Home Birth & Apgar Scores in the AJOG October 2013, some clarity.

In the October 2013 issue of the American Journal of Obstetrics & Gynecology (AJOG, also known as the Gray Journal) there are two “research” articles discussing outcomes related to birth setting. In today’s blog I take a critical look at both of them so if asked about them by a prospective client you can give a salient response. Since science has been corrupted by money and ideology it is difficult to know what to believe these days making reliance on common sense and clarity of intent that much more important.

The first article begins on page 323 and is titled, “Apgar Score of 0 at 5 minutes and neonatal seizures or serious neurologic dysfunction in relation to birth setting”. This ominously titled article is authored by Amos Grunebaum, MD out of Cornell University with multiple co-authors including Frank Chervenak, MD who we all know to be fervently biased against home birthing. In a previous blog I have been critical of the authors of this article for their deviation from scientific norms by promoting their paper through an uncontested press release more than a month prior to its publication. Thus, headlines received prior to any critical review. Let’s take a look at the data and methodology of this study and then analyze their conclusions.

The stated objective is to examine the occurrence of 5-minute Apgar scores of 0 and seizures or serious neurologic dysfunction for 4 groups by birth setting and birth attendant (hospital physician, hospital midwife, birth center midwife, and home midwife) in the United States from 2007-2010. They used birth certificate data files from the U.S. Centers for Disease Control’s National Center for Health Statistics for singleton newborns >37 weeks and >2500 grams.

In order to trust the results of any study we must first trust the information upon which the study is based. A retrospective study of birth certificate records, especially as used in this study, is ripe with unreliability. A simple example is the inability to determine precisely who attended a birth as the signature on the record does not mean that practitioner was actually there. I have signed birth and death certificates in my career for patients I did not care for simply because I was the physician on call and was asked to do so by the hospital staff. In 2003 the standard Certificate of Live Birth was upgraded to include the location of birth as hospital, birth center, or home. And it was further specified as accidental, intended, or unknown if intended. In 2008, only 27 states were using this upgraded form yet the Grunebaum study admits to using all U.S. births from 2007-2010 that met their inclusion criteria of >37 weeks and >2500 grams (of the 16,693,978 births they included 13,891,274). The second study I will discuss calls this methodology into question as their use of the more accurate revised form had them exclude nearly 50% of American births in the year 2008 alone. To summarize, birth certificate information is notoriously unreliable and often does not differentiate whether the birth was planned or unplanned, attended or unattended. Yes, someone has to sign it but it does not mean the doctor or midwife signing actually attended.

The authors then rely on the 97.5% of states (?) that had collected data on the presence or absence of neonatal seizures or serious neurologic dysfunction in their birth certificates. I would question the reliability and collection methods of this data. The definition of a neonatal seizure is seizures occurring in the first month of life. Birth certificate data is usually filled out in the first couple days of life. I am not sure how the authors then used this data responsibly. Also, it would be important to know long term outcomes of the neonates who experience seizures or serious neurologic dysfunction and how that correlates to lifelong disability. This study does not clarify this endpoint.

The term relative risk (RR) is used in this study to emphasize their conclusion that homebirth attended by a midwife has an overall 10.55 RR of a 5 minute 0 Apgar score. The RR is slightly higher in primips than in multips for all categories but RR can be quite misleading especially in the headline of a press release which was their intention, I believe. The overall risk in this study of a 5 minute Apgar score of 0 in the hospital attended by a physician was 1.6/10,000 births. For home births with a midwife it was 1.63/1,000. While this is a 10-fold increase it is still rare when you consider all the other risks of birth. It is purposeful deception to use statistics selectively in this way. Especially when they conclude that all obstetric practitioners must disclose this information to all pregnant women who express an interest in out-of-hospital birthing. “Surprisingly”, this article concludes with a recommendation that concurs with an article written last year by Dr. Chervenak on the professional responsibility of physicians to recommend against planned out-of-hospital births to women who express an interest in it. Amazing that based on a risk of .163% of a 5-minute Apgar of 0 doctors are told to advise against home birth but a 33% risk of surgical birth is no problem. A higher risk of infection, breast feeding issues, psychological trauma, mother-baby separation, induction/augmentation are not reasons to warn mothers against hospital birthing? The skewing of data to funnel women down the medical path is without shame. What more can I say?

Well, on this article there is one more glaring point to make. I could not find anywhere in this article a distinction between a live born newborn with a 5-minute Apgar of 0 and a stillborn. If a woman at term was diagnosed with an intrauterine fetal demise at term and chose to have her baby at home would that count as a 0 Apgar at 5 minutes? Finally, I have spent more than 27 years working in hospitals with NICU teams. When a baby is born with a very low or zero Apgar at 1 minute it is pretty much standard of care for the NICU team to rush in and perform their initial magic of resuscitation. Even if the baby were to be allowed to expire at 30 minutes or was to be revived only to die hours or days later the Apgar score at 5 minutes would not be a 0!! I would submit that the risk of 0.16/1000 for a 0 Apgar at 5 minutes in the hospital setting as quoted in the article is artificially low. And if this reasoning sounds logical then the entire premise of using the 5-minute Apgar score as a marker of quality of care by practitioner or location is undermined and serves to fit the Chervenak model of selective ethics! Maybe it would be professionally responsible for physicians to tell their patients that!

(Please see my comments following this blog)

The second article on page 325 in the October 2013 issue of the AJOG is titled, “Selected perinatal outcomes associated with planned home births in the United States” by Y.W.Cheng, MD et al, from UCSF. This was a retrospective study, also, of term singleton live births in the U.S. in 2008. Of the over 4,000,000 births that year, 2,081,753 met the study criteria of using the 2003 birth certificate revision discussed above. Of these births 0.58% were planned home births. They found that planned home births had a higher rate of 5-minute Apgar score less than or equal to 4 with a RR of 1.87 (3.7/1000 vs. 2.4/1000) and a RR of 3.08 for neonatal seizure (6/10,000 vs. 2/10,000). They also concluded that women with planned home birth had fewer interventions such as operative vaginal delivery and induction/augmentation. They also broke down planned home births by CNMs or “other” midwives.

Their findings and the presentation of their data in style seemed much more neutral and unbiased. For instance, they do state that infants born to women with a planned home birth are more likely to have a neonatal seizure (6 vs. 2 per 10,000, still a small number) but also say that NICU admission was lower among infants of planned home birth (RR 0.23). They did emphasize that outcomes for homebirths with CNMs did not differ significantly from hospital births but that with “other” midwives the risks were greater. However, I could not find a definition for “other” midwives in the article.

I found the self-reflection and critiquing of their own research to be honest and refreshing in stark contrast to the first article’s air of certainty which feels like smugness to me (my bias!). Cheng, et al admit their study has limitations. “As a retrospective study, it may have included confounding or missing data that could potentially bias our findings.” They go on to say, “….administrative data, such as birth certificate data, may contain inaccurate information.” Now isn’t that refreshing to hear from a researcher? They also honestly admit they could not identify or differentiate women who planned a home birth but who were transferred to hospitals which they admit occurs in 10-15% of planned home births  (Notice the use of 10-15% rather than the skewed numbers of up to 47% Dr. Chervenak used in a previous opinion piece last year). This could elevate the risks at home but they admit they cannot be sure. Finally, Dr. Cheng concludes, “Because of the complex tradeoff between maternal benefits and neonatal risk, women who contemplate location of birth should be fully informed about both sites”.

Here are 2 articles, side by side, both presenting a selected endpoint on the outcomes of term singleton births by location and practitioner. However, the difference in style and honesty is striking. The first article has a co-author with a deserved reputation for skewing his data to fit his ideology. While I cannot quantify his influence on his fellow co-authors I can use experience and common sense to recognize bias, selective data mining, intentional omissions and flaws in methodology and conclusions. It is important for all of us to look at research with a critical eye. Understand that relative risk is rendered far less meaningful when we are comparing a small number to a multiple of a small number. I must agree with Dr. Cheng. Once the sperm and egg unite there are risks assumed. True, not skewed, informed consent must be given about all options. And respect for the individual is paramount for it is the essence of ethics to respect the autonomy of patient decision making and it cannot be expected that given the same information two people with differing life experiences will always reach the same conclusion. Finally, good science does not need to be preempted by a press release. I have been concerned of late that science is more and more being corrupted by money and ideology. While we may not prevent this we must remain aware of it and read critically and maintain a healthy skepticism.   

