"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, December 24, 2011

Blog Talk Radio with Gena Kirby

Last Monday I had the privilege of being interviewed by Internet Radio personality, Gena Kirby. We met in person last month at the premiere of "More Business of Being Born" in Santa Monica. Gena, who resides in Texas, asked if I would come on her weekly program to discuss the reality of breech birthing in America. We had a great 90 minute chat on this subject and, of course, many others and took a couple of questions from listeners. You can find the full podcast at: http://www.blogtalkradio.com/progressive-parenting/2011/12/20/breech-birth-a-reality-a-conversation-with-dr-fischbein
Listening will not be time wasted and comments here or on Gena's site would be appreciated. Merry Christmas to all. Dr. F

Wednesday, December 14, 2011

We can all learn something from Ibu Robin

Inspired! One cannot spend time with midwife Robin Lim and not come away with a sense of peace and inspiration. For over 20 years Robin has cared for women at her clinics in Bali, Indonesia. Providing health and maternity services to all women regardless of economic status in a country in desperate need. For her tireless efforts she was awarded the CNN Hero of the Year award this past week.


I was fortunate enough to have a few minutes with her last evening at a gathering in Montecito, CA. What wonderful, and sometimes tragic, stories she has to tell. So much love and nurturing affection in the room full of people eager for such sanity in the world of birthing. In the midst of all the deserved attention and accolades that Robin is receiving I read an article written by Stacia Guzzo titled, "The Paradoxical Perception of Midwifery in American Culture". The contrast it presents is startling and disturbing and speaks for itself. Please take a moment to read.


Thank you Robin and Wil and Mary Jackson and all my colleagues and friends who, by example, bring peace, common sense and respect for the individual back to birth. Dr F

Wednesday, December 7, 2011

Breech Birth, a Reality

I was watching the brilliant movie "Inception" for the umpteenth time and saw a parallel for what those of us who believe that breech birth is just a variation of normal are up against. Like a virus, an idea, once implanted, is very hard to eradicate. Whether true or false, if this idea takes hold it changes the participant and the playing field and, thus, the world we live in.

Up until the early 90's delivering selective vaginal breech babies was taught in residency programs and practiced by obstetricians in the real world. When I trained there were studies supporting this idea including the pivotal work of Martin Gimovsky, MD in the early '80s.

Obstet Gynecol. 1980 Dec ;56 (6):687-91 7443110 Cit:22 Neonatal performance of the selected term vaginal breech delivery.
[My paper] M L Gimovsky, R H Petrie, W D Todd

Several authorities have recommended cesarean section for all intrapartum breech presentations. The present study documents that judiciously selected fetuses at term in breech presentation may be safely delivered vaginally by a selective management protocol that requires cesarean section when mandated criteria are not met. The outcome and performance of 6 years of vaginal breech deliveries were evaluated. Those in the control groups were delivered by spontaneous vertex vaginal and elective repeat cesarean section procedures. Morbidity was not different in the protocol breech vaginal delivery group and in the controls. Mortality was found only in the nonprotocol-managed breech vaginal delivery group, which also had a morbidity 5 times greater than that of controls. Approximately half the term breech presentations that are properly selected and managed may be safely delivered vaginally, thereby avoiding a significant number of cesarean sections and subsequent inherent risks.


As residents we were eager to learn and excited for the opportunity to practice this skilled art and at Cedars-Sinai Medical Center in Los Angeles selective vaginal breech deliveries were the norm.

But in the 1990's the idea began to grow that maybe delivering breeches vaginally was risky. This thought culminated with the publication of the "Term Breech Trial" by Mary Hannah, MD in 2000.

Lancet. 2000 Oct 21;356(9239):1375-83.
Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group.
Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR.
SourceDepartment of Obstetrics and Gynaecology, Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario, Canada. mary.hannah@utoronto.ca

BACKGROUND: For 3-4% of pregnancies, the fetus will be in the breech presentation at term. For most of these women, the approach to delivery is controversial. We did a randomised trial to compare a policy of planned caesarean section with a policy of planned vaginal birth for selected breech-presentation pregnancies.

METHODS: At 121 centres in 26 countries, 2088 women with a singleton fetus in a frank or complete breech presentation were randomly assigned planned caesarean section or planned vaginal birth. Women having a vaginal breech delivery had an experienced clinician at the birth. Mothers and infants were followed-up to 6 weeks post partum. The primary outcomes were perinatal mortality, neonatal mortality, or serious neonatal morbidity; and maternal mortality or serious maternal morbidity. Analysis was by intention to treat.

