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2012-01-04T09:33:00.000-08:00

January 1,2012. Well, its a new Year! It began with a home visit this afternoon on a new client referred by Mary Lou O'Brien. Alison's second pregnancy was persistent frank breech at 38 1/2 weeks. Her 1st delivery was a beautiful home birth with Mary Lou. As always required, Alison and Dave, her husband, had the right mental "stuff" and no physical problems. We discussed her option of external version after more natural methods had been unsuccessful. However, the cost of going to the hospital for this family was prohibitive so they accepted the very small risk and great benefit of trying to flip the baby at home in bed. Without medication but with warm olive oil, nurturing surroundings and a portable ultrasound available, not to mention a very cooperative baby, the version took less than 30 seconds. An easy forward roll put the baby's head down to the delight of mom, dad & little brother Ocean. We were all overjoyed for them and proud to be able to offer choice, informed consent and alternatives such as external version and breech delivery options. Thanks Mary Lou. Be sure to let us know what happens next. A peaceful 2012 to all.

Blog Talk Radio with Gena Kirby

2011-12-24T09:51:00.000-08:00

Last Monday I had the privilege of being interviewed by Internet Radio personality, Gena Kirby. We met in person last month at the premiere of "More Business of Being Born" in Santa Monica. Gena, who resides in Texas, asked if I would come on her weekly program to discuss the reality of breech birthing in America. We had a great 90 minute chat on this subject and, of course, many others and took a couple of questions from listeners. You can find the full podcast at: http://www.blogtalkradio.com/progressive-parenting/2011/12/20/breech-birth-a-reality-a-conversation-with-dr-fischbein
Listening will not be time wasted and comments here or on Gena's site would be appreciated. Merry Christmas to all. Dr. F

We can all learn something from Ibu Robin

2011-12-14T07:29:00.000-08:00

Inspired! One cannot spend time with midwife Robin Lim and not come away with a sense of peace and inspiration. For over 20 years Robin has cared for women at her clinics in Bali, Indonesia. Providing health and maternity services to all women regardless of economic status in a country in desperate need. For her tireless efforts she was awarded the CNN Hero of the Year award this past week.

http://www.cnn.com/video/?/video/bestoftv/2011/12/11/heroes-hero-of-the-year.cnn#/video/bestoftv/2011/12/11/heroes-hero-of-the-year.cnn

I was fortunate enough to have a few minutes with her last evening at a gathering in Montecito, CA. What wonderful, and sometimes tragic, stories she has to tell. So much love and nurturing affection in the room full of people eager for such sanity in the world of birthing. In the midst of all the deserved attention and accolades that Robin is receiving I read an article written by Stacia Guzzo titled, "The Paradoxical Perception of Midwifery in American Culture". The contrast it presents is startling and disturbing and speaks for itself. Please take a moment to read.

http://feminismandreligion.com/2011/12/13/1722/

Thank you Robin and Wil and Mary Jackson and all my colleagues and friends who, by example, bring peace, common sense and respect for the individual back to birth. Dr F

Breech Birth, a Reality

2011-12-07T06:29:00.000-08:00

I was watching the brilliant movie "Inception" for the umpteenth time and saw a parallel for what those of us who believe that breech birth is just a variation of normal are up against. Like a virus, an idea, once implanted, is very hard to eradicate. Whether true or false, if this idea takes hold it changes the participant and the playing field and, thus, the world we live in.

Up until the early 90's delivering selective vaginal breech babies was taught in residency programs and practiced by obstetricians in the real world. When I trained there were studies supporting this idea including the pivotal work of Martin Gimovsky, MD in the early '80s.

Obstet Gynecol. 1980 Dec ;56 (6):687-91 7443110 Cit:22 Neonatal performance of the selected term vaginal breech delivery.
[My paper] M L Gimovsky, R H Petrie, W D Todd
Several authorities have recommended cesarean section for all intrapartum breech presentations. The present study documents that judiciously selected fetuses at term in breech presentation may be safely delivered vaginally by a selective management protocol that requires cesarean section when mandated criteria are not met. The outcome and performance of 6 years of vaginal breech deliveries were evaluated. Those in the control groups were delivered by spontaneous vertex vaginal and elective repeat cesarean section procedures. Morbidity was not different in the protocol breech vaginal delivery group and in the controls. Mortality was found only in the nonprotocol-managed breech vaginal delivery group, which also had a morbidity 5 times greater than that of controls. Approximately half the term breech presentations that are properly selected and managed may be safely delivered vaginally, thereby avoiding a significant number of cesarean sections and subsequent inherent risks.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1021563/?page=1

As residents we were eager to learn and excited for the opportunity to practice this skilled art and at Cedars-Sinai Medical Center in Los Angeles selective vaginal breech deliveries were the norm.

But in the 1990's the idea began to grow that maybe delivering breeches vaginally was risky. This thought culminated with the publication of the "Term Breech Trial" by Mary Hannah, MD in 2000.

Lancet. 2000 Oct 21;356(9239):1375-83.
Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group.
Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR.
SourceDepartment of Obstetrics and Gynaecology, Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario, Canada. mary.hannah@utoronto.ca

Abstract
BACKGROUND: For 3-4% of pregnancies, the fetus will be in the breech presentation at term. For most of these women, the approach to delivery is controversial. We did a randomised trial to compare a policy of planned caesarean section with a policy of planned vaginal birth for selected breech-presentation pregnancies.

METHODS: At 121 centres in 26 countries, 2088 women with a singleton fetus in a frank or complete breech presentation were randomly assigned planned caesarean section or planned vaginal birth. Women having a vaginal breech delivery had an experienced clinician at the birth. Mothers and infants were followed-up to 6 weeks post partum. The primary outcomes were perinatal mortality, neonatal mortality, or serious neonatal morbidity; and maternal mortality or serious maternal morbidity. Analysis was by intention to treat.

FINDINGS: Data were received for 2083 women. Of the 1041 women assigned planned caesarean section, 941 (90.4%) were delivered by caesarean section. Of the 1042 women assigned planned vaginal birth, 591 (56.7%) delivered vaginally. Perinatal mortality, neonatal mortality, or serious neonatal morbidity was significantly lower for the planned caesarean section group than for the planned vaginal birth group (17 of 1039 [1.6%] vs 52 of 1039 [5.0%]; relative risk 0.33 [95% CI 0.19-0.56]; p<0.0001). There were no differences between groups in terms of maternal mortality or serious maternal morbidity (41 of 1041 [3.9%] vs 33 of 1042 [3.2%]; 1.24 [0.79-1.95]; p=0.35).

INTERPRETATION: Planned caesarean section is better than planned vaginal birth for the term fetus in the breech presentation; serious maternal complications are similar between the groups.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(00)02840-3/abstract

Finally, those that were against teaching or performing term vaginal breech deliveries and did not want to investigate further had their evidence. Nevermind, that within 2 years after the paper was published there were a slew of articles and papers critical of and refuting Dr. Hannah's research and conclusions.

Well summarized here: http://www.breechbaby.info/termbreechtrial.pdf

Too late! The seeds of the IDEA that breech vaginal birth is dangerous had been planted. And this idea was rooted in welcoming fertile ground as it justified the easier, less time consuming, more lucrative and thought to be less liability ridden c/section as standard of care for frank or complete breech at term. An idea, regardless of its validity, is made all the more powerful when it fits the current trend in the medicalization of birth and the fear based model that restricts individual choice. It infects the population and the profession to the core and has led to a stoppage of even teaching the knowledge and technique of vaginal breech delivery to future practitioners. Our halls of higher learning have no shame in denying future mothers this option due to a simple idea based in fear.

Fortunately, some forces are beginning to wake up from the nightmare and realize that "inception" has taken place. Maybe they have a "totem" of their own or just maybe common sense is an antedote to the viral model of a long festering idea. The Royal College of Ob/Gyn in England and The Society of Ob/Gyn of Canada have issued statements in the last couple of years in support of retraining new doctors in the methods of vaginal breech delivery. Even the American College of Ob/Gyn has a clinical guideline paper in support of selective vaginal breech delivery as a reasonable choice for the skilled practitioner and the informed woman.

Those of you who know of my work are aware that I have supported true informed consent and birth choices including the option of vaginal breech delivery. I have been ostracized in my former local community for many of my views and this has led me to choose the path of supporting women's choices in the home and birthing center setting where I do believe that common sense, individuality and evidenced based medical practice can freely occur. With the help of social networking, celebrity advocates and a growing number of devoted maternal care givers an old idea, that normal birth is not a disease and that selected vaginal breech is just a variation of normal, is being resown. I believe we can awaken my colleagues and the American populace from "limbo" even if it is one person at a time. A good idea need not be a virus. It may awaken us, as in Christopher Nolan's incredible movie, to the sanity and reality of the beauty of home and family and natural birth.

It is with these comforting feelings that I and my birthing Instincts team of Beth and Jaclyn and doula Robin announce the successful home breech birth on 12/5/11 of an 8 pound baby boy to glowing parents Hallie & Michael. Planning a home birth with the great midwives of South Coast Midwifery they found themselves in the not uncommon dilemma of persitent frank breech at term. Having no success with the usual measures to turn the baby they looked for options. Sadly, they could not find a single facility in Orange county willing to allow them a natural birth. C/section only! Lorri from South Coast knew of my practice and my philosphy and referred them for a consult only last week. We spoke several times for several hours and really connected. They had the right stuff and met all the criteria for a selective breech delivery. The very next day labor began and in less than 7 hours Hallie gave birth at home in their bed with grandma present. Congratulations to them on this blessed event and for their conviction.