Dr. Stu

www.drstuspodcast.com

We need a better way to dialogue

The American Journal of Obsterics & Gynecology has recently published Dr. Chervenak's response to my letter to the editor which I wrote in response to his opinion piece against planned home birth. I have commented on this in a couple of blogs on this site (see November 2012). I even went so far as to put together a power point presentation breaking down his arguments and would be happy to debate him in an honest forum. My letter was published last April but the AJOG rules of LTE are very restrictive and I was limited to 400 words. In his rebuttal to me letter he continually sites that I did not prove what I said or that I lacked documentation or failed to provide supporting evidence. These tasks are pretty much impossible with 400 words. A fact I am sure Dr. Chervenak is aware since his rebuttal to me was allowed 641 words. This is the serious defect in our ability to communicate differing views to the powerful in academia and simply leads to childlike finger pointing and ego inflation without any real chance of clarity and honest dialogue. His reliance on studies, often ones in disrepute, skewing of data and denial of or failure to accept evidence and common sense contrary to his desired outcome of his opinion piece is a common thread in many of his thoughts and papers. I accept that he is a bright man with differing views than mine. My point is not to convince him of alternatives. My ideal is to present clarity over agreement so readers and my medical colleagues have the basis on which to make their own decision. Here is a link to his original article (which might be password protected), my 400 word limit letter to he editor followed by his 641 word response.  Lastly, kudos to the American Journal for publishing a midwife's response, as well, which I have also posted.

Dr, Fischbein's LTE:
In a recent opinion piece, “Planned home birth: the professional responsibility response,” Chervenak et al¹ argue against the ethics of home birthing stating that advocates of planned home birth have emphasized 4 points: patient safety, patient satisfaction, cost-effectiveness, and respect for women’s rights. “We provide a critical evaluation of each of these claims and identify professionally appropriate responses of obstetricians and other concerned physicians to planned home birth.”
Regarding patient safety, the authors say, “Maternal and fetal necessity for transport during labor is often impossible to predict.” Home birth women by definition are selected based on their health. They labor as nature intended without interventions. In experienced hands, transport is rarely “impossible” to predict. The authors state the most common reasons for transport are pain relief and prolonged labor, neither being unsafe. The argument against home birth in the United States continues by presenting safety data from South Australia, a system that has no resemblance here.
The authors state, “It is antithetical to professional responsibility to intentionally assign any damaged or dead pregnant, fetal, or neonatal patient to this category, even if the number is small.” Yet ample evidence exists that similar cohorts of normal women delivered out of hospital vs a hospital have cesarean section rates of 6% and 24%,² respectively. By that standard the increased morbidity of the hospital model if held to the same standard would be professionally irresponsible.
Regarding patient satisfaction, the authors assume the high rates of transport undercut the raison d’être of planned home birth. A Dutch study from 2008 showing persistent levels of frustration for up to 3 years in 17% of transported women is cited.³ That implies an 83% satisfaction rate. A fairer comparison would be the satisfaction rate of US women with successful home vs hospital births. I disagree with the solution of supporting “homebirth-like” environments in the hospital setting.
Minimal savings in cost comparison data from Britain are cited, vs US cost comparisons. The cost of a typical home birth in the United States is about 35% of that in hospitals. Savings over a cesarean birth approach 80%.⁴ When cesarean section rates approaching 35%⁵ are factored in, the savings is even more significant.
Regarding women’s rights, the authors avoid using the beneficence-based model of ethics which, as with vaginal birth after cesarean, supports a woman’s reasonable choice.⁶ Instead it is stated, “From the perspective of the professional responsibility model, insistence on implementing the unconstrained rights of pregnant women to control the birth location is an ethical error and therefore has no place in professional perinatal medicine.” But home birth advocates do not support unconstrained rights or rights-based reductionism.


Dr. Chervenak's Rebuttal:
Dr Fischbein claims that our criticism of planned home birth from the perspective of the professional responsibility of obstetricians does not succeed. Ethical analysis of planned home birth, like ethical analysis of all topics in obstetric and medical ethics, should be both evidence-based and argument-based.1
On the topic of patient safety, Dr Fischbein states that the need for transport can be predicted in “experienced hands” but provides no documentation for this claim. The Birthplace in England study reported on transport rates as high as 45%.2 Dr Fischbein bears the burden of proof to identify evidence-based criteria for the reliable prediction of the need for transport and fails altogether to meet this professional obligation. He then states that “pain relief and prolonged labor” do not indicate unsafe clinical conditions, again without supporting documentation. The claim that the experience in another country does not apply in the United States requires Dr Fischbein to demonstrate the disanalogy, which he does not do.
Dr Fischbein states that a cesarean delivery rate in the hospital setting of 24% results in an unacceptable increased morbidity when compared to the out-of-hospital cesarean delivery rate of 6%. As applied to planned home birth, the claim is absurd, inasmuch as cesarean deliveries are not performed in the home setting. Even if the comparison were not absurd, simply reporting the rates of a procedure in the absence of outcomes data does not count as evidence-based reasoning. Worse, the paper that Dr Fischbein cites provides outcomes data on care in birth centers.3 Planned birth at home, the focus of our paper, is not planned birth at a birth center. The outcomes in the latter cannot be represented as the outcomes of the former. The disanalogy is obvious–and egregious.
Regarding patient satisfaction, our point in citing the Dutch experience was–and remains–that in one of the most highly developed home birth systems in the world there are significant rates of failure to achieve patient satisfaction. A dissatisfaction rate of 17% is high per se and therefore intrinsically clinically significant. Asserting the obvious corollary of 83% satisfaction should be read for what it is: an attempt to distract the reader from a substantial, documented problem with planned home birth. Dr Fischbein then states that he disagrees with national efforts to improve the homelike setting of hospital delivery without any supporting reasons. Asserting conclusions in the absence of supporting reasons is what Plato–long ago–had Socrates in the Dialogues characterize as “mere opinion,” which never counts as argument-based reasoning.
As to cost-effectiveness, we emphasized that analyzing the cost of home birth by comparing charges for home birth to charges for hospital birth is incomplete and therefore potentially misleading. Dr Fischbein’s invocation of relative costs of vaginal vs cesarean delivery does not address relative overall cost. His claims about comparative cost are therefore incomplete and misleading.
As to women’s rights, Dr Fischbein invokes the ethical analysis of vaginal birth after cesarean delivery by Charles,4 who argues that the autonomy of pregnant women is justifiably constrained by the professional judgment of obstetricians about what is medically reasonable.4 Dr Fischbein neglects to inform his reader that Charles4 bases her argument explicitly on our approach to obstetric ethics. Having rejected our approach (albeit without any supporting argument), Dr Fischbein invokes a paper based on it. Dr Fischbein succeeds in both deceiving his reader and violating the principle of noncontradiction. This principle forbids simultaneously holding a proposition and its denial to be true and is therefore a disabling mistake in both evidence-based and argument-based reasoning.
Planned home birth is a serious topic in obstetric ethics. Judgments about its ethical acceptability must therefore be deliberative–explicitly appealing to the results of evidence-based and argument-based reasoning.5 Dr Fischbein’s letter does neither and therefore makes no serious contribution to how obstetricians should understand their professional responsibility concerning planned home birth.

Midwife's Letter To the Editors:

The clinical opinion related to planned home birth by Chervenak et al¹ requires a midwifery response.
Home birth is a complex choice that includes the rights of women over their bodies; these rights do not go away because health professionals or governments ban them. The authors suggest that women’s rights should be superseded by the clinician’s obligation to protect the pregnant woman and the “fetal, neonatal patient.” This paternalistic discourse privileges the baby’s rights over that of the woman’s. Any risk to the baby’s health dominates with woman’s rights and risks to the woman’s health subjugated. A civilized society considers women to be more than just vessels to grow babies. To postulate that women’s opinions, concerns, and intelligent consideration for their own health and their baby’s health should be superseded by an obstetrician is unacceptable. The argument by Chervenak et al¹ that a woman’s right to make decisions and control what happens to her body is a “purely contractual model” and “rights reductionism” is contrary to the human rights movement. The United States, as a signatory to the Convention for Elimination of Discrimination against Women, recognizes this important principle.²
The authors assume that hospital birth and obstetric intervention will confer improved safety and better outcomes but the US cesarean section rate has increased far more than its rate of decreasing perinatal mortality and the United States is one of the few developed countries with increasing maternal mortality, yet Caution needs to be taken when discussing safety and safer care; until such a time as there is no mortality or morbidity associated with childbirth, no one can promise complete safety regardless of birth setting.Women worldwide cite the loss of personal autonomy and increasing use of interventions in hospital birth as unsafe for both them and their babies and see this as an unacceptable risk. When this is put in the context of comparable perinatal outcomes for the baby many women consider that hospital birth provides an increased risk with few benefits for them.
If women are supported, listened to, and provided with information they will make decisions based on the best outcome for them and their baby. Health professionals providing maternity services should be seeking to provide safe, woman-centered care for all women regardless of where they choose to birth.

