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