FINDINGS: Data were received for 2083 women. Of the 1041 women assigned planned caesarean section, 941 (90.4%) were delivered by caesarean section. Of the 1042 women assigned planned vaginal birth, 591 (56.7%) delivered vaginally. Perinatal mortality, neonatal mortality, or serious neonatal morbidity was significantly lower for the planned caesarean section group than for the planned vaginal birth group (17 of 1039 [1.6%] vs 52 of 1039 [5.0%]; relative risk 0.33 [95% CI 0.19-0.56]; p<0>

INTERPRETATION: Planned caesarean section is better than planned vaginal birth for the term fetus in the breech presentation; serious maternal complications are similar between the groups.


Finally, those that were against teaching or performing term vaginal breech deliveries and did not want to investigate further had their evidence. Never mind, that within 2 years after the paper was published there were a slew of articles and papers critical of and refuting Dr. Hannah's research and conclusions.

Well summarized here: http://www.breechbaby.info/termbreechtrial.pdf

Too late! The seeds of the IDEA that breech vaginal birth is dangerous had been planted. And this idea was rooted in welcoming fertile ground as it justified the easier, less time consuming, more lucrative and thought to be less liability ridden c/section as standard of care for frank or complete breech at term. An idea, regardless of its validity, is made all the more powerful when it fits the current trend in the medicalization of birth and the fear based model that restricts individual choice. It infects the population and the profession to the core and has led to a stoppage of even teaching the knowledge and technique of vaginal breech delivery to future practitioners. Our halls of higher learning have no shame in denying future mothers this option due to a simple idea based in fear.

Fortunately, some forces are beginning to wake up from the nightmare and realize that "inception" has taken place. Maybe they have a "totem" of their own or just maybe common sense is an antidote to the viral model of a long festering idea. The Royal College of Ob/Gyn in England and The Society of Ob/Gyn of Canada have issued statements in the last couple of years in support of retraining new doctors in the methods of vaginal breech delivery. Even the American College of Ob/Gyn has a clinical guideline paper in support of selective vaginal breech delivery as a reasonable choice for the skilled practitioner and the informed woman.

Those of you who know of my work are aware that I have supported true informed consent and birth choices including the option of vaginal breech delivery. I have been ostracized in my former local community for many of my views and this has led me to choose the path of supporting women's choices in the home and birthing center setting where I do believe that common sense, individuality and evidenced based medical practice can freely occur. With the help of social networking, celebrity advocates and a growing number of devoted maternal care givers an old idea, that normal birth is not a disease and that selected vaginal breech is just a variation of normal, is being re-sown. I believe we can awaken my colleagues and the American populace from "limbo" even if it is one person at a time. A good idea need not be a virus. It may awaken us, as in Christopher Nolan's incredible movie, to the sanity and reality of the beauty of home and family and natural birth.

It is with these comforting feelings that I and my birthing Instincts team of Beth and Jaclyn and doula Robin announce the successful home breech birth on 12/5/11 of an 8 pound baby boy to glowing parents Hallie & Michael. Planning a home birth with the great midwives of South Coast Midwifery they found themselves in the not uncommon dilemma of persistent frank breech at term. Having no success with the usual measures to turn the baby they looked for options. Sadly, they could not find a single facility in Orange county willing to allow them a natural birth. C/section only! Lorri from South Coast knew of my practice and my philosophy and referred them for a consult only last week. We spoke several times for several hours and really connected. They had the right stuff and met all the criteria for a selective breech delivery. The very next day labor began and in less than 7 hours Hallie gave birth at home in their bed with grandma present. Congratulations to them on this blessed event and for their conviction.

I do believe that term breech presentation should be treated as just a variation of normal. And if selection criteria are met then informed consent and choice belong to the woman and her loved ones. While a hospital that respects autonomy would be an ideal place for these women to give birth that is not the current reality we live in.
Choices are so extremely limited. That is just one of the most compelling reasons why another birthing option is so needed in America. Under the current medico-legal and economic climate I do not foresee hospitals and physicians currently in practice changing from the "breech is dangerous" idea. The dream of the Sanctuary Birth & Family Wellness Center and I and a few of my colleagues, too, is to build our own maternity facility where individuality and common sense and respect for birthing are, once again, the norm. Dr. F