Wouldn't it be great if those on high in academia with opposing views were willing to come and speak at, say, the international breech conference or a gathering of homebirth advocates? Wouldn't it be great if academia invited those of us with legitimate alternate points of view to speak at their conferences. The dialogue would be amazing. I have heard all of their arguments but I can tell you that almost none of the residents and students have ever heard any of mine. Sadly, this tit for tat silliness through edited letters that take months to publish and can be quite time consuming for those of us not on academic salary is a poor way to communicate. What happens mostly is what ACOG district VIII is doing next week in Hawaii by having a lecture on home birth at their conference given by Amy Tuteur, a notorious anti-midwife, anti- homebirth blogger. C'mon academia, you can do better. We have so many outstanding intellects and actual practitioners of the trade who are willing to have courteous dialogue in real time.

Dr Stu

From their fruits ye shall know them

Today is the Jewish New Year, Rosh Hashana. It is a time for renewal, a time for family and, soon, will come a time to atone for one’s sins on Yom Kippur. In order to really ask forgiveness for a sin we must first recognize that we have sinned. Once recognized, moral teaching would hope that we accept self-reproach. Penitence is showing remorse for having done wrong. Only to a penitent man can come redemption, and a man redeemed will experience happiness and joy in work and life much more readily.

“It’s not who we are but what we do that defines us”, so says the superhero in a recent Batman movie. And while not all movies contain such wisdom, on occasion they do. Good men and women, loving to their children and respectful of their parents, can sometimes do bad things. It does not mean they are bad people. For example, a businessman may be a great father and donate time and money to local charities but end up going to jail for embezzlement a la Bernie Madoff. Which leads me to my point; how does a good person become a bad doctor? How has a hospital become more of a danger to birth than a benefit? Specifically, how have the practitioners of medicine evolved from the noble, “first do no harm”, to embrace a culture of expediency, cowardice and fear. And how has the hospital machinery, what is considered the norm today, really performed when it comes to outcomes over the last generation?

If you have followed my writings, talks, blogs and more recently my podcasts you will know the answer to many of these questions. More than 50 years ago the takeover of medicine began by the profiteers who, by definition, looked at the business side of medicine as if it were an automobile factory. How to become more efficient? How to avoid liability? How to control costs? Essentially, how to control everything! But medicine is not automobiles. It’s people, individual people, often with life altering issues that don’t fit the assembly line thinking. It’s messy by the businessman’s standard. But rather than realize that, or maybe even despite realizing it, there was just too much money to be made and power to be had by taking it over. Lost in this was the lonely patient. And soon even the practitioner, the person actually doing the work, was just a cog in the machine. Initially, a very noisy cog but gradually the noisy cogs get “greased” and became what they once detested or they are beaten up and replaced by the system. Doctors either become a “part of the crew, part of the ship” (to ironically quote another Pirate story) or they were tossed overboard, sometimes metaphorically and sometimes literally.

With the seeming inevitability of a government takeover of healthcare and the race to socialized medicine this metamorphosis will be complete. The designed impersonalization of the system frees any one or group of people from responsibility. And once an immense and monolithic entity is freed from any culpability it will always lead to corruption and tyranny. It will be like the current Internal Revenue Service scandal of oppression where no one is responsible and those that should be plead the Fifth Amendment and are never brought to task. However, unlike the IRS, those that seek the takeover of the health care system will sugar coat their motives under the disguise of “safety”. “The welfare of humanity is always the alibi of tyrants” was written by French Philosopher Albert Camus almost 60 years ago. Awareness of this mechanism is of utmost importance for it explains much about the fruit our system is baring.

How is it that good, well-meaning people inside the system have let this happen and may even support it? It is human nature for members to want to be accepted in their group and for many it is their dominating psychological motivation. When the businessmen, lawyers, politicians and administrators who run health care now send out a message of how things are to be done, well, who are the nurses and doctors, dependent on the system for their livelihood, to complain? And so these good people who admittedly love their families and possibly regularly attend their church just easily surrender to EMR and to limited formularies and to restrictive policies like VBAC bans and mandatory lab tests and one size fits all lengthy admission forms and annual board recertification and silly mandatory human resource seminars. Need I go on? Policies and actions that put individual patient’s desire and rights off the radar screen if not dead last. Not only do the caregivers submit but they begin to defend their behavior as “standard of care”! They join committees and participate in this bureaucratic process so as to be accepted and “part of the crew…” Even when they know there are other options and evidence supported choices. I suspect that the administrators and their ilk know this, too. And in order to justify the correctness of their position they ridicule or ignore evidence to the contrary. This is called cognitive dissonance and I have written on this before. (“Safety or Cognitive Dissonance” May 27, 2012  http://www.supportdrfischbein.blogspot.com/2012/05/safety-or-cognitive-dissonance.htmlhttp://www.supportdrfischbein.blogspot.com/2012/05/safety-or-cognitive-dissonance.html   )

The failure of good people to stand up on behalf of each individual family they care for may be practical but let’s not call it right. The good people that leave their home each day to drive to work at the local hospital do not say to themselves, “Let’s see what mischief I can cause today for some poor suffering patient” or “Let’s see how impersonal I can make our policy so that I limit the institution’s liability”. But somehow that is what happens each and every day for over 50 years in this profession. In 1970, the cesarean section rate in the United States was < 6%, In 1990 it was 22% and now in 2012 it is 32.8%. There has been little decline in the neonatal death rate between 1970 and 1990 and almost none in the last 23 years. Yet the cesarean section rate has gone up 500% since 1970 and over 50% in the last generation with no measurable benefit. Did something suddenly happen to an American woman’s pelvis in one generation? While some modifications of policies are all too slowly reappearing we still have archaic, often ridiculous policies affecting laboring mothers negatively. Some are restrictive movement, restrictive oral intake, standardized charting requirements leading to interruption of natural labor, 90% epidural rates, mother-baby separation and over testing for questionable indications often resulting from economic gain and fear. This fear comes, not so much in the mother, but emanating from the practitioner who endures the realities of the professional climate rather than speak out. A great proportion of women do not have fond memories of their birth process and many women will suffer lifelong emotional and physical trauma from unnecessary inductions and cesarean sections. Babies, too, do not benefit from what is so often considered standard care. Early induction or surgical birth leads to increase risks of lifelong health issues. Ubiquitous standardized policies of immediate vaccination, eye care in culture negative moms and interruption of bonding are for what benefit again?

Courage is the rarest of good human traits. It is not courageous to stand up in front of a group and say what they want to hear. It is courageous to take a moral stand into the lion’s den. My colleagues are good people but they are not courageous. Those that purport to run healthcare, the businessmen, their lawyers and the politicians are worse because they disguise their motivation in the sheep’s clothing of safety. They have to know these outcomes are not what they should be. They have to know the policies they follow when it comes to birth are often dead wrong. How could a 33% cesarean section rate be acceptable to them. Why do they treat mothers and babies as two separate entities? There is so much reliable data that other options are reasonable. They do not respect the individual or the right of informed consent and refusal. And, quite frankly, in normal healthy mothers their statistics and outcomes are awful. Individuals are often good people. When they join organizations, however, they can become conflicted and end up doing bad things. The outcomes of groupthink are easily corrupted and rarely pure and morally upright. Just look at history. The fruits of the impersonal system of healthcare we call normal are rotting and subjugation to this model has not led us to higher ground. On this we should reflect and repent and the Jewish New Year can be an inspirational time to do so. We can redeem ourselves by doing better on behalf of our patients and our souls. Our acts are what define us. “From its fruit shall the tree be known.” (Matthew 7:16)

Shana Tovah, Dr. Stu

Student Intern Experience

For 2 months this summer I had a premed student spend 3 days a week with me as a student intern. I had a great time with Marybeth and it was a learning experience for both of us. What follows is a brief summary of her experience and I am hopeful that more students will follow in her footsteps. I look forward to the day when current medical students and possibly even obstetrical residents will desire to step out of the academic medical bubble and experience another way of doing things. Dr. F

"I started my internship hours on Wednesday, 18JUN13.  I arrived at The Sanctuary Birth and Family Wellness Center for 1300 in order to do requisite confidentiality paperwork and got a brief familiarization with office procedures such as prepping files, keeping track of client due dates, etc.  Dr. Fischbein had 4 clients scheduled for the day.  I got to participate in 2 ultrasounds, both were 20 week anatomy scans and both families wanted to know the sex.  One of his clients is pregnant with twins.  After Dr Fischbein chatted with patients, he referred to me if I had any questions and gave my direct patient contact time.  I also took a fundal height using a tape measure on the twin's mama's belly.  Because one of his clients canceled, I used the most of my hours at the clinic to read up on the twin situation and review the chart to see if the twins were monochorionic and/or monoamnoitic or not.  

