"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.

Sunday, March 20, 2011

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


  1. That was a beautiful post! You sound like a midwife! :-) As an apprentice myself, and having had two of my three at home, you captured the "normalcy" of having your baby at home well. Home allows the birth to flow, rather than channelling it down a foreign path.

  2. Thanks, Emily. Birth now feels like my favorite comfy sweater instead of a scratchy, overstarched shirt. If only my fellow physicians felt the same the birth world would be so much better off. Please share this post with your friends and colleagues. Dr. F

  3. I always feel sad for women who don't look forward to their labors. If their caregivers felt the way you feel perhaps those women would anticipate much much more than just getting to hold the baby after the "inconveniences" of labor. I was a homebirth mom that made a non-emergent transfer to the hospital but dispite my very difficult labor I never felt more powerful or more loved and respected in my life than I did while in labor at home with my husband and midwives. I look forward to my next planned homebirth come this June.