"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


  1. Testing ability to post for my friend Jennifer M.

  2. There are great disconnects in how obstetrics is delivered in the U.S. Straightforward dialogue, real communication among the stakeholders, and - most important - the voices of mothers are all missing. I wonder how we can change that.

  3. Thanks, Stu. This study should be recognized for its extremely flawed nature. Having spoken with an epidemiologist about this, I believe it may be a simple (yet blatant) input/clerical error responsible for the incredibly high number of zero APGAR reported here that do not correspond to real APGARs recorded at live births. What if they had no option to enter a value for "no APGAR" so they recorded all those situations as "zero" APGAR, an obviously very different thing? That would explain these wonky numbers a bit...

  4. LIke you, I have been ignoring Amy Tuteur. Amy's dialog reflects how she is unable to formulate a logical argument.
    http://www.skepticalob.com/2011/03/epidural-hysteria.html She calls my article garbage, but her conclusion at the end, actually supports my research.
    Amy- "The bottom line is that what gets is (sic) to the baby is far smaller than the amount of medication injected into the mother's epidural space."
    (judy- I certainly hope so!)
    Amy- If the epidural does not sedate the mother, it certainly won't sedate the baby."
    (judy- but the mother is sedated!)

    But now that she is a spokesperson for AJOG, paid to speak at their conference in Hawaii last Sept, it is time to confirm if she is who she says she is. Her medical license lapsed in 2003, when she was about 40 years old. I would like to know if she finished her residency and am asking anyone in Boston to find out she ever practiced. I would like to have a conversation with anyone who ever worked with her, because it is hard to imagine her holding a job of any kind.

    I think it is no longer the time to ignore her. The comparison to Hitler is apt. Everyone ignored him until it was too late.

    Judy Slome Cohain, CNM
    75 first author publications
    why homebirth is 1000 times safer than hospital birth for low risk women in the US.

  5. Stu- write to me judyslome@hotmail.com

    I published a letter to editor to Grunebaum AJOG, and they published it, but also, i had to cut it down to 400 words whereas Grunebaum/Chervenak were allowed 490 words in their reply. I want to send you my original letter.

    Please write to me