Dr Fischbein prefers to sit with patients in his office fully clothed first and discuss their concerns before they go to an exam room.  He likes to take his time with patients.  So we did another ultrasound, this time a vaginal one to try to get a gestational date because they are more accurate for crown rump length that early than the belly ultrasounds.  It's was a struggling pregnancy and before the end of my internship it did result in a miscarriage.  Then there were 3 pap smears with 3 CBCs and 3 breast exams.  

The internship continued in this fashion. In order to meet my first goal of learning about the birthing process, I attended on home visit with Dr. Fischbein, one homebirth, and one post-partum visit.  The homebirth was very intense for me.  Initially I just observed quietly while she labored and pushed in the birth pool.  Occasionally the midwives asked me to fetch warm water for them and such.  Dr. Fischbein mostly hung back on the couch so that the midwives could do their thing without him interfering as he is there for backup.   This mama had been laboring for many hours and was getting tired so they called Dr. Fischbein into action.  After mama did some solid pushing in the tub, on the birth stool, seated in her husbands lap, and in their bed, everyone agreed it was an ok time to help with some forceps.  Dr. Fischbein always found a way to pull me in and give me lessons on things, so while mama was pushing from her own bed, she was at the edge with a foot up on my shoulder and I held her leg so I was right up close and personal with this birth.  He first assessed the head by finding the sulcus because he told me you can only use forceps when baby is in certain positions, otherwise it is too dangerous. He explained the risks like bulldogging shoulders and dystocia to the mama and daddy. Once he determined baby was in a good position for what type of forceps he would be using, he numbed mama with some novocaine in case he ended up doing an episiotomy.  I got to see him get the forceps in place, again right up close and personal with a foot on my shoulder and her leg in my hands, and with each contraction mama pushed, he wedged the forceps with baby out a little more, and I had a front row seat to all of this.  He did end up doing the episiotomy, a quick clean cut which gave more room for the forceps and within seconds baby was out and on mama's chest and she had the drug free homebirth that she wanted after all.  It was amazing.  The cord stayed attached for quite awhile as it finished pulsing so that baby could get all her good oxygen and blood from there.  The family had their time to be gentle and relax and the midwives went back to work with the rest of it, helping the placenta, etc, and then Dr. Fischbein was back in the game to repair the tear.  He explained that sometimes mamas get tears along the sides from forceps but this mama luckily didn't.  I held the spotlight while he repaired the cut.  I'm not going to lie, it was a lot of blood.  A lot of blood.  Once he got done with the repair, it hardly looked like much had gone on down there at all.  

Overall I participated in over 20 ultrasounds, some for pregnancy, some for fibroids, some for cysts.  By the end of the internship, I was able to start making out images on my own.  Like anything, it is its own language in a way, and you have to develop fluency in it.  Ergo, I was easily able to meet my goal of learning how to use ultrasound as a diagnostic tool.  

In order to achieve my third objective, like all the previous objectives, it depended upon what the patients presented.  Nobody needed an external version and nobody ended up being a breech vaginal delivery.  I did, however, do urine tests, which is really simple and just involved dipping a color-changing wand into the urine and comparing the results to the answer key if the urine had any protein or sugar in it.  I also attended LE Leche gatherings and was able to assist pre-natal mamas in preparing for breastfeeding.  One mama asked if drinking beer really helped to increase supply and I was able to provide her with sound, good guidance.  It was pretty nice that Dr. Fischbein would just refer to me when any of his patients had breastfeeding questions.

I enjoyed everything about this internship.  It was an absolutely amazing experience.  The only thing I really felt disappointed by was that I didn’t get to see more breech work or a breech delivery. I’m very grateful to SMC for having such an opportunity to design one’s own internship and incredibly grateful to Dr. Fischbein for patiently allowing me to walk in his shadow for two months. I am also amazed by how much I learned and did in just 2 short months with Dr. Fischbein.  He was an incredible mentor."

VBAC is Normal

All you have to do is look at Beth's face to understand the miracle of normal birth. Baby Maiya, born by VBAC today at the Santa Clarita Birth Center in Newhall, CA. Keeping it positive. No other words necessary! Congratulations Beth & Robert. Thank you Renee, Juli & Victoria.  Dr. F

Acceptance yes, but not Acquiescence!

(Printed with permission)
Yesterday I flew to Minneapolis for a family gathering and to honor my father on his upcoming 93rd birthday. And, yesterday a lovely couple in southern California had their beautiful baby born breech....by cesarean section.

Flashback to 10 days ago: I received a call from a couple living in San Diego about to have their first baby. Planning a home birth all along they discovered at 38 weeks their baby was in the breech position. Their midwives suggested many of the usual techniques such as chiropractic adjustment, acupuncture with moxi and position changes but to no avail. They were referred to a very nice doctor in the area who scheduled them for a cesarean section. They were never given the option of a vaginal breech birth. Typical of the home birthing culture they were well informed and looked into this option on their own via an internet search which is how I came to meet them.

10 days ago they drove up to Los Angeles for a consultation. We talked for an hour and a half about options and discussed the current literature as well as risks and benefits of both cesarean and vaginal delivery. I gave them copies of Dr. Marek Glezerman's great review on the subject and did an exam and ultrasound to be sure she met the criteria necessary for a safe vaginal birth. Their baby was in the complete breech presentation, flexed head, 7+ pounds, normal anatomy and clinically generous pelvis. And, of course, they truly had the right "mental stuff". Perfect! And even better, they had family in nearby Thousand Oaks, California who were happy to allow them to stay and have their baby at home. So all we had to do was wait for labor to ensue. The only hiccup in the plan was that for months now I had a vacation with my daughter planned and so purposely did not take any regular clients at that time. But breech babies are determined late and, surprise, like many aspects of pregnancy they don't know there is a plan.

So, they moved in to the sister's home and we all crossed our fingers. On the day before I was to leave she came to the office at 38 6/7 weeks announcing she probably passed her mucus plug (oh oh, we could see where this was going). We already knew there were no options she could find in San Diego and the only other breech supportive doctor in Los Angeles, a city of 4 million people, over 100 hospitals and 10 million in the whole metro area was not an option for this family. Two obstetricians in a city of that size who openly and willingly support the evidenced based option of selected vaginal breech delivery. One supporting home delivery and only one supporting hospital birth. Shameful!

Aware of my travel plans, together, we came up with the backup plan of going back down to San Diego while I was away and if labor happened, well, that was baby's decision and they would have a cesarean section with the nice doctor they had met near home in familiar surroundings and close to their midwives. Sure enough, about 7 hours before I was to leave my cell phone rang to say she broke her bag of waters. "Clear fluid!", she proudly announced in her always optimistic and cheerful voice, "But feeling no contractions". We had a nice but brief talk in her car on the freeway back to San Diego. By sunrise she was being prepped for her cesarean and when I reached Denver to change planes I had a beautiful picture of her baby on my phone and a lovely message of thanks. A happy ending and a great lesson in acceptance from a very special couple. So then why did I feel so sad?

That's a rhetorical question, of course. I am sad that informed and legitimate choice is being denied all over our country. I am sad that the leaders of my profession sit idly by and do nothing to train future doctors in the skills of breech delivery. I am sad that hospitals and obstetricians and committees and administrators discourage a reasonable choice. I am sad that insurers and lawyers, who live symbiotically, continue to be the medical decision makers in America. I am sad that when I take rare and deserved time off there is essentially no one to cover me. And, I am sad that this wonderful couple could not experience what they wished for and may now have to deal with the whole VBAC problem next time. I am sad and I am angry. And you all should be, too.   Dr. Stu

Revisiting The Vaccine Question

The to vaccinate or not to vaccinate controversy is far from ended despite a recent statement from the CDC based on an Institute of Medicine (IOM) review that concludes, "the evidence favors rejection of a causal relationship between thimerosal–containing vaccines and autism". I have seen this statement repeated in many recent news items including one in USA Today yesterday. (That just doesn't sound right....USA Today yesterday). I do not profess to have any expertise on this subject other than what I hear and read. Which means I am as confused as you are since the truth does not seem as black and white as the IOM would have us believe. I also, do not think there is any conspiratorial process going on between big Pharma and big Government.

