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
www.birthinginstincts.com
(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:
http://ideas.time.com/2011/11/07/what-ricki-lake-doesnt-tell-you-about-homebirth/
Time Ideas did eventually publish an edited version of my comment to Dr. Tuteur. Read it at:
http://ideas.time.com/letters/the-home-birth-debate-continues/?iid=op-main-lettereditor
"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.
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I was fortunate to get a sneak peak of MBOBB in Wasilla, Alaska and found it empowering and enlightening. Birth is such a personal and powerful moment in life that I find it ridiculously presumptuous that any physician find it to be her place to tell any women where, when and how she should birth. I find it heart breaking that it is another women who is speaking out to limit the choices of birth options. While perhaps she believes she has the best interest of families, mother, babies at heart, she should recognize within herself that part of womanhood that tells her that her birth is within her control and isn't something anyone gets to tell another woman how to do. And really, the movies aren't a PR stunt for home birthing, but rather a message to women to educate themselves, believe in themselves and be courageous in birth choices! I am lucky to work with a doctor who believes in supporting birth options, but I see the entire obstetrical community has a ways to come!!
ReplyDelete~Jenn RN
Amen... and amen!
ReplyDeleteStuart, I have to wonder WHY Someone who claims to engage in the free wheeling breezy confidence that Dr. Dumbass Amy exudes, who even had the gall to title one of her first blogs "Homebirth DEBATE" is so very reluctant to debate you publicly?
ReplyDeleteWouldn't it stand to reason that if she (and the fifteen guys who play her on the internet) was so very confident in her positions that she could take thirty minutes out of her busy beaver blogging day to come on my radio show for a good old fashioned birth debate with Dr. F and Jenny Hatch?
Amy! Paging Dr. Amy!
I agree Jenny - "Dr." Amy seems to be a flimsy foil used by the establishment to further its agenda.
ReplyDeleteDr. Fischbein has it right: get the information you need to make the right decision for you. And remember, doctors are service providers, just like mechanics, plummers, electricians, etc. They work FOR YOU.
This post was refreshing and well-reasoned. (I'm sad to see the resort to name-calling in the comments, but with the tone of much of the original material, I'm afraid it can't be helped.)
ReplyDeleteI had a really horrible recovery from a probably-not-necessary c-section ("suspected big baby" and "failure to wait") and am feeling pretty conflicted about having more kids. I don't know how I can avoid another c-section when I couldn't the first time around unless I stay home, but I don't know that I'm comfortable doing that.
I guess what I want to know is how I can find a doctor like you in my area -- what can I ask and where should I look to find someone who's willing to follow evidence-based medicine and who can talk to me like an educated human being instead of a brainless vessel?
Crystal, find out if there is a local International Cesarean Awareness Network (ICAN) chapter in your area (ican-online.org). They can help you process your experience, learn what you need to ask to find the right care provider for a VBAC, and give you the opportunity to talk with other women who have had cesareans and VBACs. You can also find lots of good information at vbacfacts.com.
ReplyDeleteCrystal, Rachel is right. ICAN chapters generally know who practices evidenced based obstetrics and is supportive of true informed consent and birth choice. Hopefully, more of the doctors in training will get wind of the idea that birth does not have to be medicalized and begin to demand proper training. With films like "Business of Being Born" and the sequel clarifying what goes on in hospitals the populace and eager young residents have exposure to alternatives.
ReplyDeleteAnd Jenny, I would be available in a heartbeat but you know why she won't ever accept. A peaceful and sweet new year to all of you. Dr. F