I do believe that term breech presentation should be treated as just a variation of normal. And if selection criteria are met then informed consent and choice belong to the woman and her loved ones. While a hospital that respects autonomy would be an ideal place for these women to give birth that is not the current reality we live in.
Choices are so extremely limited. That is just one of the most compelling reasons why another birthing option is so needed in America. Under the current medico-legal and economic climate I do not forsee hospitals and physicians currently in practice changing from the "breech is dangerous" idea. The dream of the Sanctuary Birth & Family Wellness Center and I and a few of my colleagues, too, is to build our own maternity facility where individuality and common sense and respect for birthing are, once again, the norm. Dr. F

My response to another rant by Dr. Tuteur

2011-12-03T06:39:00.000-08:00

In the November 7th, 2011 online edition of “Time Ideas” internet blogger Amy Tuteur attacks Ricki Lake and Abby Epstein’s sequel to the popular “Business of Being Born” and continues her rant against home birth and the midwives who support this option. Had Dr. Tuteur actually viewed the 4 part DVD, “More Business of Being Born”, she would find that the film was not an advertisement for home birthing but rather a documentary that presented evidenced based medicine and real life experiences in hopes of educating the viewers on their options for birthing in America. In her zeal to critique anything that has to do with the movement she argues, disingenuously, four major points.
As to point #1:
As a board certified and practicing obstetrician who has worked with both CNMs (certified nurse midwives) and LMs (licensed midwives, also called certified professional midwives CPMs), my experience is that they are both consummate professionals in their area of expertise. Licensed midwives in California are licensed by the Medical Board of California, the same agency that licenses physicians. This consumer protection agency sees fit to certify these professionals to care for low risk pregnant women. In my extensive experience spanning 30 years of collaboration with them in California I have direct knowledge of their work. They have extensive didactic education with accredited institutions and are trained in the care of normal birth through the mentoring and supervision process. The model of care they provide is based on prevention and nurturing and the trust that birthing a baby is a normal bodily function.
Dr. Tuteur believes that having a university degree and extensive in-hospital training is required to care for normal pregnant women. I would state without reservation that midwives do normal birth better than most obstetricians who are trained in surgical birth and rarely experience a normal labor from start to finish. By labeling licensed midwives second class, Dr. Tuteur demonstrates for us her pejorative style that is her reputation when confronted with facts and issue she disdains. In other developed nations the model of care of collaboration between midwife and doctor is the norm. Whether to choose a CNM or an LM is a matter of preference for the informed woman.

As to point #2:
Dr. Tuteur says “All the existing scientific studies…show that American planned home has triple the risk of neonatal death”. This is a stance she consistently takes on her blog site and when quoted in articles and is patently false. The use of hyperbole is also a trademark of Dr. Tuteur and strains further her credibility on this subject. Does any reader really believe that “All” the studies of any topic are on one side only? The American College of Obstetrics & Gynecology (ACOG), of which I am a member and Dr. Tuteur is not, has consistently taken a position against home birthing and the basis for their recent opinion relies almost entirely on a meta-analysis of his selection of 11 out of more than 50 studies encompassing several decades by Wax, et al. The criticisms of his conclusions are numerous in the literature and even include some by the authors he has cited. There is certainly no consensus. Dr. Tuteur seems to assume that her statistics end the discussion. Even Wax, himself, admits that if you accept his data as indisputable the overall increased risk of a fetal death at homebirth is 1 in 1,133. While every loss is significant the evaluation of this risk is a personal decision. No pregnancy is without risk and hospital birthing is no exception. Parents must be allowed to weigh the much greater risk of intervention and surgical birth and the multitude of complications that can arise from them in context with their own life experiences. True informed consent and respect for patient autonomy is not a virtue that Dr. Tuteur seems to value.

As to point #3:
Dr. Tuteur cites a Netherlands study in the 2010 British Medical Journal which had the surprising finding of a higher fetal death rate in low risk women cared for by midwives than for high risk women cared for by obstetricians. The analysis of scientific articles is not a simple task, often comparing apples to oranges and that is the case here. Recall that Dr. Tuteur states that the Netherlands does not allow licensure of CPMs therefore one must conclude that the midwives caring for Dutch women are the equivalent of CNMs, a category of midwife that Dr. Tuteur approves of. Secondly, the study does not clearly define location of labor as a factor, only the care provider. Also, as tragic as a fetal loss is, again, it cannot be used in isolation as the only endpoint when determining models of care. The use of this study as a condemnation of home birthing is, again, disingenuous. The authors’ conclusions are not the condemnation of the midwifery model but that a reevaluation of the Netherlands care system is warranted.

As to point #4:
I agree that if the Midwives Alliance of North America (MANA) has meaningful data they should consider publishing it. Supporters of the midwifery model want the best for their patients and would be accepting of criticism if that is what the statistics showed. For those interested in seeking their data there is a legitimate application process that provides access. Dr. Tuteur seems to be eager to attribute sinister motives to MANA while bathing herself in righteous indignation. Those who know of her antics see her for the internet provocateur she is. One who calls for informed decisions but skews her information, refuses offers to debate opposing views publically, obfuscates her own background and motivation and seems to take pleasure in demeaning those with whom she disagrees. Unlike Dr. Tuteur, I applaud Ms. Lake and Ms. Epstein for bringing the issue of how American women give birth to the forefront. Honest dialogue, true informed consent and individual autonomy in life’s most precious moments are the business for us all.

Stuart J. Fischbein MD, FACOG
www.birthinginstincts.com

(This essay was submitted to the op-ed editors of online Time/Ideas more than a week past. Since I have yet to hear any response from them I have elected to post it here. Dr. F)

You can find the original article by Dr. Tuteur at:
http://ideas.time.com/2011/11/07/what-ricki-lake-doesnt-tell-you-about-homebirth/

Time Ideas did eventually publish an edited version of my comment to Dr. Tuteur. Read it at:
http://ideas.time.com/letters/the-home-birth-debate-continues/?iid=op-main-lettereditor

More hypocrisy from Dr. Stephen Carter

2011-11-23T08:39:00.000-08:00

I have not blogged in a while as I have been involved with some other great projects. "More Business of Being Born" premiered a couple weeks ago. I highly recommend this 4-part DVD as an adjunct to Ricki and Abby's BOBB for those who wish to educate themselves in birthing options. It was such a fun gathering of good souls. Great to see my colleagues Glen Elrod from Wasilla, Alaska and Robert Biter up from San Diego along with so many nurturing people who trust birth. I must say I did not know what to expect as we previewed the Celebrity Birth Segment. But I was pleasantly surprised as I found it both entertaining and informative. I have yet to see part 4 on VBAC but colleagues tell me I am in it and did not make a fool of myself so thats reassuring.

My co-author, Victoria Clayton and I were at the Ventura County Book Fair a couple weeks ago promoting "Fearless Pregnancy". I was honored to teach a suturing class to more than 25 birth professionals at the Santa Clarita Birth Center. And of course there is that birthing thing. In the past week I have had my first failed VBAC and another beautiful home delivery of twins. Please check out my summary in the news section of www.birthinginstincts.com

On a very sad note, my friend, mentor and colleague of 30 years passed away early Monday morning. Irwin Frankel was a wonderful physician, very hands on and old school. He was a passionate teacher with knowledge and patience and a calming influence and everyone adored him, patients and colleagues alike. They do not make them like him anymore and his passing signals the end of an era. I will miss him very much.

The contrast between an honorable man like Dr. Frankel and Pleasant Valley Hospital's own Dr. Carter could not be more stark. Some people actually fool themselves into believing what they say and some are just fools. I do not pretend to know the motivation of Dr. Carter and will leave that up to the reader. For those who have followed the antics of the obstetric committee and administration at PVH and St. John's in Oxnard in this blog and in the Ventura County Star towards midwifery you will know what I am talking about. In a recent article regarding the debate over closure of the maternity ward at PVH Dr. Carter, once again, stepped in it. Please take a moment to read the recent article "St John's Pleasant Valley Hospital Postpones Decisionon Closing OB Unit"

I commented on the article as follows:

Dr. Carter says, "I've worked here since '98 and I've never felt the lack of an NICU was a big deal. It's nine miles away." Yet Dr. Carter was an integral part of the OB committee that agreed on a year long ban of midwives for just that reason. Former CEO, Mike Murray, echoed Dr. Carter's position in a story in this paper at the time. Citing "safety" as the reason for the midwife ban. It would seem from Dr. Carter's words here that safety was never the issue. Which we all really knew anyway. The motivation for keeping or closing the unit will remain economics. Also, the reporter should try to see how much the anesthesia and pediatric departments have brought pressure to bear for closure. It is hypocritical to argue safety then but not now. The policies in place at that hospital over that past several years are what have destroyed the census. I agree with Ms. Graf that closure of the woman's unit at Pleasant Valley would be a blow to the community. Sadly, with the unexplained departure of the supportive Mr. Bibby and the current economic forces in the medical industry it would be surprising to see our little haven survive.

.

