"All that is necessary for the triumph of evil is for good men to do nothing" Edmund Burke, 18th century Philospher.

"A long habit of not thinking a thing wrong gives it a superficial appearance of it being right." Thomas Paine

"The welfare of humanity is always the alibi of tyrants." Albert Camus

"Choice is the essence of ethics: if there were no choice there would be no ethics, no good, no evil; good and evil have meaning only insofar as man is free to choose." Margaret Thatcher, March 14, 1977

“It is difficult to get a man to understand something, when his salary depends on his not understanding it.” ― Upton Sinclair

Explaining the Cause

I am a practicing obstetrician who is a strong supporter of patients rights to informed consent and refusal. I believe a patient has the right to choose her own path given true and not skewed informed consent. Following that tenet, just as a woman should be able to choose to have an elective c/section she should be able to choose not to have one, as well. The American system of hospital based obstetric practice has been eroding those choices for women for quite some time. Due to concerns of economics, expediency and fears of litigation women are being coerced to make choices that may not be in their best interest.

I have had a long relationship collaborating with midwives and find the midwifery model of care to be evidenced based and successful. I was well trained at Cedars-Sinai Medical Center in the mid 80's to perform breech deliveries, twin deliveries, operative vaginal deliveries and VBACs, and despite evidence supporting their continued value, hospitals are "banning" these options. Organized medicine is also doing its best to restrict the availability of access to midwives.

Home birthing is not for everyone but informed choice is. Medical ethics dictates that doctors have a responsibility and a fiduciary duty to their patients to provide true, not skewed, informed consent and to respect patient autonomy in decision making. Countries with the best outcomes in birthing have collaboration between doctors and midwives. This is not what has been happening in the hospitals of America. Its time for a change and the return of common sense.

The midwifery model of care supports pregnancy as a normal function of the female body and gives a legitimate and reasonable alternative to the over-medicalized model of birth that dominates our culture. Through this blog I hope to do my part to illuminate what is wrong with our maternity care system and what is right with it. I do not expect all to agree and that is OK. We must all understand that given honest data it is not always reasonable to expect two people to come to the same conclusion. Our differences should be respected.

Tuesday, September 17, 2013

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’ĂȘtre 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

Thursday, September 5, 2013

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