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
"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
"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.
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.
Subscribe to:
Post Comments (Atom)
Posts
Well written and frustrating. I'm in the same situation though I do have the means for homebirth fortunately. Actually, just sent you an email about it. I'm angry for Maria and for other mothers, like myself, who find themselves up the creek without a paddle.
ReplyDeleteDear Dr.Fischbein
ReplyDeleteIt’s a great pleasure to read your blog. I find your post very informative. Thank you for sharing your insights.
As a reader, I consider your writing to be a great example of a quality and globally competitive output. It would be a great thrill and honor if you could share your genuine ideas and knowledge to our community, Physician Nexus. With this you can gain 1000 physician readers from over 62 countries on Nexus.
We would love for you to visit our community. It's free, takes seconds, and is designed for physicians only - completely free of industry bias and commercial interests.
Best,
Romeo Dayanghirang Jr.
On behalf of the Physician Nexus Team
www.PhysicianNexus.com
Infuriating and unconscionable. Thank you for speaking up for Maria. Please let us know when you find out what happened.
ReplyDelete