"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.

Friday, September 23, 2011

Junk Science or an Inconvenient Truth?

In a recent article published in the Green Journal, ACOG's monthly academic publication, and much their credit, it was revealed that many guidelines used as "gospel" to counsel patients on OB/Gyn matters are not based on good science. In an article by Christie Haskell on the CafeMom web site she notes the following:

According to Professor of Medicine, Dr. Andrew D. Auerbach, "more than two thirds" of recommendations are based on anecdotal evidence or even just expert opinions, which are wrought with personal biases. While opinion can be helpful where we don't know things, it doesn't always translate into what's best for the patients.

In the new study, Dr. Jason D. Wright of Columbia University in New York and colleagues went through 717 practice recommendations from ACOG, the nation's leading group of ob-gyns.

They found 30 percent of those were based on top-notch evidence, so-called randomized controlled trials. About 38 percent came from observational studies, whose value is limited, and 32 percent were purely expert opinion.


Awareness of this information is crucial in the informed consent process. Asking questions of your doctor about the veracity of the evidence for his/her recommmendation is a good idea and should be greeted with respect by your practitioner. Remember, ACOG guidelines are meant to be just that, guidelines, and yet once published they become the basis for strict hospital policies and fodder for trial lawyers. Again, I give credit to the editors and the author for pubishing this article. Hopefully, it is based on good scientific method. Dr F
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2 comments:

  1. AnonymousSeptember 26, 2011 at 10:51 PM

    Thank you, Dr. Fischbein, for the work that you do. Your voice is very strong to me in this subject matter, and I know how rare it is in this climate to find both a male AND an obstetrician who respects women and birth in the manner that you appear to. I know you're up against a lot of criticism, but as far as I can see, it was unfortunately inevitable and to be expected. The climate is very hostile.

    This particular post of yours and the article you refer to struck me as no surprise, and I had fun circulating it to see if anyone would take note. I don't think a lot of people are ready to hear it, and it's just as I often call it myself-- an "inconvenient truth".

    In any case, I wish there were more like you.

    Elizabeth
    writer, natural childbirth advocate

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  2. UnknownSeptember 27, 2011 at 11:59 PM

    Elizabeth, Thank you for the kind, supportive words. The climate of hostility you speak of is to be expected when established "norms" are legitimately challenged. Ad hominum attacks and pounding the table are the standard fare of those without an argument or unwilling to debate. I have written ACOG about recommendations based solely on level C evidence (committee opinion) and the lemming like tendency for administrators and policy makers to incorporate these guidelines into standards of care. Wholly irresponsible and damaging on so many levels. Dr F

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