"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.

Tuesday, November 13, 2012

The Battle Against Home Birth Choice Escalates

Another anti-home birth article was published in this months American Journal of Ob/Gyn. I want to stress that this is an OPINION piece and not a study. I have already seen many news articles that refer to a new "study" out against the safety of home birth. I cannot link it directly but I am certain it will continue to get lots of play from home birth detractors. This one is specifically written to assist obstetricians in developing arguments and reasons not to support the option of home birth. Planned home birth: the professional responsibility response. Chervenak, et al. AJOG Clinical Opinion November 2012 The positions and arguments presented there are worthy of point by point review in the proper forum. For now, here are some of my quick insights: This is nothing new from Dr. Chervenak. In my opinion he gets lost in his own glow on this subject into which he has put an inordinate amount of time and effort. I am still confused how he places fetal rights above those of the mother in todays society. While I agree that the fetus has rights it would seem the abortion without restriction argument has won the day in the recent election cycle making that argument questionable at best. He cherry picks much of his data and suggests a model of professional responsibility ethics that fits his purpose while excluding the beneficence model he has supported in the past. He still relies on the disputed Wax paper and a lot of data from Southern Australia. I know nothing about southern Australia but I highly doubt it is as filled with proximate medical centers as is Los Angeles County or other large urban areas in America. Quoted rates of transfer from the Netherlands study seem high relative to my own 26 years of experience working with home birth midwives. Nonetheless, a nonemergent transfer, as most of them are, is not a reason to deny a woman the option. I read some of his data and examples and anecdotes and come to completely different conclusions as to the decision process. Clearly, we both have a bias. Chervenak is a bright man who considers his opinions to be truth and unassailable. I do agree with his recommendation that doctors and hospitals become more friendly and nurturing to women and offer a full course of options. Until that day comes, however, there is no place like home as a legitimate choice for some women. Dr. F

Term Breech Trial R.I.P.

“Hands off the bum” was the message at this year’s Heads Up International Breech Conference. It was quite a gathering in Chevy Chase, Maryland. I want to express my most sincere gratitude to Robin Guy and her whole team for putting together a marvelous weekend. I attended as a moderator and panelist and feel very fortunate to share the spotlight with luminaries in the field. We were honored to have doctors Anke Reiter from Frankfurt, Germany, Andrew Bisits from Sydney, Australia, Marek Glezerman from Israel, Martin Gimovsky from Newark Beth Israel Hospital in New Jersey, Michael Hall from Colorado and Dennis Hartung from Wisconsin. Midwives Ina May Gaskin, Ibu Robin Lim, Jane Evans and Betty Anne Daviss were amongst a host of experts and educators in the world of breech delivery. It was a marvelous weekend with so many nurturing people supporting the reasonable option of selected vaginal breech delivery. Research was presented from 3 major academic centers that support the safety of vaginal breech as a reasonable and evidenced based choice and putting to rest, hopefully forever, the Term Breech Trial as something to be relied on as a basis for denying the breech option. There seems to be no significant difference in neonatal morbidity between vaginal and cesarean section for breech. There is a greater risk for the mother in this and future pregnancies when c/section is performed. All agreed that a change is needed in education for young physicians and midwives. Reintroducing breech delivery will not be easy as the skill and willingness has waned. We all believe the leaders of our profession including ACOG in the U.S. need to take a more active role in encouraging this movement. Ideally, specialized breech training centers such as exists in Frankfurt, Germany will open up creating the volume needed for interested doctors and midwives to learn the skills. Dr. Reiter presented her and Dr. Frank Leuwen’s techniques of delivering breech babies meeting their selection criteria in the all-fours position. They use MRI to measure the pelvic conjugate as their main criteria for inclusion. Other presenters used more traditional inclusion criteria but all agreed that selected vaginal breech delivery in experienced hands is a reasonable choice with a 60-70% chance of success. As with VBAC, if this option is dismissed by hospitals and doctors then they are wrongly condemning that percentage of women to surgery and the greater risk that incurs. Choice belongs to the informed woman! We were treated to videos and testimonials and birth stories from professionals and from some brave women willing to share their personal histories. Never let it be said that a healthy baby is all that matters. Some of these women still shed tears when they recall their births and how they had to struggle against skewed informed consent and a system that had failed them. We as a profession can do better. A special thanks to my colleague Beth Cannon, LM for her support of my bid to bring breech back to Southern California. And to Kimberley Van Der Beek for taking 4 days away from her family to share her breech experience, speak on two panels and host movie night. Changing old habits, especially those that are bolstered by convenience, economics and liability concerns will not be easy. But honesty and ethics must prevail to maintain the respect our profession deserves. Selected vaginal breech delivery is an evidenced based option that should be honored. This means offering it should attempts to turn the baby fail if the practitioner is comfortable and competent or referral to someone who is if they are not. For it is inevitable that some women will present in advanced labor with the breech presenting. Best we all relearn the skills as to be an obstetrician means more than just being proficient with a scalpel and a pap smear. I look forward to spreading the word and the skill. Thank you Coalition for Breech Birth!