Saturday, December 3, 2011

My response to another rant by Dr. Tuteur

In the November 7th, 2011 online edition of “Time Ideas” internet blogger Amy Tuteur attacks Ricki Lake and Abby Epstein’s sequel to the popular “Business of Being Born” and continues her rant against home birth and the midwives who support this option. Had Dr. Tuteur actually viewed the 4 part DVD, “More Business of Being Born”, she would find that the film was not an advertisement for home birthing but rather a documentary that presented evidenced based medicine and real life experiences in hopes of educating the viewers on their options for birthing in America. In her zeal to critique anything that has to do with the movement she argues, disingenuously, four major points.
As to point #1:
As a board certified and practicing obstetrician who has worked with both CNMs (certified nurse midwives) and LMs (licensed midwives, also called certified professional midwives CPMs), my experience is that they are both consummate professionals in their area of expertise. Licensed midwives in California are licensed by the Medical Board of California, the same agency that licenses physicians. This consumer protection agency sees fit to certify these professionals to care for low risk pregnant women. In my extensive experience spanning 30 years of collaboration with them in California I have direct knowledge of their work. They have extensive didactic education with accredited institutions and are trained in the care of normal birth through the mentoring and supervision process. The model of care they provide is based on prevention and nurturing and the trust that birthing a baby is a normal bodily function.
Dr. Tuteur believes that having a university degree and extensive in-hospital training is required to care for normal pregnant women. I would state without reservation that midwives do normal birth better than most obstetricians who are trained in surgical birth and rarely experience a normal labor from start to finish. By labeling licensed midwives second class, Dr. Tuteur demonstrates for us her pejorative style that is her reputation when confronted with facts and issue she disdains. In other developed nations the model of care of collaboration between midwife and doctor is the norm. Whether to choose a CNM or an LM is a matter of preference for the informed woman.

As to point #2:
Dr. Tuteur says “All the existing scientific studies…show that American planned home has triple the risk of neonatal death”. This is a stance she consistently takes on her blog site and when quoted in articles and is patently false. The use of hyperbole is also a trademark of Dr. Tuteur and strains further her credibility on this subject. Does any reader really believe that “All” the studies of any topic are on one side only? The American College of Obstetrics & Gynecology (ACOG), of which I am a member and Dr. Tuteur is not, has consistently taken a position against home birthing and the basis for their recent opinion relies almost entirely on a meta-analysis of his selection of 11 out of more than 50 studies encompassing several decades by Wax, et al. The criticisms of his conclusions are numerous in the literature and even include some by the authors he has cited. There is certainly no consensus. Dr. Tuteur seems to assume that her statistics end the discussion. Even Wax, himself, admits that if you accept his data as indisputable the overall increased risk of a fetal death at homebirth is 1 in 1,133. While every loss is significant the evaluation of this risk is a personal decision. No pregnancy is without risk and hospital birthing is no exception. Parents must be allowed to weigh the much greater risk of intervention and surgical birth and the multitude of complications that can arise from them in context with their own life experiences. True informed consent and respect for patient autonomy is not a virtue that Dr. Tuteur seems to value.

As to point #3:
Dr. Tuteur cites a Netherlands study in the 2010 British Medical Journal which had the surprising finding of a higher fetal death rate in low risk women cared for by midwives than for high risk women cared for by obstetricians. The analysis of scientific articles is not a simple task, often comparing apples to oranges and that is the case here. Recall that Dr. Tuteur states that the Netherlands does not allow licensure of CPMs therefore one must conclude that the midwives caring for Dutch women are the equivalent of CNMs, a category of midwife that Dr. Tuteur approves of. Secondly, the study does not clearly define location of labor as a factor, only the care provider. Also, as tragic as a fetal loss is, again, it cannot be used in isolation as the only endpoint when determining models of care. The use of this study as a condemnation of home birthing is, again, disingenuous. The authors’ conclusions are not the condemnation of the midwifery model but that a reevaluation of the Netherlands care system is warranted.

As to point #4:
I agree that if the Midwives Alliance of North America (MANA) has meaningful data they should consider publishing it. Supporters of the midwifery model want the best for their patients and would be accepting of criticism if that is what the statistics showed. For those interested in seeking their data there is a legitimate application process that provides access. Dr. Tuteur seems to be eager to attribute sinister motives to MANA while bathing herself in righteous indignation. Those who know of her antics see her for the internet provocateur she is. One who calls for informed decisions but skews her information, refuses offers to debate opposing views publically, obfuscates her own background and motivation and seems to take pleasure in demeaning those with whom she disagrees. Unlike Dr. Tuteur, I applaud Ms. Lake and Ms. Epstein for bringing the issue of how American women give birth to the forefront. Honest dialogue, true informed consent and individual autonomy in life’s most precious moments are the business for us all.

Stuart J. Fischbein MD, FACOG

(This essay was submitted to the op-ed editors of online Time/Ideas more than a week past. Since I have yet to hear any response from them I have elected to post it here. Dr. F)

You can find the original article by Dr. Tuteur at:

Time Ideas did eventually publish an edited version of my comment to Dr. Tuteur. Read it at: