"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.

Wednesday, January 29, 2014

The Hazmat Birth






On the header of my blog are a few of my favorite historical quotes. I think my favorite has become Albert Camus’, “The Welfare of humanity is always the alibi of tyrants!” Fear is the easiest way to manipulate. And claiming safety is a perfect way to shut down any discussion. It’s good for you. It’s safer for the children. You don’t want to put your baby in danger, do you? We live in a world where ACOG admits that 2/3’s of its guidelines are not based on good scientific evidence. Yet they put them out anyway. In my world, on a daily basis, I am told directly or from print media about manipulation of women through skewed or even overtly false information. When it comes to pregnancy the bowing to the false god of safety has become the standard. Your baby is too big. Your baby is too small. Your pelvis is inadequate. The head is smaller than the shoulders which might get stuck. The fluid is decreasing. The cord is around the neck. You are 3 days overdue and your placenta is getting weak. VBAC is too dangerous. Your breech baby’s head might get stuck. Hospitals are safer. Induction is easy. Cesarean sections are routine.

Then there is the mockery of choosing an alternative to the fear based standard birthing world. Home delivery is for pizza! Having your baby at home is like driving your child without a seatbelt (This is the latest flippant simile from a doctor in Australia. Which, by the way, was how my generation grew up and I don’t recall massive death on the highway). Or as Jim Gaffigan, the comedian, quips, “when I told my friends we were having a home birth they said, Yeah, we were going to do that but we wanted our baby to live!”. Choosing a home birth is selfish! Why would you pick a lesser trained midwife? How would you feel when something goes wrong!

Ah, the something goes wrong theory of birth. Perfectly understandable in today’s fear based, litigious world. Risk management is something we all do every day. As individuals we just don’t have departments staffed with lawyers to do our personal risk management. Even if you could afford one can you imagine your life with every decision being scrutinized for safety and risk? Susie, you are not allowed to have that chocolate chip cookie because we have calculated that the risk/benefit ratio is adverse to your long term health and the viability of your family unit. Laughable? Far-fetched? Maybe, but this is the climate of the standard medicalized world we now live in. You cannot eat in labor because there is a 1/100,000 chance you might aspirate in an emergency. You must have an IV just in case. Please sign these consent forms about surgery and death after your next contraction. Sorry, hospital policy says you have to wear those belts continuously.

This past week I came upon a top secret correspondence from a local hospital that read something like this: “The OBGYN Department and the Infection Control Division would like to remind you that eye protection (e.g. glasses, goggles) and a face mask are required for all providers participating in a delivery.  We thank you for your cooperation with this important safety issue. The last sentence is the sinister one. Putting that tagline on anything gives it the appearance of concern and reasonableness. This may seem like a small thing but its insidious message is a continuation of the threat to all of us who value individual autonomy and see vaginal birth as something beautiful. This hospital, likely complying with some edict from some committee or oversight organization and almost certainly without a single adverse event in their institution, has turned the birth of a baby into a hazmat situation. My call to the author of this correspondence for clarification went unanswered. For those who have actually attended an un-medicated birth, a home birth or a water birth, can you imagine what the mother must think if she were to look down at a goggled and masked face catching her baby? I understand for an unscreened mother wearing protection would be a reasonable choice. But most women are screened and, unless there has been a series of incidents, universally requiring this garb is not about safety. It is about protecting the institution from liability. Plausible deniability should a worker catch something who was not wearing the hazmat protection hospital policy required. The risk managers are just doing their job. However, I believe minimizing risk must be weighed against common sense and personal choice in a free society. Sadly, common sense is losing and will continue to do so until the masses lose enough services or are inconvenienced enough that finally tort reform becomes a hot political topic.

Why have they come forth with this new rule now would be a logical question. Has there been some epidemic of exposures? I mean, vaginal birth without mask and goggles has been going on for millennia. No, it’s simply a symptom of the micromanaged and over-regulated reality we are now living in. I also just read an editorial about getting rid of the doctor’s white coat. Why now? Has there been an epidemic of disease spread by the hospital lab coat? Changing dirty coats makes good sense but banning them? Will the next suggestion be changing clothes between hospital wards, between rooms? And why won’t your own clothes be carriers of bad humours and thus need to be banned. And I can tell you that wearing scrubs from home and all day and night from the ward, to the call room to the cafeteria does not sound exactly hygienic. Wearing disposable gown and gloves makes sense in an infectious disease setting but in the maternity ward, really? So the why now question is really that someone somewhere just thought it up in response to usually an isolated incident. There are legions of administrative personnel whose job it is to try to diminish risk. The foolishness is they believe they actually can in every case no matter what the consequences down the road. Their job is to protect their job and their institution and their tyranny is always justified by safety.

There are two realities in the birthing world as I see it. One is fear based, often absurd, seeing pregnancy as illness, believing that interventions make benefit greater than risk and using safety as a canard for control. The other is trusting of nature, understanding of the imperfections of life and looking at pregnancy as wellness and a normal function of the female body. I have lived in both worlds and have a unique perspective. The first is uncomfortable and often riddled with self-deceit cloaked in cognitive dissonance. The latter is my choice and I try to be a vanguard for it. This past week I had the good fortune to attend a beautiful home VBAC in the hostile birth world of Santa Barbara and an inspirational water birth in Beverly Hills. I wore a t-shirt and sweat pants and was goggle-less and mask-less and I am delighted to report I am well and happy. 
 
All good things, Dr. Stu
 
 
 

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