"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, April 6, 2012

Art Class or Martial Art Class, a primer on choices

Recently there have been a series of original research papers and some review articles favorable to what I have been advocating for several years. Articles supportive of the safety of home birthing have come out recently. Possibly in response to the flawed Wax paper. The catalyst for these papers could be a return to sanity and evidence based writing or it could be because more investigations are occuring due to rising consumer demand for an alternative to the hospital model. Whatever the reasoning it is good to see well done studies that concur with common sense.

In a recent study of more than 11,000 VBACs looking at outcomes and timing of intervention to prevent fetal injury it was found that the rupture rate was 0.3%, that of those only about 17% suffered serious injury and the success rate for VBAC in this study was 84%!!

Glezerman, et al had a well written paper in Medscape that reviewed the history of breech delivery and clearly defined the damage done by the poorly conducted Term Breech Trial in 2000 by Hannah. “This single piece of research profoundly and ubiquitously changed medical practice and effectively removed planned VBD from delivery wards in the western world.” And, “The TBT was a blatant example of how an inadequate randomized controlled trial can change medical practice.” In the year that followed release of this study the breech c/section rate in the Netherlands went from 57% to 83%.

The subsequent Premoda study from 2006 included 8000 (4 x TBT #s) women with singleton breech. This study found no difference in perinatal morbidity or mortality in breech babies delivered by c/s versus vaginal delivery. Yet nothing has changed as far as hospital policies toward breech nor has residency training in this skill returned.

Similar papers have come out in the last decade about the safety of term vaginal twin delivery. Surprisingly, and little known, was a paper published in 2000 in the Green Journal by Blickstein, et al which concluded, "There was no evidence that vaginal birth is unsafe, in terms of depressed Apgar scores and neonatal mortality, for breech first twins that weighed at least 1500 g.” So there is even evidence in ACOG's own journal about the safety of first twin breeches and yet more than 80% of all twins and nearly 100% of breech first twins are delivered by c/section in the United States. Even more surprising was this conclusion: “We did not see any intrapartum fetal entanglement, one of the most frequently cited specific complications of vaginal birth of breech first twins despite its overall rarity.”Our series that combined the experience of 13 centers and was five to eight times larger than previous reports, cast doubts on the relevance of the locked twins as a contraindication to vaginal birth.” Yet for as long as I can recall until present day, midwives and physicians are taught to fear the dreaded interlocking head scenario of Breech/vertex twins. While there are anecdotal cases, usually in premies, there is no hard data to support this ubiquitous premise.

Some who advocate for hospital birthing and condemn any and all who participate in home birthing are quick to point to the "safety" argument. The "what if something goes wrong" crowd will always use fear and blame to make their point. This blog is not to discuss the open argument about the safety of home vs. hospital birthing. I have done that before and will again. My point today is to reiterate the AMA code of ethics that supports respect for patient autonomy and decision making. “Conflicts of interest should be resolved in accordance with the best interest of the patient, respecting a woman’s autonomy to make health care decisions.”

What are the risks of the choice? What are the benefits of the choice? Whose choice is it? What is the role of the practitioner to give true informed consent based on evidenced based science? What is the role of the practioner when the patients choice differs from the practitioner's bias? These are very important questions and should always be analyzed with respect to a code of ethics. If I cannot support what a patient desires I am free to refer her elsewhere but I should not deny her information or skew my counseling to funnel her down a path of my choosing.

How we interpret risk vs benefit may be quite different from family to family. Differing life experiences and levels of education make blanket policies inadequate and dishonest. Something that carries a risk of 0.3% (or 1/333) also means that there is a 99.7% chance it will not happen. To have policies or adminstrators or insurers or writers condemn a woman for choosing a path based on her own risk assessment is totalitarian and not ethical. Banning VBAC, outlawing midwifery, skewing counseling on breech or twin deliveries for reasons (true or false) of safety is disingenuous at best. Is it not safer to put your child in art class than martial arts? Tennis is safer than football. Watching National Geographic Channel carries less risk that SCUBA diving or rock climbing. Should some higher authority decide which activites are allowed under the canard of safety? Would we allow or lives to be restricted in this way? I wouldn't want that sort of restraint on my liberty.

When it comes to choices such as home birthing, VBAC, breech and twins we must continue to respect the individuality of the decision. Same goes for choice of caregiver. Patients have the right to be educated. Educated people cannot be expected to always come to the same conclusions. Ethics dictates allowing for personal choice and responsibility. Decisions concerning one of life's most memorable events are personal and big government, big business and busy body know-it-alls (yes, you Dr. Amy) should just shut up and respect our differences.

Warmly, Dr. F

Tuesday, April 3, 2012

Breaking the Silence

April 3, 2012
Its been 3 months since my last post after taking a hiatus from blogging. It's not for a lack of events but just a needed break. Much has happened in the birthing world since 2012 began. I have been remiss is not writing a tribute to my dear friend and colleague, David Kline, who passed away suddenly on February 6th saddening us all. His imprint on the midwifery and home birthing world in Los Angeles was widespread and his passing left a huge hole in so many of us. There does not exist a more consumate professional, dedicated physician nor loving husband and father than David. I was at his home for some comraderie and chile the day before his passing watching as his team beat my choice in the Superbowl. I expected to have about 30 more annual Superbowl gatherings with my friend. I think of him every day and feel a sadness every time I walk past his empty office and recall his grumpy exterior hiding that mischievous sense of humor. He was taken way before his time and he will be missed.

It may sound a bit prophetic but it does seem that as one door closes, another or several seem to open. Dave supported a lot of the local midwives when others would not. When the news of his death spread throughout the community there were many questions about who would backup all the midwives. The confusion was intense but short-lived as several other doctors stepped forward and offered assistance. Thank you to Drs. Lipedes, Ghozland and Chin for doing the right thing.

Last month I had the honor (and stress) of attending 2 women laboring with breech babies 65 miles apart on the same day. There are not a lot of options for this variation of normal in Los Angeles but I was able to juggle being in 2 places at once despite the famous LA traffic. What a joy to assist in an early morning birth of a baby boy in the Hollywood Hills. thank you Beth, Sara and Yvonne. The other client was a TOLAC and breech who arrested at 8cm. Unfortunately, there was no place to take her where pitocin augmentation would be permitted for a breech and so a repeat c/section was necessary in Ventura. Thank you Karni and Haley for your support. Glad to have you on my team. Someday, soon I hope, many more options will be available in a freestanding facility. The end of February also saw the home delivery of almost 16 pounds of twins born vertex/breech on mom and dad's bedroom floor. Patience is a virtue that midwives have more than OBs. Thank you for the lessons Molly, Katherine and Sheila.

On April 1st I spoke at the Natural Baby Fair in San Diego on VBACs, Twins and Breech delivery. My talk was titled, "Raider of the lost arts", and I reviewed the history of these options in light of some bad science and current evidence based medicine. I enjoyed the audience and the opportunity and got to spend a little time with Ina May to boot. The week before I made the 7 hour drive up to Sacramento to sit in on the California Medical Board Midwife Advisory Council public forum on changing some of the wording in the licensed midwife regulations. The essence of the hearing is to change the requirement of "supervision" to one of "collaboration". The panel consisted of 3 Board administrators, 3 lawyers and no actual Medical Board members. It is a tedious business buried in minutia for what seems to be a simple thing. I am glad I went if only to gain insight into this completely foreign process. By their own admission it may take 2 years to make changes to these 2 paragraphs. How did 2700 pages of Obamacare get passed in 90 days? Sigh! I think it would be very difficult for me to live and work in the administrative world. I prefer hands on in the privacy of a clients home with the immediate gratification of the joy surrounding birth.

I was delighted to create about 23 informational videos for about.com earlier this year on a wide variety of OB and Gyn topics and had a good time speaking at the West LA ICAN meeting on March 4th. Also, did a Skype interview with Sarah and Steve Blight of yourbabybooty.com. Oh, and found time to ride my horses, hang with my kids and cheer on the LA Kings Hockey Club, too.

Which brings me to the last and more serious issue which surfaced today. That of the continuing plight of midwives across the country who are being persecuted and prosecuted for simply helping women who choose to stay home to give birth. The absurdity of the idea that it is OK for a woman to give birth at home alone but in certain states if they ask someone experienced and trained to help them then that assistant may be arrested. Rhetorically speaking, how did we get here? If a neighbor or cab driver assists you it is a good samaritan but if someone who actually knows what they are doing assists it is a crime. Where are the feminists on this issue? Please spread the word that women and families need to start screaming and pounding the table if necessary to be heard by lawmakers. Civil disobedience can be a good thing but lives will be ruined. Bad laws need to be revoked, not just broken. Dr. F