The health care system is set up to create and protect the Dr. Carters of the world while what is really needed are the Dr. Frankels. Irwin held himself to such high standards that he did not need administrators and lawyers and confidential peer review committees and investigative journalists to inspire him to do the right thing. While those at Pleasant Valley Hospital impersonally debate the future of the women's unit surrounded by syncophants and protected from liability let's not pretend you and I don't really know what is going on there. Dr F

More thoughts on the "Affordable" Heathcare Act

2011-09-30T19:23:00.000-07:00

Last April I gave a speech at a tax day rally here in Thousand Oaks, CA expressing my opinions on some of the chilling effects of the government getting into the healthcare business. The text of that speech can be found in the April 2011 archives on this blog. On October 12th I will be a member of a panel speaking on this same subject at a dinner in North Ranch, CA. I will post the details here as the date draws closer for anyone locally who would like to attend.

One of my biggest criticisms of the health care bill is the intrusion of immense government into the realm of the very personal issues of healthcare and the expansion of the administrative state well beyond its scope granted by the U.S. Constitution. Taking a closer look at what this legislation is about reveals it has almost nothing to do with the distribution of medical care and is simply about control and bean-counting of our lives and enrichment of some favored groups.

Writing in the September 2011 publication, "Imprimus", of Hillsdale College, author Edward J. Erler has this to say:
"The administrative state, of course, always seeks to extend its reach and power. This is an intrinsic feature of a system where administration and regulation replace politics as the ordinary means of making policy....This is tantamount to denying that legitimate government derives from the consent of the governed...(taken from The Declaration of Independence). Obamacare certainly fits the description of the activities denounced in the Declaration. The number of regulations and the horde of administrators (not to mention lawyers) necessary to execute the scheme are staggering. We have only to think here of the Independent Payment Advisory Board. It is commission of 15 members appointed by the President, charged with the task of reducing Medicare spending. This commission has rule-making power which carries the force of law. The Senate, it is true, will have the power to override its decisions--but only with a three-fifths majority. There are no procedures that allow citizens or doctors to appeal the Board's decision. The administrative state--here in the guise of providing health care for all--will surely reduce the people under a kind of tyranny that will insinuate itself into all aspects of American life, destroying liberty by stages until liberty itself becomes only a distant memory."

As a concrete example it has been announced that diagnosis coding, required by Medicare and all insurance companies, will be changed in 2013. Currently, ICD-9 coding has about 12,000 diagnoses. The new ICD-10 coding to go along with the mandated electronic medical records provision of the bill will have 140,000 diagnosis codes. Is this for the betterment of health care or will it be used for micromanaging and regulation and eventual rationing of health care resources? What do you think? You know what I think! Dr. F

Junk Science or an Inconvenient Truth?

2011-09-23T22:49:00.000-07:00

In a recent article published in the Green Journal, ACOG's monthly academic publication, and much their credit, it was revealed that many guidelines used as "gospel" to counsel patients on OB/Gyn matters are not based on good science. In an article by Christie Haskell on the CafeMom web site she notes the following:

According to Professor of Medicine, Dr. Andrew D. Auerbach, "more than two thirds" of recommendations are based on anecdotal evidence or even just expert opinions, which are wrought with personal biases. While opinion can be helpful where we don't know things, it doesn't always translate into what's best for the patients.

In the new study, Dr. Jason D. Wright of Columbia University in New York and colleagues went through 717 practice recommendations from ACOG, the nation's leading group of ob-gyns.

They found 30 percent of those were based on top-notch evidence, so-called randomized controlled trials. About 38 percent came from observational studies, whose value is limited, and 32 percent were purely expert opinion.

Awareness of this information is crucial in the informed consent process. Asking questions of your doctor about the veracity of the evidence for his/her recommmendation is a good idea and should be greeted with respect by your practitioner. Remember, ACOG guidelines are meant to be just that, guidelines, and yet once published they become the basis for strict hospital policies and fodder for trial lawyers. Again, I give credit to the editors and the author for pubishing this article. Hopefully, it is based on good scientific method. Dr F

Trip to Israel

2011-09-16T06:07:00.000-07:00

Every now and then it is beneficial and theraputic to take a mental and physical break from our routine. We all need a refresher course on what are the really meaningful things in life and a change of perspective that comes with traveling can be just the thing. Such was my experience in my first trip to the holy land. My daughter and I, along with 168 other Dennis Prager listeners, enjoyed 10 fantastic days touring Israel. From Tel Aviv to the Golan Heights, Ceasaria to Kfar Blum, Nazareth, Bethlehem, Masada, floating in the Dead Sea and, finally, Jerusalem we experienced history, religion and the co-existence of a vibrant working society. After a visit to these places it is unlikely that one can ever look at the world the same again. We had the opportunity to hear interviews and lectures from a cross section of ideas including the Palestinian Mayor of Bethlehem, a member of the Israeli defense forces and an amazing woman at Yad Vashem to a former ambassador along with the wisdom of Mr. Prager. As he always says, "Prefer clarity over agreement". Seems pretty clear to me that any real peace in the Middle East will not occur in my lifetime. Nonetheless, one must continue to try and it begins with open dialogue and free access to information for the children of the Arab world. For freely educated children are the only hope that old enmities will die out.

As I return to Los Angeles and the work that I love I am hopeful that some of the lessons I learned in Israel can be applied to my profession. I believe more than ever that my profession has been going in the wrong direction. Widening the divide between caregivers for birth by hardened rhetoric does not benefit those we wish to serve. We have a duty to educate the future generations of obstetricians in the skills needed for vaginal birthing and encourage them to reach out to our midwife colleagues in a way that organized medicine has vehemently resisted in my professional life. Collaboration benefits everyone and honored co-existence makes for a more peaceful world for children like my daughter to inherit. That would leave a beautiful legacy for the Middle East and for the birthing world. Dr. F

Ventura County Star op-ed: complete essay

2011-08-27T20:28:00.000-07:00

In the August 27, 2011 online edition of the Ventura County Star I had an opinion piece published. Due to length constraints it had to be edited. The complete essay is as follows:

The Medical Model of Obstetrics has Gone too Far

Two weeks ago Maria saw me for a consult near term with her fifth baby. Her first baby was a C-section, followed by three uncomplicated vaginal births in Mexico. Though a vaginal birth would be safer and healthier, Maria was told by the local community hospital that she must have a scheduled C-section. They didn’t tell her she could go elsewhere. They didn’t tell her she had the right to refuse surgery.
Hospital birthing remains the right choice for many and certainly the best choice for some. But it must be realized from the moment a women leaves her home in labor until she puts the baby in the car seat to drive home everything that happens is counterintuitive with nature’s design. The hospital model is illness, not wellness. You leave your nest to arrive at an emergency room. You are placed in a hospital gown with monitors around your belly and a blood pressure cuff strapped to your arm. An IV is inserted. You need permission to go to the bathroom. You are not free to walk around and move and you are not allowed to eat. You are asked to sign consent forms and are constantly interrupted. And you are on the clock. All these policies lead to interventions that disturb the process of labor and contribute greatly to the rise in surgical birth.

If women are nurtured and left to their own natural instincts the birthing process works quite well. Home birthing respects normal physiology. When other mammals labor they go off to some safe, quiet place, shut down their higher cognitive brain, and allow their primitive instincts to come forth. When accidentally disturbed or frightened, labor stops and they get up and run away. There is no place like home for many to feel safe and nurtured and uninhibited.

At home women can move about freely, rest in their own bed, eat their own food and shower and bathe as desired. They can labor silently or cry out without concern for who is listening in the next room. The mother and baby need not be separated and the cord is left alone. There is no timetable.

Families that choose home birth are often some of the most well-informed. Often the choice is made because, like with Maria, the local hospital and medical community do not support reasonable medical choices such as vaginal birth after cesarean section (VBAC) or breech delivery. These women trust their birth team and the process and they have mastered their fear allowing labor to progress as nature intended.

Yet the medical organizations that represent doctors like me actively oppose home birth. In 2007, 2008 and again in 2010 ACOG issued statements against home birth, criticizing midwives who aren’t Certified Nurse Midwives.
The sad truth is that for most Americans birth remains shrouded in mystique and fear. Hospitals and the medical model of obstetrics have gone too far. They have taken something beautiful and natural and convinced us it is an illness.
We now have three generations who have grown up with hospital birthing as the norm. Doctors rarely—if ever—see unmedicated births, and very few—if any—have attended home births. The ones who trust birth—who want to give breech babies or twins a chance to be born vaginally—often face ostracism and ridicule from their peers.
We are told that modern medical interventions for all pregnant women are our savior. Albert Camus said, “The welfare of humanity is always the alibi of tyrants.” The safety net a hospital provides for those that truly need it is wonderful. But safety is often used as a canard for control. There is nothing safe about a surgical birth rate of 33%.
Partly because of the rising C-section rates and the antagonism that exists between doctors and midwives, birth in America is much less safe than in more than 40 other industrialized countries, where collaboration of midwife and doctor provides a much better model of care. The safety problems in America are not because a tiny percentage of women are giving birth at home. They are because we are interfering technologically with the natural process of birth to the detriment of American mothers and their newborns.
In a country founded on personal liberty the choice of how to give birth belongs to the individual woman. She is entitled to true, not skewed, informed consent and the right of self-determination. The medical profession has the duty to respect that right. The American Medical Association (AMA) code of ethics states, “Rational, informed patients should not be expected to act uniformly, even under similar circumstances, in agreeing to or refusing treatment.” The refusal to grant Maria her choice of a vaginal birth was neither medically indicated nor ethical.

The women of America deserve better than what the medical model of obstetrics has provided. The strength of a woman has no better champion than Margaret Thatcher who said, “Choice is the essence of ethics: if there is no choice there would be no ethics, no good, no evil; good and evil have meaning only insofar as man is free to choose.”

Stuart J. Fischbein, MD

Sanctuary gets some press

2011-08-24T22:39:00.000-07:00

My colleagues, Heather and Aleks, were featured in todays Daily Breeze. I liked the article because of the clarity it provides. Reading the comments of Aleks and Dr. Rosenthal could not make the difference in birth approaches more clear. One based on trust, the other on fear. One respecting the process, the other concerned about blame. Yes, both are realities. In which one would you like to live? Dr. F

http://www.dailybreeze.com/lifeandculture/ci_18749525

Who Speaks for Maria?

2011-07-26T21:37:00.000-07:00

The hospitals in Ventura County where I used to admit patients continue their de facto ban on vaginal birth after c/section. There is no appealing to the clinical evidence, ACOG and NIH recommendations or even their sense of fairness. Today I saw a patient whose story must be told.

Maria R. is a Gravida 5, Para 4 hispanic female. Speaking to her via an interpreter today convinces me she is educated and well informed of her birthing options. For you see, she had a c/section in Mexico with her first baby and has had 3 successful VBACs all in Mexico since. I saw her early in pregnancy as a consult and reviewed her options including her right to have a vaginal birth at the hospital of her choice. No one can force her to have surgery. She does not want a c/section. She knows the risks to her are much greater with a repeat c/section that with a vaginal birth. She knows the likelihood of a successful VBAC for her is greater than 90%.

Maria is now 39 weeks. She is schedule for a "unelective" repeat c/section in 6 days. She came in today thinking she might be in early labor. She was concerned about having to have surgery against her wishes but is not the type to raise a stink. My associate, much to her credit, has contacted the hospital and anesthesia department on Maria's behalf and has been told that a planned VBAC is not an option. If she were to arrive at the hospital without time to wheel her into the operating room she would then be "allowed" to deliver vaginally. My associate, who is currently on vacation, is afraid to stand up for this patient's safety and rights because she is aware of my story and the hospital's history of how they deal with conscientious dissenters. Her last labor was so fast she barely made it to the hospital. I told her that she has the right to refuse surgery should she show up too early. She would be a great candidate for a home birth but her family lacks the means and her insurance does not cover that option.

Maria and I spoke for a while during her visit. When she left, my nurse and I shared our feelings. A combination of anger and frustration would best describe them. Why should this woman be forced into such a situation? Clearly, there is no one who can argue on clinical grounds that she is not the ideal VBAC candidate. Clearly it is safer for her to deliver vaginally. Clearly it should be her informed choice. And I wonder, should she suffer a complication from an unnecessary surgery who is responsible? Will hospital administrators, OB and anesthesia committees stand up and say its their fault?

ACOG and other organizations have written much about the ethics of home birthing. Dr. Nicholas Fogelson and I had a letter to the editor published in the August 2011 Green Journal responding to Dr. Chevernak's rigid stance against it. Where do the ethicists stand on this one? Who speaks for Maria? The silence is deafening! Dr. F

http://journals.lww.com/greenjournal/Fulltext/2011/08000/Obstetric_Ethics__An_Essential_Dimension_in.24.aspx

Fighting for a Breech Birth

2011-07-21T17:49:00.001-07:00

Karin Ecker is a mother, artist and filmmaker in Byron Bay, Australia. I get the impression she never saw herself in the role of activist but circumstances often dictate a different path. She has produced and directed a wonderful documentary that follows her story of trying to achieve a birth of her choice against a system that is not accommodating. I highly recommend her film "A Breech in the System" for everyone who supports a woman's right to be informed and choose. Her video would make a thoughtful gift for those faced with a decision such as Karin's. Please check out her site at: www.abreechinthesystem.com
I hope to sponsor a screening sometime this fall in the SoCal area once the bussle of summer calms down.

You can also view Sara & Doug's Breech home delivery on my site at: www.birthinginstincts.com
I find it moving every time I watch. Dr F

LA Times chimes in on rise in Home Birth

2011-07-11T22:20:00.000-07:00

July 11, 2011: Writer Olga Khazan highlights the usual pros and cons of home vs. hospital birthing. Some of the usual suspects appear, including some quotes from me.

http://www.latimes.com/health/la-he-home-births-20110711,0,7182324.story?page=1

I did comment to the writer on the story as follows:

Olga, I saw your article today. I think it was objective but there are some clear disputes to some of the statements and facts presented. Risk of uterine rupture is 0.5 % and of those only a small fraction actually end up as disasters. This risk is similar to the risk of requiring an emergency in any mother having her 1st baby according to the NIH study. I am not sure why someone thinks that over 35 is a risk factor for home birth. Your 2 pro-hospital experts continue to espouse the anti-CPM biased position of ACOG but I do not know where else the USC doctor gets his information. As for Dr. Tuteur, did you actually check out her current credentials or did she just tell you her background? I do not believe she is a Fellow of ACOG nor is she practicing. When was the last time she was actually seeing patients? What do you really know about her? She has her web following but is a provocateur who oftens throws vitriol publically at home birth parents and advocates. I have had many encounters with her and have asked her on several occasions to debate. She has never responded even when asked through an academic intermediary. You quote her as saying "all the existing scientific evidence...that home birth increases the risk of death" but then go on to point out a major study that does not. Also, even if you accept ACOGs conclusion of a 2-3 fold increase risk of neonatal death it is still far less than 1 in 1000! You also point out a single tragic outcome from a homebirth but fail to describe multiple similar tragedies occuring in hospitals despite all that technology and often caused by the interventions that push the uterus and baby beyond normal. After our discussions about these issues I am disappointed that you decided to use an anecdote as something against home birth when clearly these things happen in hospitals as well. Just ask my partner. I know you are limited by the number of words you can write so I do understand your position. I hope you understand mine. Maybe someday you can sponsor a public forum where Drs. Ouzounian and I can debate. All the best to you, Dr. Fischbein

I think the recent increase in stories and publicity about home birth is a sign that the public interest is rising. Watch for those opposed to raise the canard of safety and push back with fear based rhetoric. Dr.F

On Informed Consent by Dr. Fogelson

2011-07-03T09:26:00.000-07:00

Another good essay by my friend and colleague, Nick Fogelson, MD on the pitfalls of the current surgical informed consent process. I encourage you to check it out at:

http://academicobgyn.com/2011/06/20/on-the-surgical-consent-process/#comment-2850

Bottom line: Doctors and patients should maintain a good professional relationship which, much to the chagrine of the "boundary" fanatics, must cross into the realm of personal insomuch as trust and nurturing and a sense that there is real caring are the best legal protection against an unforseen outcome. As you know, I believe that the continued march toward shift medicine, hospitalists and electronic medicine will only magnify the inevitable errors that will occur and there will be no face of responsibility. Sadly, the "impersonal" model is a much better formula for patient dissatisfaction and inevitable law suit. Until some miracle happens I will continue to preach the path to government endorsed managed healthcare is bad for patients and health care providers but good for lawyers. I do hope I am wrong. Dr. F

HBAC in Water

2011-06-17T11:33:00.000-07:00

June 16, 2011: Her first birth story was a nightmare filled with fear, unprofessionalism and coldness that is one I hear all to often. Ending in an "emergency" c/section in the pushing phase with little humanity or respect for family wishes was not what this woman had envisioned. What a difference from the events of today. Desirous of a nurturing environment for her VBAC and with a trust in the process that comes from education and faith, this marvelous woman delivered at home in water in her own living room held and surrounded by husband, family and the Birthing Instincts birth team.
www.birthinginstincts.com

There is another way to give birth that respects both woman and process. Individual demand is the catalyst that will lead to a change in the system. It has to be. Congratulations to all who witnessed this blessed event. It was an honor to be accepted as a part of your family. Dr. F

SOGC Understands

2011-06-13T08:12:00.000-07:00

In celebration of the International Day of the Midwife on May 4th, 2011, the Society of Obstetrics & Gynecology of Canada (SOGC) has put out a news release calling for more collaborative care for pregnant women. The president of SOGC has this to say:

“The SOGC acknowledges that it is the mother’s decision to decide where she would like to give birth,” stated Dr. André Lalonde, executive vice-president of the SOGC. “Most babies are born without serious complications. As ob/gyns, our specialized training allows us to address the unique requirements of high-risk situations. What matters is that all professions acknowledge each other’s competencies and work together to provide mother and baby with the quality care they need, when they need it, where they want it.”