So, when asked my opinion recently by a client I was happy to be able to refer them to Jennifer Margulis' new book, "The Business of Baby". Its subtitle talks of what doctors won't tell you and what companies try to sell you and how to determine what's truthful. She presents an extremely well researched and referenced discussion without a personal agenda. Vaccines have performed miracles in the 20th Century, eradicating polio and small pox and minimizing risks from a variety of illnesses from mumps to measles to tetanus. When I traveled to endemic areas I did not hesitate to get vaccinated for yellow fever.

But, as will all aspects of life and, as I have related to pregnancy, there is nothing that is risk free. In my career I have seen a case of Guillain-Barre Syndrome related to a routine vaccine. We know that if the threat of a small pox epidemic from bioterrorism were ever to occur that the vaccine would save millions of lives but a few people would have an allergic reaction and die. Because of our ridiculously litigious American society this predictable and medically acceptable risk would result in lawsuits and has scared so many small pox vaccine manufacturers that only one company remains. Not having the capability of having this vaccine mass produced could be devastating. But I digress.

Whether to vaccinate or not is a personal decision that each of us has to make for ourselves and our children. What I can say is that in healthy women I see no reason to give universal hepatitis B vaccine to a newborn as is the policy in many hospitals. Always ask about this one. It makes absolutely no sense in families who are not active hepatitis B carriers. And almost every pregnant woman is routinely screened for this. Measles, mumps, Rubella, chicken pox and such options as Guardasil for HPV and the flu shot are never mandatory so do your own research as to the pros and cons. (One article out of Japan has shown that high doses of daily Vitamin D has been more effective against the flu than vaccination. Reminder: This study does not end that debate, either.)

I will end this blog with one last example of the rigidity of the academic-medical model taught to most pediatricians. A story related to me by one of my current pregnant clients and one that I hope most pediatricians would abhor. While searching the area for a supportive pediatrician she asked his position on routine vaccination. He stated that he recommended the standard vaccine regimen but that he would still accept her baby into his practice if she chose not to. This sounded most reasonable until he added that if she chose not to vaccinate her baby that he and his associates would only be available for her phone calls during business hours. He would not care for her baby after hours and on weekends should her baby become ill! Seriously, that is what she was told and I believe her. Off to the emergency room with you! As I think about it I am still shaking my head. How does a person say something like that? Does it not seem a bit unethical to that physician? It would be much more honorable to suggest she go elsewhere. I guess this is the new ethics and there is no vaccine against it. Caveat Emptor!

DrStusPodcast.com

Ok, so many of my colleagues have noted that I always have an opinion and usually a strong one and a relevant one. They say, and I agree, that I should get out there more and advocate for the good things we do to counter so much of the bloviating that goes on from those against reasonable ideas and choices in birthing. Finally I have taken this advice to heart. It is with excitement and a big smile that I am announcing the creation of my very own podcast with original name of Dr. Stu's Podcast with Brian Whitman at www.drstuspodcast.com

Brian is my friend and an accomplished radio personality currently on morning AM radio 870 in Los Angeles and brings his expertise and wit to the show. We discuss timely medical issues and current events. No topic is off limits from the medical world to politics to current events and, of course, LA Kings hockey. Its an informative, informal conversation and banter so come join us. Your support, as always, is appreciated.

Listen online or download for free on iTunes as Dr. Stu's Podcast. The first 3 episodes are up. I will be adding at least 2 new ones every week. Please pass it on, give it a high "5" ranking. Comments and questions are welcome at drstuspodcast@gmail.com

Truth v. EDA, Preparing Ourselves Part 1

This is a longer version of a letter to the editor I had published in the AJOG in response to an opinion piece by a physician and ethicist who has previously stated his dislike for all things home birth. Should a home birth antagonist whose name shall not be spoken quote these opinions as fact in some future presentation, say in Hawaii, maybe in the end of September then it will be good to have honest, coherent counter arguments. Hope this is helpful,  Dr. Stu

Redefining Ethics. Truth or Tyranny? 

In a recent opinion piece published earlier this year in the AJOG, “Planned Home Birth: The Professional Responsibility Response”, Chervenak, et al(1) argue against the ethics of home birthing stating that advocates of planned home birth have emphasized 4 selling points: patient safety, patient satisfaction, cost effectiveness, and respect for women’s rights. “{The Authors} provide a critical evaluation of each of these claims and identify professionally appropriate responses of obstetricians and other concerned physicians to planned home birth.” Most of what followed in the rest of his article was neither inductively or reductively logical.

As to point 1, patient safety, he says, “Maternal and fetal necessity for transport during labor is often impossible to predict.” Home birth women by definition are cherry picked for their health. They are allowed to labor as nature intended without interventions. In experienced hands, transport is rarely “impossible” to predict. He states the most common reasons for transport are pain relief and prolonged labor, neither being unsafe. He continues his argument against home birth in America by presenting safety data from South Australia, a system that has no resemblance here.

He summarizes his anti-safety position this way: “It is antithetical to professional responsibility to intentionally assign any damaged or dead pregnant, fetal, or neonatal patient to this category, even if the number is small.” Yet ample evidence exists that similar cohorts of normal women delivered out of hospital vs. hospital have c/section rates of 6% and 24% respectively (2). By the author’s very own words then, the increased morbidity of the hospital model if held to the same standard would be professionally irresponsible.

As to point 2, patient satisfaction, he assumes the high rates of transport undercut the raison d’etre of planned home birth. He cites a Dutch study from 2008 showing persistent levels of frustration for up to 3 years in 17% of transported women. Conversely, that would seem to imply an 83% satisfaction rate. A fairer comparison would be the satisfaction rate of American women with successful home birth vs. hospital birth, but none was made. His solution of supporting “homebirth-like” environments in the hospital setting, sadly, shows a complete lack of understanding of mammalian birth.

As to point 3, cost effectiveness, he cites minimal savings in cost comparison data from Britain. Again, the author is using foreign data from a country with single-payer, socialized medicine when a simple Google search easily produces reliable American cost comparison data. This tactic is most concerning in its dishonesty. The cost of a typical home birth here is about a third of that in hospitals. Savings over a cesarean birth approach 85% (3). When c/section rates approaching 35% in the hospital setting are factored in the cost savings is significant.

Finally, as to point 4, respect for women’s rights, Dr. Chervenak makes the classic straw man argument. He avoids altogether using the beneficence based model of ethics which, as with VBAC, supports a woman’s reasonable choice (4).  Instead he states, “From the perspective of the professional responsibility model, insistence on implementing the unconstrained rights of  pregnant women to control the birth location is an ethical error and therefore has no place in professional perinatal medicine.” But home birth advocates don’t support unconstrained rights or rights based reductionism. Dr. Chervenak has created a whole new theory of ethics, “professional responsibility ethics”, which in his opinion trumps beneficence based ethics and respect for patient autonomy.

Skewed evidence, selection bias, straw men and anecdotes do not equal data but that is what is presented by the authors as an ethical argument against home birthing. This group of well credential authors has written an article that is more propaganda than evidence based opinion. They might as well have said, ACOG thinks home birth is very, very bad and asked us to make up an argument on their behalf.

1.       Chervenak, FA, et al. Planned Home Birth: the professional responsibility response.  Am J Obstet Gynecol. 2013 Jan;208(1):31-8

 

2.       Journal of Midwifery & Women’s Health Volume 58, Issue 1, pages 3–14, January/February 2013

 

3.       http://transform.childbirthconnection.org/resources/datacenter/chargeschart/statecharges/

 

4.       The Hastings Center Report: “The Ethics of Vaginal Birth After Cesarean”, Sonya Charles http://www.medscape.com/viewarticle/767504_3

 

 

Stuart J. Fischbein, MD FACOG

Medical Director, Sanctuary Birth & Family Wellness Center

Los Angeles, CA

 

A Letter to Sacramento

Dear California Representatives:


I am writing to express my support for the independent practice of midwifery in California and the reasonableness of the choice of home birth. I am a practicing obstetrician, trained at Cedars-Sinai Medical Center, board certified in 1989, a Fellow of ACOG for more than 20 years and co-author of the book, “Fearless Pregnancy, Wisdom & Reassurance from a Doctor, a Midwife and a Mom”. The American College of Ob/Gyn (ACOG) frequently does not represent the majority of its members when it takes a position, and their motivation is not always patient centered. A recent paper published in their own journal reported that 2/3rd of their practice guideline bulletins are based on Level C evidence.(1) Level C evidence, by definition, is not based on the best science and represents only consensus opinion. Truth and ethics should be everyone’s overriding concern. Consensus is frequently assumed to be based on truth when, in fact, it often is not.

