"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

5 comments:

  1. I am really pleased to see your response to this article. Thank you for clarifying that it is opinion and not fact.

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  2. Hello Dr F
    I have just come across your blog, and appreciate your wisdom.
    I am an independent midwife in Melbourne (Australia).
    We are experiencing growth in interest in vaginal breech birth in major public maternity hospitals.
    The deskilling of midwives and doctors in vbb is not going to be easily reversed. Breech vaginal birth should be a competence of every midwife. Obstetricians need skill in vbb too, as well as surgical births, but the nonsense that happens again and again is that women are told they can't have a vbb because the hospital can't guarantee that a suitably skilled obstetrician is present, and of course spontaneous onset of labour means that birth happens at most inconvenient times.
    One of the major questions in the exam I sat in 1973, when I studied midwifery, was on spontaneous breech birth. I do encourage all midwives to upskill for breech births.

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    1. Thanks, Joy. Retraining will be a major hurdle in U.S. residency programs but advocating for that is necessary and urgent before the skill is lost. Spreading the word about the safety of selected breech delivery is a good start.

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  4. I feel the same. I am an OB/Gyn resident. When I have a baby, I would like the option to give birth at home.

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