See the entire press release at:

http://www.sogc.org/documents/medInternationalDayOfTheMidwifeENG110504%20(2).pdf

Long Distance VBAC

2011-06-07T22:51:00.000-07:00

On June 4th, just after sunrise, I was honored to particpate in the birth of a beautiful baby boy to a delighted couple who traveled down from Oregon to have their baby at the Sanctuary Birth Suite. Mom had a c/section with her first child and when it was difficult to bring the baby through a low transverse incision her physician had to "T" the incision to accomplish the delivery. Because of this incision her operative report stated that a repeat c/section should be recommended. She had a midwife in Oregon but could find no doctor willing to back up her desire for a VBAC. The couple researched her options and found me through the internet. After corresponding for a bit they decided to travel down and meet the team. We all hit it off and upon reviewing the records I did not see a reason she should be forced to have a repeat c/section and felt an attempt at VBAC was reasonable. In my training we often allowed women with low vertical c/sections to have a trial of labor with good success. This is not the same as a classical c/section. At 36 weeks she moved the family down to Los Angeles and just 2 days after her due date went into labor. Less than 12 hours later she gave birth to an 8 pound, 7 ounce baby brother.

We were honored that she chose to educate herself in the risks and benefits of all her birth options. This is a right that belongs to all pregnant women. That there was no one she could find in the entire state of Oregon to support her is tragic. This is a trend that I hope can be reversed by truth and example and loud word of mouth. Dr. F

You must watch this!

2011-06-07T15:53:00.000-07:00

Andrew Laming, MP attacks Labor's sneaky attempt to snuff out home births in Australia. The liberal party in Australia wants to outlaw home birth. Yes, the liberal party. The one that favors abortion rights but decries home birth rights. Three cheers for Mr. Laming who makes a compelling argument for choice.

http://www.youtube.com/watch?v=zNJA4k-2OkI&feature=share

How headlines are often deceiving!

2011-06-01T07:11:00.000-07:00

In the April 2011 edition of the American Journal of OB/GYN Dr. Wax responds to many of his critics in the letters to the editor section. Hope you can find it at www.AJOG.org

My comments to this were part of a conversation I had with my colleague Nick Fogelson in South Carolina and were as follows:

So much to say but will summarize. Everyone has bias. I do feel comfortable, however, with Wax's contention that he had none when setting out to do his study. His last point, that most criticism comes from birth choice advocates, is a bit silly as not much criticism would be expected from hospital birth advocates in a paper that is not critical of hospital births. That Wax concludes there is an increased risk of neonatal mortality of 1 in 1,333 in home vs. hospital birthing does not seem worthy of all the hullabaloo. Most people would not consider this number to be a reason to or not to have a home birth. So, even if we were to accept his paper as flawless, is this number so substantial as to base an entire ACOG committee opinion on? Not being adept in statistics I cannot comment on the science of his calculations. But if we give Wax credit for being truthful we do have to put some credence in the knowledge and science of those authors of some of the papers he uses who disagree with him as well.
When a headline says a 2-3 fold increase in neonatal death it looks scary. When you see the increased risk is really less than 1 in 1000 its not so bad to many. when I counsel patients on interpreting statistics I often use the example of disease X. Say it has a frequency of 1:1,000,000 last year and this year there were 2 cases or 1:500.000. Both very small numbers. However, advocates for funding of research into disease X can say the rate doubled. Very misleading.
Do you agree that the increased risk is still very small and, if so, why do you think organized medicine is so vehemently against informed choice? The risk of c/section in hospitals surpasses 1 in 3 and yet does not draw close to this much finger pointing from ACOG.

I thought it very important to point out the manipulation of statistics by ACOG to make a point and another way to look at the numbers it deems so impressive in its argument against home birth. Lies, damn lies and statistics! Dr. F

Board Recertification Abuse

2011-05-29T19:34:00.000-07:00

When the chains of bureaucracy obstruct the physician’s ability

to care for patients appropriately, the physician has an ethical duty to

discard the chains and escape, to be free to practice according to the

physician’s best clinical judgment, as opposed to the substituted

judgment and whims of arrogant bureaucrats.

Lawrence R. Huntoon, M.D., Ph.D.

The American Association of Physicians & Surgeons has taken a stand on the ridiculous burden of annual Board recertification. The onerous and tedious requirement of annual board certification is without evidence to support its efficacy. It has long gone past the goal of quality maintenance and taken on the life of a self sustaining monster with the apparent self-interest of monetary gain and power. Here are some comments by my longtime associate and friend, Howard Mandel, MD FACOG as well as Dr. L.R. Huntoon that expose another view of annual MOC (Maintenance of Certification).

Dear Dr. Huntoon:

I thank the editors of the Journal of American Physicians and Surgeons for their publication of Dr. Dubravic's insightful article regarding board certification and recertification. As an obstetrician/gynecologist who finished my residency in 1985, I was required to take my boards and earned a 10 year certificate. If I would have graduated in 1984, I would have been boarded for life. The ABOG, requires a two part exam, the first written and the second a three hour oral examination, part of which is based on the first entire list of all the physician's hospitalized patients plus a significant number of representative outpatient visits. I passed both examinations the first time and was reboarded 10 years later. Since that time, my speciality board has changed the requirements to six years and now a yearly exam as well as the MOC. In Los Angeles where I practice, we have observed the erosion of younger physicians partaking in our local speciality meetings. The LA OB/Gyn Society is a skeleton of what it once was. The LA OB/GYN Annual Assembly, which was once world renown, with upwards of 700 participants attending, barely has 150 attendees, many of which are retirees. I hypothesize that the numerous hours and costs required to maintain our certification have added to the demise of these once impressive meetings and organizations. Another unfortunate outcome is the destruction of the collegial relationships developed by OB/GYNs in our region. I would scientifically study my theory, yet I am too busy preparing for yet another annual examination. Perhaps, the ABMS or any of the individual sub specialities can spend some of their resources on why comradery, collegiality and membership in local organized medicine has plummeted since the introduction of reboarding.

Respectfully,
Howard C. Mandel M.D., FACOG
10309 Santa Monica Boulevard
Los Angeles, California 90025
310-556-1427

And another message from Dr Huntoon, The Editor-in chief of the Journal of American Physicians & Surgeons:

Subject: Re: MOC article from the Journal of American Physicians and Surgeons

This is not unlike what happened with the AMA.

When the AMA made the "secret" agreement with the
government for exclusive use of the CPT coding system (in 1983),
the AMA made a huge leap in the direction of no longer being
financially dependent on membership dues for survival.

Once an organization gets in a position of no longer depending
on membership dues for survival, they are no longer accountable
to the membership and the needs of the membership.

In the current MOC environment, our specialty organizations see the
potential for huge windfall profits as the specialty organizations will be providing
the CME and practice evaluation tools needed to comply with MOC.
Once the specialty organizations start down this road, there will be no turning back.
The specialty organizations, like the AMA, will no longer be dependent on membership
dues for survival and accountability to the membership will be severely eroded or lost.

The leadership of specialty organizations, many of whom are in academic medicine and
who may see a significant financial benefit by providing compliant CME/evaluation tools,
are not likely going to lobby to stop this trend.

It is likely that the grassroots membership is the only hope for stopping it.
Alas, physician apathy and reluctance to "get involved" or "speak out against"
the trend are significant barriers to overcome.

Those who believe in exerting ever increasing control over medicine (like implementing
onerous MOC and MOL requirements), fail to appreciate the adverse consequences
of their actions.

A significant percentage of physicians in this country are over the age of 55.
As physicians get closer to retirement, many will simply refuse to jump through
all of the nonsensical, non-evidence-based bureaucratic hoops, just to remain in
practice in an environment where they can be expected to be paid less and less
which each passing year. They will retire or do something else.
The shortage of physicians, which will occur, cannot be replaced over night.
Many patients will suffer with increased waiting times and decreased access to care.
The MOC/MOL bureaucrats who engineered this debacle cannot provide the care.

Ultimately, we need to educate patients about these predictable adverse consequences
of MOC/MOL.

As a start, feel free to copy the articles our journal has published on MOC and
place them in your waiting rooms for patients and distribute them to your colleagues.
AAPS has published a White Paper on our recertification survey. You can find all of the
articles we have published by searching the Cumulative Index on our website under the terms
"maintenance of certification" and "maintenance of licensure."
Our journal website is www.jpands.org
And, as I have said before, we would be happy to accept more commentaries
on this topic.

L.R. Huntoon, M.D., Ph.D., F.A.A.N.
Editor-in-Chief
Journal of American Physicians and Surgeons
Editor@jpands.org

Welcome Taj

2011-05-26T08:12:00.000-07:00

For those in the obstetric profession who have not experienced the joy and peace and marvel of a home birth, whatever their reason may be, I would suggest they stop and think a second time. Last evening Karni and I were once again privileged to assist in the home birth of baby Taj and the rebirth of a woman and her family unit. That is all there is to say. Home birth is filled with wonderful stories that never make a headline and yesterday was one of those moments. There is so much more to giving birth than just giving birth and the home environment absolutely enhances the experience for informed women who freely choose that option. There is room in the birthing debate for more open mindedness and a respect for the process. Congratulations to Amara & Mike and thank you for the privilege. Dr. F

Panel discussion at Bini Birth on June 1st, 2011

2011-05-24T07:52:00.000-07:00

Check out what Bini Birth and Ana Paula Markel are up to on June 1st. After an all day workshop with Naoli Vinaver there will be a panel discussion with Naoli, Dr. Elliot Berlin, Dr. Suzanne Gilbert-Lenz, Davi Kaur Khalsa and me on Breech and Other Variations of Normal. June 1st from 7-9 PM at Bini Birth, 5355 Cartwright Ave, Unit 313, North Hollywood, CA 91601. Hope to see you there.

http://us2.campaign-archive1.com/?u=d2f5c0d977688cdd08f0b431c&id=96a87fdf44&e=3f8f30c19b

Another sign of the times.