Requiring licensed midwives who assist California women with the reasonable choice of home birth to have supervision from obstetricians who are reluctant to do so or are prevented from doing so by their malpractice policy, without first mandating physician supervision in the same law, is essentially a de facto way to eliminate home birth without lawmakers having to overtly come out against choice. I have worked with both Certified Nurse Midwives and Licensed Midwives over the last 27 years as a back-up physician, supervising physician, direct employer, and in collaboration assisting pregnant women with delivering their babies both in the hospital and home setting. This experience makes me uniquely qualified over my academic and administrative colleagues to give perspective to this debate. I am hopeful that what I have to say will cause you to take a moment to reconsider long held positions about the very nature of human birth.

Licensed midwives (LMs) are highly educated, dedicated and nurturing specialists trained in the art and science of normal birth. Physicians are trained as specialists in abnormal or problem pregnancy. LMs spend an hour at each prenatal visit, which allows them to use their expertise in preventative care. Physicians are limited by the medical model to short prenatal visits and are experts at treating disease. Normal pregnancy is not a disease and my physician colleagues do not receive adequate training in normal birth and, therefore, fail to recognize the natural mammalian process of birth. I am certain that a great degree of the friction between these professionals comes from a lack of understanding of what midwives do and how they are trained and the perpetuation of the myth by organized medicine that they are somehow substandard.

My experience with midwives has shown me that they want the best for their clients and are not anti-medical zealots. They seek consultation and transport when appropriate. Ideally, both midwives and physicians would benefit if the supervision requirement was removed altogether and transport was made less stressful. For one of the large concerns of physicians is their vicarious liability as a “supervisor.” Malpractice tort reform would be a benefit to all of California’s health professionals but until that day comes the supervision requirement provision should be removed to protect doctors willing to support midwives and possibly allowing for more to come forward. This might make access to choice for California woman more available and that is a good thing. The countries with the best statistics have home birth supported by midwives and the smoothest collaboration with physicians and hospitals for transport. It is in this area that California has failed.

Medical ethics dictate that patient autonomy and decision-making is to be respected. And not all patients who are given unbiased and true informed consent should be expected to reach the same decision. Physicians have a fiduciary duty and an ethical obligation to discuss the risks and benefits of all reasonable options. In the skewed argument against the safety of home birth the benefits are never discussed. And the counseling given by doctors almost never reflects equally on the safety and risk of birthing in the hospital. The assumption that hospital birthing and the high rate of medical interventions resulting in a 33% cesarean section rate is safer than home birth for low risk mothers should be challenged. A very large and recently published Dutch study in the prestigious British Medical Journal showed home birth of properly selected women to be safer than hospital birth.(2) Women who have been given true informed consent may well choose a home birth and a midwife as the best option for their family. Sometimes, due to restrictive hospital policies or complete bans on certain evidenced based reasonable options, a woman’s choice of a home birth is all she has as in the cases of a vaginal birth after cesarean and breech birth.

I would also like to bring your attention to the argument often given by physicians with contempt for home birth transports because of the occasional bad outcome. Almost all transports from a home birth are for the common issues such as pain relief and exhaustion. All too often the term transport is equated with emergency and that is simply not the case. While it would be wonderful if bad things never happened we should learn from history that trying to legislate absolute safety is impossible and only leads to one size fits all policies which are ethically incompatible with patient autonomy. And while a bad outcome in a home birth gets spread all over the internet, a similar bad outcome in the hospital is hushed up and protected by a veil of confidentiality and HIPPA regulations. Hospitals are not always the safest place to be and certainly not the most nurturing and any honest obstetrician can relate numerous disasters, some preventable and some not, that occurred under the watch of an obstetrician and labor and delivery staff. Hospitals and newborn intensive care units can do wonders when needed and my intention would never be to diminish that. However, we must begin to rethink how we look at normal birth and a woman’s free exercise of all reasonable choices and that is where your leadership is most needed.

In summary, I am hopeful that you will take these points into consideration when you deliberate. Home birth and licensed midwifery are reasonable options and therefore ethically sound. While collaboration between doctors and midwives in many western countries has led to better outcomes and statistics the United States continues to lag way behind. Putting our midwives at the mercy or pleasure of reluctant obstetricians is not a constructive idea. Home birth is here to stay. It is a choice many women want and restricting access to the best professionals through medically unfounded legislation will not serve our citizens well. Collaboration and congenial consultation and transport are what is needed. Please allow licensed midwives the freedom to practice and remove the burdensome obligation of direct physician supervision. The status quo only leads to fear and mistrust because of the overwhelming legal concerns facing every doctor forcing them to make decisions that do not put patients first. I would relish the opportunity and be delighted to discuss any aspect of this issue with you, your distinguished colleagues and any members of the medical community holding an alternate point of view.

Sincerely,

Stuart J. Fischbein, MD FACOG
Home Birthing Specialist



1: Wright JD et al. Scientific Evidence Underlying the American College of Obstetrics and Gynecologists’ Practice Bulletins. Obstetrics & Gynecology, September 2011; Volume 118; No.3; Pages 1-8

2: de Jonge A, et al. Severe adverse maternal outcomes among low risk women with planned home versus hospital births in the Netherlands: nationwide cohort study. BMJ 2013;346:f3263 doi: 10.1136/bmj.f3263 (Published 13 June 2013)

Legislative Alert - AB 1308

Greetings to all of you and hoping this finds you and your families well and expecting of a fun summer. I am writing to ask your help in fighting a provision in a bill currently making its way through the California Senate that could severely affect the ability of licensed midwives to practice in the state. AB 1308, if passed and enforced, would make it a violation of law for a midwife to practice without physician supervision. It has already been passed by the state assembly and is, in part, sponsored by ACOG. The physician supervision provision has been in the statute since 1993 but has never been enforced because it has previously been seen as unworkable. Most physicians are either unwilling to supervise or are prevented from doing so by their malpractice insurance carrier and/or a hostile hospital administration.



AB 1308: http://leginfo.legislature.ca.gov/faces/billTextClient.xhtml;jsessionid=5c82f256d9253d2e4326c4312ddf?bill_id=201320140AB1308



Last Thursday, Adeola Adeseun, the attorney for CFAM (California Families for Access to Midwives) and I met with the aide to state Senator Ted Lieu in Redondo Beach. It is his committee that is currently reviewing the bill. The Senator was in Sacramento but we had a very productive meeting with his aide, Veronica, for over an hour. We need to send a lot of emails over the next 24 hours to senator.lieu@senate.ca.gov



They need to briefly state their support for licensed midwifery, the choice of home birth and then give a little anecdotal story about their experience. Positive tone is preferred but those who had issues with transport, hospital staff and physician reception can also speak up. They should reference AB 1308 and their concern that enforcement of physician supervision in light of modern day realities is likely to be stifling to the reasonable choice of a home birth with a licensed midwife and lead to less, not more, access to a reasonable choice for the women of California. We would prefer they do away with the physician supervision clause altogether in much the same way the chiropractors and acupuncturists are licensed and free to practice independently of orthopedic surgeons. My good friend and associate, Howard Mandel, MD, felt that another analogy might be more appropriate. Family practice physicians often have far less training in pregnancy and birth than a midwife and yet, once licensed and credentialed, are able to practice their trade without supervision. Like midwives, they rely on appropriate consultation. Consultation, not supervision, makes sense. Striking the supervision requirement altogether in the bill would also benefit obstetricians by removing the vicarious liability that some fear when supportive of a local midwife.



Can you please take a moment to email the Senator today? senator.lieu@senate.ca.gov



Also, can you bombard your contacts, friends and supportive family, especially if they live in the 28th district but any will do, and ask them to send an email to their state senator?


It is really important to get this out today.


Below are a few logical and passionate letters written by some wonderful people. I can’t thank them and you enough for the support shown for the reasonable choice of licensed midwifery as an option for the women of California.