Friday, November 2, 2012

Ethics Under Assault

It’s a story that seems all too common; the recurring harassment of supportive and optimistic doctors willing to collaborate with midwives. Honest and brave doctors who want to provide evidenced based options to women are forced into a choice of business survival vs. professional morality. The power of the big over the small, the bully over the weakling, it’s a story of sham peer review to maintain the status quo. Somewhere along the line the ethical and moral code we swore to uphold gets pushed aside for expediency, economics and fears of liability. The story plays out as good people who remember their fiduciary duty to their patients are harassed and eventually squashed by the behemoth that is conveniently called the “standard of care”......... Because the established medical machine says that something is outside their rigid community standard then the supportive doctor cannot be allowed to individualize his care and support other reasonable options. They believe that “consensus” equates with truth. It does not. And if you are not in their fold then you are a danger to them, their liability and their livelihood and must be coerced into conforming or risk the isolation from colleagues and the threat from hospital committees and administrators. This is happening all over the country and recently to some wonderful local doctors. Having been through this I would not wish it on anybody......... The modern doctor-patient relationship is not the one we grew up with. Although doctors are still expected to treat their patients with the same measure of duty, skill and care that has always existed there are new and powerful outside forces pressuring that relationship. There has always been a duty owed to the patient that remains a “fiduciary” wherein the patient’s interests must be paramount to those of the doctor. This faith and trust placed in the doctor by the patient all too often comes in conflict with the doctor’s own interests. Doctors have many pressures put on them by third parties such as government agencies, malpractice insurance companies, hospital administrations and third party payers. Often these interests directly conflict with the fiduciary duty to the patient.......... As I see it, too many of my colleagues have succumbed to these pressures and thus prioritize not on what is best for the individual patient but what is going to help them survive financially. There is no doubt of the reality of the difficult choice they must make for themselves. If they truly thought about this it would be very painful. But in the mode of groupthink that has overwhelmed my profession the pressuring of the rare nonconformist is understandable. So as to remove themselves from responsibility the majority go along with policies that violate their fiduciary duty but protect them from direct culpability. They use the, “I wish I could honor that choice if only the hospital would allow it”, excuse rather than stand with the few who think decisions should still belong to the informed patient. On the simplest level these brave few who choose to honor Hippocrates make the tyrannical majority look bad and, so, they must be vilified.......... Furthermore, under the American Medical Association’s Code of Ethics there exists the beneficence model to which we are all supposed to adhere. According to Sonya Charles in her recent Medscape article on The Ethics of VBAC, 2012 The Hastings Center the beneficence model makes a peculiar claim: “To interpret reliably the interests of any particular patient from medicine’s perspective. This perspective is provided by accumulated scientific research, clinical experience and reasoned responses to uncertainty. It is thus not a perspective peculiar or idiosyncratic to any particular physician. Based on this model, the physician cannot refuse to accommodate any request for alternative treatment that is supported by scientific research and clinical experience."......... My point is this: Hospitals, medical staffs and groups of physicians that wield power over individual physicians and smaller groups and threaten their livelihood if they do not conform to whatever standard they deem appropriate are violating both their fiduciary duty and their ethical obligation to the people of their community. Doctors who support patients who choose a midwife are honoring their ethical obligation. Doctors who allow for selected breech delivery, VBACs and twins are honoring their fiduciary duty and their ethical obligation to put their patient’s reasonable choice ahead of their own self interest. It would be just as ethical for a doctor to say to a woman that he cannot support that choice but refer her to someone who can. It is also the ethical and, I would say, moral responsibility of those doctors to aggressively advocate for those reasonable choices in the facilities in which they practice and with the insurers who restrict the rights of patients to choose. It is too easy to throw up ones hands and do nothing but it is not right, it is not moral......... What is also not acceptable is for doctors to skew their consenting to funnel patients into choices they prefer. It is a violation of their ethical code to punish doctors who put the fiduciary interests of reasonable patients before their own. Worse, it is immoral to do these things for financial gain or for expediency in lifestyle. Yet, sadly, this goes on every day and has become the accepted norm. I encourage every patient to educate themselves on reasonable choices for their health. Go discuss them with your practitioner. If you are met with skepticism or disdain present the ethical and fiduciary argument and see what response you get. Many doctors have lost sight of these simple tenets and seek retribution when confronted by a colleague who tries to point this out. The power for change lies with the consumer and those of us who honor the doctor-patient relationship as it was once intended are counting on you for help.