2011-05-20T12:13:00.000-07:00

I had the great fortune to attend my stepson's graduation ceremony from NYU Film School this past Wednesday in New York City. A time honored tradition that the NYU faculty did a fantastic job with. About 35,000 people attended the ceremonies at Yankee Stadium and mother nature was kind as we had dry skies in an otherwise rainy week. Even the sun poked out for a moment while former President Bill Clinton gave the keynote speech to the graduates and happy families. Then each college dean recognized their respective graduating class. What was most telling for me was that the NYU Law School graduated 1020 new lawyers while the Medical School produced only 178 physicians. Almost a 6:1 ratio of lawyers to doctors. Shouldn't it be the other way around?

A sad statistic on an otherwise glorious day.

More on Breech and Informed Consent

2011-05-15T09:31:00.000-07:00

http://www.breechbirth.org.uk/birthchoices.html

For those interested, the Royal College of Obstetrics & Gynecology has put out revised parameters supporting an option of vaginal breech delivery. Based on research that debunked a lot of the information in the earlier Term Breech Trial that organized medicine originally jumped on to recommend c/section for all breeches. The RCOG is way ahead of ACOG in the strength of their statement and the commitment to try to reeducate practitoners in the art of breech delivery. If you are breech or have a client who is breech at 35-36 weeks this would be an excellent educational, calm reasonable website to refer to families who want to know more. Might keep them from surfing the interent in unfiltered and sometimes hysterical sites.

When considering a home breech delivery, as that may be the only option left in many areas, it is important to give true informed consent. The most significant difference in a home birth with a skilled practitioner is the lack of ability to use Piper forceps for my midwife colleagues since this is out of their scope of practice. Trained physicians can use these helpful aids and I carry them in my birth supplies. Once again, showing the collaborative approach of midwife and doctor teaming up can provide optimal care. Of course, we all know how few doctors there are willing to collaborate with the midwife community and the pressure those few are under from their peers. Also, the diminishing number of doctors skilled in breech delivery is concerning. Lastly, home birthing also lacks the immediate availability of general anesthesia in the extremely rare case where complete uterine relaxation is necessary to assist in delivery of an entrapped head. Women need to know these things but they must be presented in the light of the reality that the likelihood of this frightening problem is extremely rare when proper selection criteria labor management for breech delivery are used. In my opinion, the risks of a complication that is life threatening is more common from a surgical birth and these should be discussed as well. Then, whatever decision is accepted by the family should be respected. Where vaginal breech delivery is the preference but not an option, an ethical practitioner should refer that patient to someone who can honor her request.

From the AMA's Code of Ethics:
The patient should make his or her own determination on treatment. The physician's obligation is to present the medical facts accurately to the patient ... and to make recommendations for management in accordance with good medical practice ... Rational, informed patients should not be expected to act uniformly, even under similar circumstances, in agreeing to or refusing treatment

Dr. F

Bad news has decibels.

2011-05-13T17:08:00.000-07:00

There is a lot of buzz when a homebirth goes awry. No one should relish in the misfortune of another. Bad things happen in birth sometimes. No matter what the location. Yet there does seem to be some piling on when a homebirth is involved. Below are a couple of links to stories or blogs in the aftermath of a midwife who pled guilty to two felonies in a home breech delivery case in Maryland. I added my thoughts to the comments section on both of them. Dr. F

http://abcnews.go.com/Health/midwife-karen-carr-pleads-guilty-felonies-babys-death/story?id=13583237

http://blogs.babble.com/being-pregnant/2011/05/12/take-back-the-night-mentality-not-so-much/

Tragic ending to a tragic story.

2011-05-10T08:23:00.000-07:00

Not much I can add to this well written story in Slate. I thought the writer did an excellent job of reporting on this sad tale. Please read and comment here. Thanks, Dr. F

http://www.slate.com/id/2293389/pagenum/all/#p2

What is.....Breech delivery at home?

2011-05-09T19:51:00.000-07:00

If I were playing Jeopardy and the answer was: "The only option left in SoCal to a woman whose baby is butt first", the question would be.......(see title).

Proud to announce the delivery of little Andrew this morning, bruised bottom and all, to excited first time parents, Eva & Jared. When faced with no other option but forced, not elective, cesarean section they chose, instead, the unlikely option of a home breech delivery. Informed of options, risks and benefits and knowing they would like to have many children they felt that c/section was a bad choice for them. Hospital vaginal birth with the one doctor who still accepts primip breeches was financially nonviable due the limitations of their HMO policy. The Sanctuary Birth and Family Wellness Center midwives and I were delighted to help this couple achieve their goal in the comfort and privacy of their own bedroom. Using the skills I learned in training and adhering to specific guidelines for the safety of breech vaginal birth made this choice possible. Respecting the right of true informed consent and all birth options made it a wonderful day for all involved. Thanks Molly and Heather Anne. Dr. F

First Tranport

2011-05-08T03:07:00.000-07:00

5/07/2011: Birthing at home can be a miracle and a blessing. On rare occasions even the best laid plans can fall short. Sometimes exhaustion sets in when too little sleep and nourishment occur over the course of a 29 hour labor. After 9 months of assisting in home birthing I finally had my first need to transport a family in labor. Thank God for backup physicians like Dr. David Kline and the judicious use of epidurals and pitocin. They do have their place. With his patience and skill a beautiful baby girl was born vaginally early Saturday morning. Mom, dad and baby were home again inless than 6 hours. This family was delighted and had the satisfaction of knowing that these interventions were necessary and what was needed by their sweet baby girl to enter this world.

Happy mother's day to them and to all of you. Big hugs all around. Relish in them as there is an emptiness when your mother is no longer with you to hold.

As for me, this was a watershed moment. It was the first time I can recall in my 25 years in private practice that I had to relinquish the care of a woman to another colleague. This felt very strange for me as I am a healthy bit obsessive about completing tasks to which I have committed. I have shared this feeling with some of my midwife colleagues today and want to thank them for their awesome support. A big hug to my friend and colleague for 29 years, Dr. David Kline, too. Thanks, Dave.
Dr. F

Only 2 state-licensed birthing centers in Central Indiana close

2011-05-01T00:00:00.000-07:00

Citing problems with insurance coverage and insurers reluctance to pay for birthing center births despite the savings of about 50% from the cost of a hospital birth these 2 centers were forced to close. The midwife running the 2 centers, Barbara Bechtel, also stated that the insurers demanded an obstetrician be her backup rather than the family medicine doctor she had been relying on. She could not find cooperation from the local obstetric community and so this option for mothers is no longer available. There was no mention of problems with bad outcomes to justify the noncooperation. But is it hard to figure out why? See the full article at the link below. Dr. F

http://www.indystar.com/article/20110430/LOCAL1804/104300333/Only-2-state-licensed-birthing-centers-Central-Indiana-close?odyssey=nav%7Chead

Ethics in the eyes of the beholder!

2011-04-29T18:24:00.000-07:00

In this months Green Journal, the ACOG publication, were 3 articles concerning the ethics of home birth. If anyone is interested in reading them please send me your email and I can send them to you. They are proprietary and password protected and cannot be linked here. One nearly brought me to tears called "An Obstetrician's Lament". The writer eloquently painted a picture of a somewhat professionally self inflicted dilemma. One took an honest look at relative vs. absolute risk and true informed consent. The third, surprisingly, upset me more than I thought. Dogmatically labeling obstetricians who participate in home birth as lacking integrity and suggesting that educated patients who refuse hospital birth should be given "respectful persuasion". In response to this article I wrote the following letter to the president of ACOG.

Dear Dr. Waldman, I just was reading the articles in this months Green Journal and came across one in particular that I found very troubling. I think you know that I am an advocate for true, not skewed, informed consent and a supporter of midwives and the option of out of hospital birthing for well informed low risk women. Dr. Chervenak and colleagues in an article titled, "Obstetric Ethics" seems to continue the College's selective bias against home birth and those who support it.

In the abstract he says this," ...Obstetricians have an ethical obligation to disclose the increased risks of perinatal and neonatal mortality and morbidity from planned home birth in the context of American healthcare and should recommend against it. Obstetricians should recommend hospital-based delivery and respond to refusal of these recommendations with "respectful persuasion". As a matter of beneficence-based professional integrity, obstetricians should not participate in planned home birth."

As my president I have to ask you if you believe this statement to be true.

As for myself, I find so much wrong with this in the context of known hospital based risks which the college does not seem as eager to recommend disclosure of. Also, the restrictions on choice occuring because of ACOG opinions and the legal and economic climate in which hospital policies restricting those choices are made. I find it repulsive that the authors, and I suspect the editors of the journal, condone respectful persuasion which seems to be just another nicer name for skewing informed consent. Am I and other obstetricians who support patients who desire an out of hospital birth acting without integrity and unethically as Dr. Chervenak proposes?

