"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.

Monday, July 29, 2013

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



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


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