"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.

Saturday, August 27, 2011

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

Wednesday, August 24, 2011

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