The demand by a better educated populace for a say in how and where they give birth is coming. The current trend in c/section statistics and interventions do not speak well for the medical model in low risk birth when compared to the midwifery model of pregnancy as wellness not illness. The obstetric profession is not preparing its doctors in training in the art of medicine any longer. Skills of breech birth, forcep and vacuum deliveries and twin vaginal birthing have disappeared from the training programs under our watch. Fear has replaced trust in that most natural of life's events. The authors and ACOG are running with a strawman argument that home birth is unsafe and building upon that questionable foundation. There is far more evidence based medicine that supports the safety of selective home birth. Certainly enough that should give pause to reasonable people labeling those that have a different view as unethical or lacking in professional integrity.

I am very concerned that we now have articles endorsed by our college that dogmatically define ethics and integrity to fit their definitions of what normal pregnancy should look like. Personally, I resent the implication. Just as the authors seem certain they know what is better for individual patients and have taken it upon themselves to label those who differ unethical, I am certain their hubris and possibly well-meaning paternalistic views are a violation of our oath and mission statement.

Again, as my president, I need to know if you agree with the finality of Dr. Chervenak's definitive statement.

Sincerely, Stuart J. Fischbein, MD

Kim Rivers responds to PV midwife ban

2011-04-26T21:09:00.000-07:00

Thanks to Kim Rivers for writing a response the the Ventura County Star article on the midwife ban at Pleasant Valley hospital. And congratulations to Kim on getting the Star to post her op-ed piece in yesterday's edition. You can find her article at:

http://www.vcstar.com/news/2011/apr/25/rivers-why-are-midwives-being-targeted/

I encourage you to read and comment. It is a rare chance for small voices to be heard. Dr. F

Another Home VBAC

2011-04-23T16:15:00.000-07:00

Why do babies so often come in the wee hours of the morning? Does seem disproportionate but makes the driving easier. I had the privilege of assisting a wonderful couple with their HBAC this morning in their bedroom in Santa Barbara. Well informed and also aware of the hostility towards VBAC in their local hospital they made a choice to birth at home. From the spontaneous rupture of membranes to the birth of the beautiful little boy took only 4 1/2 hours. Assisted by dad with grandparents hovering about we welcomed Lucas's little brother Matias Esteban into the world. Dr. F

I guess "When" is this Monday

2011-04-20T05:37:00.000-07:00

The Headline in the Ventura County Star reads:

Midwife restrictions at St. John's Pleasant Valley Hospital will be lifted next week

http://www.vcstar.com/news/2011/apr/18/midwife-restrictions-will-be-lifted-next-week/

While good news is always nice to pass along, midwife Lynn Olson says it best. This (ban) should never have happened in the first place. So 14 months after they were inexplicably removed to the canard of "safety issues" per the former CEO, midwives are set to return on Monday. Oddly, seems that Lynn and Joyce, the only 2 CNMs working there, need to be recredentialed. Sort of unusual since they have maintained their credentials at the sister hospital, St Johns, all this time. This would seem to be a new policy or legal barrier placed on them and only them as it has always been that credentialing at one of the 2 campuses gave you privileges at both. Lastly, the administration has supposedly used these 14 months to create new policies to ensure safety of midwife patients. Yet they do not detail what those policies are nor why doctors working there throughout the midwife ban could function without them. I have the belief that these decisons will someday be looked at under a microscope and those most involved held responsible for their unrepentant and inexplicable actions against these devoted CNMs. For now, good news for the women of Camarillo. Dr F

Where we are likely headed....

2011-04-16T19:00:00.000-07:00

Jason Fodeman, MD wrote an article on Townhall.com today that is worthy of mention. It is titled: "The New Heath Law: Bad for Doctors, Awful for Patients". You can find it at:

http://townhall.com/columnists/jasonfodeman/2011/04/16/the_new_health_law_bad_for_doctors,_awful_for_patients

The article is taken from a White Paper analyzing the PPACA (better known as ObamaCare) authored by Dr. Fodeman for the Galen Insitute. It is certainly worth reading no matter where you fall in the debate. I happen to agree with him and am not optimistic about the long term health of our health care system. Please take the time to read the full link below.

http://www.galen.org/fileuploads/NewHealthLaw_BadForDoctors_AwfulForPatients.pdf

Thanks, Dr. F

Text of Dr. F's 2011 Tax Day Rally Speech

2011-04-16T18:53:00.000-07:00

For the second year in a row I was asked to speak at the Tax Day Tea Party Rally at the Thousand Oaks post office. This is the text of my address:

I have been asked to give a practicing doctor’s perspective on what is happening to our health care system.

I would like to begin by telling a brief parable about the farmer and his horse:

The Farmer & His Horse

There once was a farmer who had a beautiful farm and a devoted horse. The horse worked long hours, never complained and loved his work. Twice a day the farmer would feed the horse and all was right in the world.

But then the farming business went into a slump and the farmer asked the horse to work longer days and plow more fields just to make ends meet. The horse never complained and loved his work. Once a day the farmer would feed the horse and all was still ok in the world.

Soon the farmer was told that the cost of hay was increasing. There were no more hours left in the day to work harder to pay the increasing costs. So he decided he would just feed the horse a little less hay each day. The horse never complained about his hunger, did his work as best he could but the world was not so good anymore.

This went on for some time. The farmer continued to work his horse really hard, had to lay off his workers and spend less on hay for his horse in order to keep his farm running. The farmer noticed his fields were looking a bit shabby. His harvest was the worst he ever had. He was baffled. Why was this happening?

Finally, he woke one morning before dawn. Dragged himself out to the barn and there was his devoted horse, lying in his stall. Starved to death!

Medical professionals and the patients they serve cannot be squeezed indefinitely. Like the poor farmer and his horse, the story will not end well.

Healthcare is not an inanimate commodity to be treated and bartered like oil or water or even hay, for that matter. It is us! And each and every one is unique.

Centralization is a bad idea and a terrible one for medicine.
What we will see as government and insurance companies continue to micromanage our lives are mandates based on ideological, nanny state one size fits all ideals. You will begin to see laws and commercials and public service announcements, paid for by government stimulus money, really, our tax dollars, which entice you by reward or punishment to follow their advice. Advice based most often on emotion and not science. You will see more brainwashing type curriculum in public schools with the purpose of indoctrinating our children early on towards the “correct” way to think.

Really, this extends far beyond just the healthcare law. What we have now unleashed in our country is a hostage situation to the American legal system. Whether it’s the local restaurateur, the small businessman, the ski resort, your family doctor or your local hospital or school we are all intimidated by a lack of restraint on our legal tort system. Quite frankly, my biased opinion thinks that the biggest obstacle to American values and common sense returning to us is the American civil legal system which promotes victimhood and extortion. If any industry was in need of reform it is that one. Where are the future leaders who are willing to take on the trial lawyers? Now that would show real bravery. Dennis Prager has rightly labeled ObamaCare, “The trial lawyers of America stimulus package”.

Recently, a midwife friendly hospital serving the needy in Greenwich Village closed its doors due to its inability to stay financially solvent while trying to comply with all the mandates, regulations and legal protections required. Many doctors are already at the point where they cannot afford malpractice insurance or continue to take on more patients for ever decreasing reimbursement. As costs inevitably go up reimbursement to providers will be decreased or care will be rationed. MediCal and medicare patients are going to find it harder to make appointments and are going to be waiting longer. Lowering reimbursement further will just devalue the doctor-patient relationship. It will push small community hospitals out of business, as it has in Greenwich Village, and lead to rationing by default. How much more work can you squeeze from a starving horse. Most doctors love our profession but hate what the business of medicine has become.

As for my practice: Carolyn asks whether I would consider giving it up and retiring early. The question is actually can I afford to keep going? This year I will turn 55. I love my work. I could continue to practice for another 20 years. The real question is “Would I be a fool for doing so”? Not only will doctors able to quit consider doing so but who in their right mind will become the future doctors in our country. Years of training and sacrifice of social life lead to a loss of a decade of fun and earning power and massive debt. Only to come out and see your expenses rising and uncontrolled but your earning power capped and regulated. The devastating threat of a career ending law suit hanging over your head like the sword of Damocles is no way to live. Having the authorization for a test or procedure denied by some non-medically trained faceless cubicle worker who can’t spell the diagnosis is maddening to those of us who care. Your medical decisions weighed and scrutinized by faceless utilization review boards, government agencies and hospital committees. None of whom will ever bother to get to know the patient you are advocating for. How many of you would want to live like this? How many of you want your children to live like this?

And I have yet to mention the looming specter of Electronic Medical Records coming by 2014. Every detail of your medical history and that of your children will be mandated to be online for bean counters of all shapes and motivations to see. Do you trust that it will remain confidential and used wisely? I don’t! And there will be a large cost of installing the hardware and mandated annual updates that will not be reimbursable to the practitioner. Adding another undo burden on the small, independent practice of doctor, midwife, chiropractor and therapist. Another not so subtle hammer to force solo doctors like me out of business or submit to joining large impersonal multispecialty groups where the individuality and art of medicine I love will disappear.

Solving this will be a complicated process. Remember, healthcare is not the problem. We have the best in the world. It is more accurate to call this dilemma a problem of healthcare access. I know it sounds radical and probably too late but I don't believe the government has any business being in the business of health care. Evidence based medicine is a simple premise that supposes that medical decisions are based on scientifically proven studies What is most scary to me in an era where we are supposed to rely on evidenced based medicine is this. All these regulations that are being instituted and forced upon us have never, I repeat, never been studied to show that they have actually improved healthcare delivery and outcomes. If anything, other countries that have tried this are backing away from it. These edicts are being rammed down out throats with no science to back them up. They are theoretical only, and the motivation is financial and control, not betterment of health and not individualized care. The canard that is always used is "safety". Albert Camus, the French philosopher, said, "The welfare of humanity is always the alibi of tyrants."

