you!

  23. THANK YOU!! Fortunately,I know of one good Dr. in Buffalo,NY. On the flipside, it took having terrible experiences to have found a good one. No woman should be threatened by Dr's or hospital attorney's because she makes her own decision to have a trial of labor/VBAC. Spread your message Dr. Fischbein especially in Buffalo,NY.

  24. All your comments are amazing. SwedeLife, you make so much sense. I am ashamed of my College for their inconsistency for if not born of ignorance then it must be of malice. I thank you for the work you all do and feel confident that ACOG's desperation is a sign that choice and the betterment of pregnancy care in America is coming. With love, Dr. F

  25. Thank you Dr. Fischbein for responding to this skewed report. ACOG continues to put flawed, non-evidence based research out there and claim that it's valid. Women and their families deserve better. They deserve the ability to have options. Without sage and supportive doctors like you (it seems that they are fewer and far between or their hands are tied, or whatever...) and without midwives having license to practice independently (as is the case for our midwives in NC), the future for normal birth looks rather bleak. We are grateful for your voice.

  26. So grateful for your common sense and breath of fresh air. May your tribe increase!

    Practicing traditional midwifery and homebirth in a state which has a rich history of safe births with old fashioned 'granny midwives' but we have not been able to obtain licensing. I hear the horror stories of mothers experiences in the highly medicalized hospital setting. My local hospital's cesarean rate is 55% which is just criminal. Families need a choice.

    Sometimes I meet or hear about a physician who is supportive of parent's choice to birth at home but they are few and far between and often ostracized by their collegues.

    Please keep speaking the truth!

  27. I hate to go off topic here, but I really would like to know who "Stork" is who replied on 01/26. I am on the Board of the Mississippi Friends of Midwives and we have legislation pending before the MS House of Reps. We could really use the support of CNM. Please contact me: info@msfriendsofmidwives.org

  28. Oh my gosh. Reading your letter made my night. THANK YOU!

  29. well said ! Thank you so much for all you do for mothers and babies. Check out my blog at


    take care,


  30. Thank you so much! We really needed this boost from you here in NY, where we won a major legislative battle last year in the removal of the written practice agreement for all licensed midwives (no one would sign them!) and now ACOG District II is planning to strike back with legislation to restrict a woman's access to home birth.
    Susanrachel Condon LM
    River & Mountain Midwives PLLC
    New Paltz

  31. Thank you for your respectful, passionate and evidenced based letter. Thank you! Working as a homebirth midwife in Upstate NY, this letter is something that I can refer to on a regular basis. It succinctly states so many points that I find myself repeating time and again. Thank you for all your work, support and for writing this letter. Bless you!

    K. Michelle Doyle, CNM, NYS LM
    Local Care Midwifery, PLLC
    Troy, NY


    Your support for the safety of women and their babies is such a blessing in the midst of so much adversity. Thank you for choosing to be a minority in this cause and I hope that your letter with all of our support and all the movements across the country supporting home birth and midwifery. And hopefully what is now a minority will become the majority or we'll find cesareans in most, if not all, births.

    I have three daughters and I shudder to think of them having babies in the future if things continue on the downward spiral. I am already educating them on birth (they're all under age 5) and hope our next is born at home so they can witness what birth is meant to be.

    A Concerned Mom and Pregnant Woman!

  33. I didn't finish my thought in my excitement of reading your post! I was going to say that I hope your letter, etc. will bring much-needed, desperate change to childbirth in America!