Dear Senator Lieu,

I am writing in support for licensed midwifery, and the right for a choice of home birth. I have learned of Assembly Bill 1308 and that if passed and enforced, it would make it a violation of law for a midwife to practice without physician supervision. That provision is completely impractical and unnecessary, as a licensed midwife is fully capable of providing the support needed for the natural delivery of a baby without having a physician present.


I am the mother of two young boys ages 6 and 2. The birth of my first son in June 2007 was a delivery by C-section at Santa Barbara Cottage Hospital after a 30-hour labor due to what the hospital staff determined was "failure to progress." There were no medical issues with me or my baby other than I had been in labor "too long" and I was convinced to have a C-section to give birth to my baby. Fortunately, everything went well and I had a healthy baby boy weighing 6 lbs., 10 oz. A few years later when I found out I was pregnant again, my only birth options where I live in Santa Barbara was to have a repeat C-section, which I did not want to endure again, knowing that my body was fully capable of a normal vaginal birth. No doctors, hospitals, or midwives in Santa Barbara were able to provide me support for a VBAC (Vaginal Birth After Cesarean). To my great fortune, I learned of Dr. Stuart Fischbein who has a practice in Camarillo that would support a VBAC home birth with a midwife present. I had a successful home birth of my second son in April 2011 weighing 7 lbs., 14 oz. after only a 4 1/2 hour labor. Dr. Fischbein and the midwife, Karni Seymour-Brown, were present along with my husband, my parents, and my older son. It was beautiful, it was happy, and it was safe. It wasn't just safe because Dr. Fischbein was there, although he is a well-skilled and knowledgeable medical doctor, but I trusted and knew my body could do it, and I was also supported by the knowledge and nurture of the midwife, Karni. Before I had children, home birth sounded like a radical idea to me, but after becoming educated about it, and about my ability to have the right to choose the birth experience that I wanted and was good for me and my baby, I have realized that home birth is the most natural and beautiful way to bring a child into this world. There is of course a time and a need for medical intervention and transport to a

hospital in certain situations, but that is rare, as are the situations that would arise to cause the need for a transport. Midwives know just as well when medical intervention and transport to a hospital is necessary, therefore requiring a physician to be present is unnecessary. I have experienced first-hand the wonderful care, support, and wisdom that a midwife provides to a mother before, during, and after birth, and I fully support the practice of independent midwifery. I encourage you, and everyone to do the same.


I am concerned about AB1308 enforcing physician supervision of a home birth with a licensed midwife, as the practicality of that does not make sense. A midwife is able to provide full support for a home birth without the need for a physician to be present. Access to this reasonable choice in California to have a home birth with a midwife would be limited with AB1308 in place. Please consider doing away with the physician supervision clause altogether in much the same way the chiropractors and acupuncturists are licensed and free to practice independently of orthopedic surgeons.

Sincerely,
Briana Villasenor
Santa Barbara, CA

Senator:

As the father-in-law of a State licensed midwife, I believe I can speak with some authority on the requirement of AB 1308 to make physician supervision mandatory for home births by midwife.
As my daughter (in-law) completed the rigorous training required by the State of California to qualify for her certification I asked the questions you are no doubt pondering as you consider your vote. Is the training sufficient? Please, if this is not something you can answer in the affirmative, take a close look at the program the State requires midwives to master. Not just complete, but master. There is a comprehensive test involved here, as well as sworn statements by supervising and qualified midwives of hundreds of hours of hands-on experience.

Is there reasonable back-up in the event of a problem beyond the scope of a midwife’s expertise? I do not know the law, but I have spoken to my daughter about my concern. She told me that as the pregnancy progresses she makes contact with the future mother’s doctor and with the hospital the mother would use in case of emergency. Further, she told me that she makes certain emergency transport is available if it is needed. Nothing—nothing—if left to chance. Be assured that no responsible midwife wants a surprise if she has to seek the assistance of a physician. My daughter does not do this to boost her own ego. She is totally caring, devoted to the safe delivery of the child and the health and well being of the mother. The instant a delivery goes outside her comfort zone; she will have the mother transported to a hospital waiting with all required information.

I have a close friend who years ago delivered two children some years apart. I talked with her at some length about those deliveries. The first child was delivered in the same manner as I was. She was in a surgery, she was a patient, and there were masked nurses and a doctor. The labor was a bit slow so she received an injection to speed things up. The doctor used a scalpel. She recalled it being cold, sterile, and not at all fun.

Her second child was delivered at her home in Fresno under the supervision of a midwife. I spoke with her the next day. She was up, feeling fine, very happy, and eager to tell me the details of the delivery, mainly that the experience took place pretty much at her own direction. She was able to assume a position that was most comfortable for her. She was able to choose the music—yes, music. She asked for and was given a cup of tea. Her husband, of course, was present and assisted her with the midwife’s gentle direction. In short, the second birth was pleasantly memorable, unlike the first, which she told me she tried to forget.


The State of California has in place a system which works—works for mothers, for children, for fathers. The State, in it wisdom, has given healthy, responsible adults the right to a birth experience of their choosing while insisting on well trained, licensed professionals to assist. For the State to insist on the direct supervision of a physician over the midwife is to increase cost, needlessly consume physician time, inconvenience all concerned, especially the mother and the father (partner). Given the safeguards presently in place, this legislation is not unlike erecting a speed bump—a BIG speed bump—on a smooth roadway where everyone is smiling an obeying the laws.

Respectfully,
Christopher Burnett
Mariposa, CA



Hello Senator,

My name is Brooke Kochel and I'm writing to in support of the midwives of California. I'm lucky enough to have had 2 midwives care for both my pregnancies. It was the most proficient, knowledgeable and compassionate healthcare I have ever received. And giving birth at my home near LA 3 months ago with licensed midwives was the safest I've ever felt.

I am also a Certified Professional Midwife and understood the level of competence of this group of women, at The Sanctuary Birth and Family Wellness. I was trained as a midwife in the state of Texas, where physician supervision is not required. It was the general consensus there that California was way behind the times to be limiting midwives ability to practice and women's ability to choose who cares for their bodies. I attended hundreds of births in Texas, witnessed normal complications and saw competent midwives firsthand. Their outcomes where outstanding, better than the physicians when low risk births were compared.

I had my first baby in Arkansas. I remember the day my midwife told me I had to go to an OB for 2 visits. I felt belittled and that my decisions about my own body were being undermined. I was mad that the government had interfered with this private, personal decision. I felt hurt, scared and anxious knowing that the social climate was unfavorable in this small town. I felt defensive because I knew the physicians were uneducated about midwifery much less supportive of it. I was questioned, scorned, put on hold for long periods of time while the doctor's office figured out "what to do with me". I had to plead with many doctors’ offices to take me, see me. My midwife told me there were no doctors that would voluntarily see me. My only choice was to be seen at a public health clinic that the state set up for low income citizens. I somehow felt that society had shunned me for making what I thought was an outstanding health choice for my unborn child. In the end, an OB saw me as a favor to a friend. Her practice had a regulation to not allow their OBs to see midwives clients when they got wind of it. I wanted to share this story so you understand the social and emotional ramifications of this law. Clients of The Sanctuary are lucky enough to have Dr Fischbein, but many are not.

If you support midwives needing supervision then it's like supporting a form of inequality.

Thank you for hearing my voice. I assure you it's the voice I've heard a hundred times firsthand from my midwife clients and the group of educated families I surround myself with here in LA.

Feel free to contact me.

Brooke Kochel
Topanga



Good morning Senator Lieu,

I am writing you this morning to express my overwhelming support for Midwives to practice in California. I am a 38 year old teacher who chose to use a midwife for my prenatal care and the births of all 3 of my children. I cannot say enough about the positive experience I had throughout my pregnancy, delivery and postpartum care. Both of my licensed midwives, Leslie Stewart and Beth Cannon, provided me with exceptional care. Their care went above and beyond the care of any obstetrician. I know this because I saw a licensed obstetrician concurrently during my second pregnancy with twins.


My midwife, Beth Cannon, would spend over an hour with me at each appt. She would help me with my nutrition, exercise, my stress level, and coaching me on how to incorporate my new babies into my already existing family. She answered all of our questions, took time examining me and the babies and prepared me and my husband for the birth of our twins. She was never rushed and always very thorough. As a result, my babies were born healthy and without complications. Dr. Stewart Fischbein, OB, was also at the birth of my twins and provided me with concurrent pre and postnatal care.


During this pregnancy I also saw, Dr. Rusalna Kadze, OB. Her care was very different from that of my midwife. At each appointment I saw her for less than 5 minutes. She never discussed nutrition, my stress level, or asked me any questions about how I was doing emotionally. On a few occasions, she didn't even measure the babies.


During both of my pregnancies I had a back-up physician, should anything arise and I needed to be transported to a hospital. My midwives always took the upmost care to make sure that I would be cared for and the babies would be safe in any situation. My husband and I felt extremely confident in our decision to have home births because we knew our midwives were working with the support of licensed obstetricians. We never needed to transport, but if we had, I am fully confident that my midwife would have, without hesitation.


I feel extremely fortunate that I was allowed a choice when choosing how and where to birth. I would not have had this experience without my very dedicated, knowledgeable, patient, loving, supportive and trained midwife. I am asking that you do your part to help keep midwifery legal in California so that many other women and families have the CHOICE on how and where they birth their children.


Thank you for listening.

All the best,
Jennifer Cole
Home birth Mother



Dear Senator Lieu,

I write in support of licensed midwifery and the choice of home birth. I had a simple pregnancy without complications and a straightforward delivery at my home attended by a midwife 5 1/2 years ago. I was glad that safe, legal home birthing is an option in California and hope it will remain so. I am concerned that enforcement of physician supervision in light of modern day realities is likely to be stifling to the reasonable choice of a home birth with a licensed midwife and lead to less, not more, access to a reasonable choice for the women of California. I would prefer to do away with the physician supervision clause altogether in much the same way that chiropractors and acupuncturists are licensed and free to practice independently of orthopedic surgeons.

Please amend AB1308 to exclude the requirement of physician supervision.

Thank you,
Vanessa Frank Garcia
Ventura, CA



Senator Lieu:

I am writing to express my concern regarding the above-referenced bill and how it affects a woman's right to choose her practitioner and model of care for childbirth.

I am an attorney and six years ago I gave birth in a birth center with the supervision of two highly competent midwives. While they had physician backup, I never met the physician and never needed to. I realize this is not always the case but my personal knowledge of the practice of these two midwives is that they are competent and when physician assistance and hospital transfer has been required, it has been accomplished.

My understanding is that physician backup is already required but not enforced and that the current bill will strengthen this provision effectively making it more difficult for women to choose midwifery over obstetrics when giving birth. Like chiropractors and acupuncturists, midwives are skilled medical professionals and requiring backup of a physician is a slap in the face to the professionalism of the practitioners. The licensing of midwives should be sufficient to ensure qualified practitioners, as in the case of chiropractors and acupuncturists, two professions that I have also elected to use.

I have professional experience that has enlightened me to the fact that the general medical community and more particularly the obstetric community is hostile toward midwives so it is difficult to find any physician willing or able to backup midwives without fear of reprisal from hospitals and insurance carriers.

I strongly urge you not to take away the choice of medical care that is the right of all mothers.

Best Regards,
Sandy Lipkin
Sandra Lee Lipkin, A Law Corporation
Ventura, CA

Dear Senator Lieu –

I am writing to you to express my concerns over a provision in Bill AB1308 that could severely affect the ability of licensed midwives to practice in the state of CA. AB1308, if passed and enforced, would make it a violation of law for a midwife to practice without physician supervision. This requirement for physician supervision would effectively limit the birthing choices for many women in the state.

Having a licensed midwife as one of the options available for women and families to choose is important as both a personal and public policy decision. I am not an advocate for, nor an opponent against, any specific type of birth option, but I do strongly believe that a woman should be allowed to make those choices that are right for her family, her baby, and herself. This includes not only hospital births with a doctor or midwife, but also births in birthing centers and home births with the support and care of a licensed midwife.

I delivered my first child in a hospital setting under the care of a physician who respected the decisions I had made for my labor and my son’s birth: no interventions, no epidural, the freedom to choose a birth position, bonding time immediately after birth, and rooming-in with my son. I was fortunate to have a physician and hospital who respected those choices.

When I discovered I was pregnant again, my husband and I were thrilled. When we discovered that I was pregnant with twins, we were doubly thrilled – but also terrified. Most doctors and hospitals across the state (and country) have very specific protocols in place for twin deliveries, including requiring an epidural and delivering in an operating room. Additionally, few doctors either know how to deliver a breech baby or are allowed to do so by their insurance or hospital: my otherwise wonderful physician from my first child’s birth was one of those doctors. If both babies were not head-first (<50 a="" be="" c-section.="" i="" labor="" of="" pregnancies="" present="" prior="" required="" this="" to="" twin="" undergo="" way="" would="">
I began to evaluate my options, because being forced to have a potentially biologically unnecessary C-section was terrifying for me. A birthing center or home-birth with a midwife was out: being pregnant with twins automatically deemed my pregnancy “high-risk”, despite all signs pointing to a normal and healthy pregnancy … with an extra baby. I was very fortunate to find a physician who will attend home births. He and a licensed midwife (or, in my case, a licensed midwife and her assistant) come to provide support – medical and emotional – at a woman’s home, where she is able to deliver in the way that she desires, surrounded by whatever and whomever gives her comfort. And that was exactly my experience: my twins were successfully delivered at home, happy and healthy, and I could not be happier with the decision I made to choose that option for myself and my family.

I know that my case was very outside of the norm inasmuch as I required and was able to have a physician present at my homebirth. Under normal homebirth circumstances, a licensed midwife and her assistant would be the ones to whom a woman would turn. I am not aware of any other physician in the state who does what my doctor did, so if AB1308 passes, it will effectively force women who do not want a hospital birth to either go without the support and expertise of a licensed midwife or it will force midwives to risk losing their licenses and livelihoods in order to attend a homebirth. Neither of these options is acceptable.

Women and families should, within sound medical guidelines, be able to exercise any and all options for the birth experience they choose to pursue: hospital, birth center, or homebirth; intervention-heavy or natural. This is a choice that should not be denied any family, and the requirement for physician supervision of a midwife in this bill effectively does just that.

I urge you to do away with the physician supervision clause altogether in order to continue to provide choice surrounding birthing options for women and families in the state of California.

Sincerely,

Elizabeth A. Nack


Good morning Senator Lieu,

I have recently become aware of the new provision AB1308 that is making its way through the California Senate. It is my understanding that this new provision could severely affect the ability of licensed midwives to practice in the state and if passed would make it a violation of law for a midwife to practice without physician supervision. Senator I cannot tell you how much of a step backwards this would be to women's health care. Midwives have been in practice for hundreds of years because of their never wavering support of those who they humbly serve. My mother and aunts were born by that fine tradition of midwifery and so was my daughter Eva Victoria Fleming. I chose to have my daughter at home with a midwife after having my son at UCLA Santa Monica with a physician. This is considered one of the best hospitals with some of the very best physicians and if I could do it over I would have had a midwife for both pregnancies and births. The amount of care, understanding and willingness to help were incredible. I was able to express concerns as if talking to an older wiser grandmother/aunt, where as calling to speak with my son's physician I often found myself speaking with the nurse after leaving a few messages.

My home birth cost our insurance significantly less than my birth at UCLA. The care given by Karni and Dr. Fischbein were unparalleled to the UCLA doctors. My contractions started at 10am and everyone was at my home by 1. I was guided through one of the toughest days of my life by two angels. My husband had already been through one birth but he was amazed by the detail and care given by these two professionals. My daughter Eva was born at 5:45 that day and I was never rushed or pushed to give her over so someone could take down weights or measurements. As both Karni and Dr. Fischbein had been a part of my birth from start to finish they could see how strong this little girl was. In contrast, my son's doctor literally ran in as I was getting ready to push. I was told to "blow air" so we could wait a little longer for her to arrive. At home my daughter was weighed and measured a few hours after the birth without a timetable and then she was handed to my husband as I was tenderly and respectfully cared for. I was bathed, fed, and generally "put back together". Dr. Fischbein and Karni did not leave my house and my side until 12 o'clock AM. Not because I was an emergency or that I may have been some possible liability but because it is a mark of whom they are and what they do. Dr. Michel Odent, OB/GYN - "We are completely lost and we have forgotten to raise the most simple questions. What are the basic needs of women in labor? The fact that midwives have disappeared is a symptom of the lack of understanding of the basic needs of women in labor."

Please let's work to keep these wonderful people an option for my daughter's children and for the future generations to come. Thank you.



Sincerely,
Victoria Pinero Fleming