How can the Tea Party help? In my perfect world, first, repeal Obama-care entirely and end the fraud that has been played on America. Then insist on tort reform and insurance reform and demand our elected leaders “Read the Bills”! Stop having insurance companies, lawyers, politicians and hospital administrators dictate medical decision making that belongs by right to patients and their practitioners. Also, encourage states that limit competition from allied health professionals such as midwives, naturopaths and alternative medical practitioners to lessen their restrictions on these caring men and women. Leave pharmaceutical companies alone. They are not the villain. And reign in the FDA and its draconian restrictions on new drug development and patient choice. Let the free market loose and trust the educated consumer to make their own life decisions and accept the consequences of those decisions.

Most doctors are excellent caring professionals. Go after fraud and bad doctors but do not lump us all together. Do not micromanage all of us who mostly want to do good work for those we serve. Confident knowledgeable people do not need micromanagement. I would like to know that when I am sick I am being cared for by someone who is a leader and not a follower.

So, we have come to a place where we have to decide who we trust. No longer can we be passive when it comes to something as important as our family’s health care. We have to take a stand. I trust the relationship I have with my personal physician. I trust my ability to judge him by his actions. I trust that she has my welfare as her primary concern. I encourage you all to educate yourselves and ask questions. You have the right to be truly informed. I trust that if he does not serve me well I can go someplace else. I do not trust big government or big business to have my back. I do not trust the nanny state to make decisions that are in my family’s best interest. I will do that and I want a country that allows me the freedom to succeed or fail. One size does not fit all. We must get away from that mentality. The best and the brightest should be going into noble professions like medicine. Sadly, unless we continue to elect leaders who repeal this horrible health care legislation, medicine will no longer remain an appealing avocation and the best and brightest will seek other interests. Possibly wasting their talents as lawyers or government workers because that’s where the money and lifestyle remain.

Finally, the government should not have the right to take my hard earned skills and demand of me to give them away for what they determine they are worth. I am not a horse to be fed ever decreasing amounts of hay. And, I never dreamed I would be before you all today making empassioned speeches. All I wanted to do was to practice my profession as I was trained to do and love my family. I am lucky. I have the good fortune of collaborating with midwives and the honor of assisting families who desire home birthing. Working outside many of the pressures and restrictions I have discussed today. But, I cannot sit idly by and watch this happen to the profession I love. I want my children to know that their dad stood up for self determination and personal responsibility.

Royal College of Ob/Gyn Supports Delayed Cord Clamping

2011-04-09T00:45:00.000-07:00

The RCOG recommends that the time at which the cord is clamped should be recorded. Early cord clamping is defined as immediately or within the first 30 seconds. The cord should not be clamped earlier than is necessary, based on the clinical assessment of the situation. Evidence suggests that delayed cord clamping (more than 30 seconds) may benefit the neonate in reducing anaemia and particularly the preterm neonate, by allowing time for transfusion of placental blood to the new born infant which can provide an additional 30% blood volume. In the preterm infant (less than 37 +0 weeks) this may reduce the need for transfusion and reduce intraventricular haemorrhage. Delayed cord clamping does not appear to increase the risk of PPH. The timing of cord clamping needs to be made by the doctor or other attendant in the light of the clinical situation. Early clamping may be required if there is postpartum haemorrhage, placenta or vasa praevia, there is a tight nuchal cord, or the baby is asphyxiated and requires immediate resuscitation

. April 2011

The International Federation of Obstetrics and Gynecology and the World Health Organization no longer recommend immediate cord clamping as a component of active management. Dr. F

HBAC in Water

2011-04-09T00:33:00.000-07:00

Spreading the word and announcing another beautiful home birth in water this past week. I was honored to attend the home birth after c/section of a wonderful family in Simi Valley. In a county that for all intents and purposes has banned the choice of vaginal birth after a c/section in the hospital I am happy to offer this option to families in the comfort of their own home. I will continue to advocate for reason and the respect for choices in childbirth that belongs to mothers.
Dr. F

ACOG silence remains deafening

2011-04-04T10:59:00.000-07:00

MEDSCAPE: Planned Home vs Hospital Birth: A Meta-Analysis Gone Wrong: A Flawed Analysis

This is potentially very significant. The authors of the British Columbia and Netherlands home birth studies that were allegedly included in the Wax Paper have published a devastating attack on that study on Medscape:

http://www.medscape.com/viewarticle/739987

Thanks to Susan Jenkins and Linda Bennett for forwarding me this link. My respect goes out to the authors of this rebuttal to the Wax, et al paper. These men and women did the honorable and tedious work of breaking down the data and critically analyzing Wax's methods and conclusions. I forwarded this information to the President of ACOG, Richard Waldman, MD. It is very difficult these days for anyone to admit they made a mistake. There is no shame in doing so, I know, and it is time for ACOG to do the same regarding Committee Opinion #476. Dr. F

Questioning Veracity

2011-04-03T21:56:00.000-07:00

After some prodding by me and others, finally, last week the Ventura County Star and writer Tom Kisken finally reported on the status of the longstanding midwife ban at Pleasant Valley Hospital in Camarillo, CA. I found the headline to be misleading, the article to be very milk toast and Mr Kisken's investigative effort into the veracity of the hospital administration to be lax at best. Those that have followed me for the past year and a half know of the issues to which I am referring. Please read and add your comment to the story at:

Midwives ban to be lifted at Camarillo hospital; question is when

http://www.vcstar.com/news/2011/mar/31/midwives-ban-to-be-lifted-at-camarillo-hospital/

I have sent Mr. Kisken the following e-mail after returning home from a fun filled weekend with my daughter and her Westlake High School choir class at the Heritage Music Festival in Anaheim. Hoarse and exhausted from chaperoning 160 kids through the event and long, good days at Disneyland and California Adventure.

Dear Tom, I just read your article is last weeks Star. I found it very disappointing. Once again you failed to get anyone to explain anything. You allowed administration to avoid answering the obvious question. "Why Certified midwives banned and not doctors?" Laurie Eberst was not even here when this happened. What could she possibly know about the truth other than what she had been fed? Where are the quotes from Ann Kelley or Eugene Fussell? If no one is talking doesn't that bother you? You quoted anonymous sources but did not say why anyone would need to remain anonymous here. How about explaining that your sources were reprimanded last time for talking to you? How about some investigative journalism into why anesthesia is and has been obstructing the midwives return? Did you speak with Dr. Kalcic? How can it possibly take more than a year to implement any policy change if they really want to change? Good investigative reporting would have asked those questions and not allowed a non-answer. Also, since I was a major part of their reasoning for the ban, why not approach me for information? Was not I the one who gave you the "push" in the first place? And what is that headline supposed to mean? It seemed almost tongue in cheek and very inappropriate. Was that story really your best work?

Sincerely, Stuart Fischbein, MD

I will patiently await his reponse and happily report any error in my facts should he wish to clarify. My colleague, Kim Rivers, has written a letter to the editor in reponse to the article. With her permission, I will post it if the Star refuses to.
Dr.F

Confirmation of ACOG damage

2011-03-28T07:55:00.000-07:00

For the umpteenth time since release of ACOG's Committee Opinion #476 I have seen the propagation of its misinformation. I use Google Alerts to help me review stories around the world on home birth. In story after story having to do with this subject, other "experts", reporters and sources quote its conclusions of a 3-fold increase in neonatal death blindly and as definitive fact. Funny, how it is almost verbatim and the virtues of home birth quoted by ACOG are never equally extolled. I can only assume it is because an organization such as ACOG has a built in gravitas that writers will rely solely on its statement without doing any further research. I have spoken about this to ACOG leaders as a consequence of its standing in the medical community. With great power comes great responsibility. ACOG and Dr. Wax have much to answer for but almost certainly will not.

So, for the umpteenth time I have written to to the writer or posted a thought in the comment section to at least give another perspective. I encourage readers to take a moment to respectfully do the same when they come across a reporter quoting an expert who categorically uses the "3-fold" line. Dr. F

Here is what I wrote this morning in repsonse to an article in The Herald, an Australian newspaper:

Dear Ms. Hadfield, For the record, Dr. Andrew Pence is quoting data that is well known to be incorrect. It is from one flawed study by a researcher named Wax who cherry picked his meta-analysis data to reach his conclusion on the perils of home birth. Dr. Wax's motives for doing so are unclear. The truth is far different. He excluded the largest studies from North America and the Netherlands which showed no such risk and, in fact, in comparable low risk patients showed far less intervention and c/section rates and greater satisfaction in women who had home births. Dr. Pence makes a common mistake in relying on data that is supportive of the established medical position rather than looking critically as a scientist should. Then relaying this misinformation as if it is undisputed fact. Reporters often go to academic sources with a blind trust that they are objective and their advice is evidenced based. Sadly, neither is often true. Home birth in low risk women is a safe alternative and a choice that belongs to them when given true, not skewed, informed consent. I would be happy to discuss this further if you are interested. Warmest regards, Dr. Stuart Fischbein, MD FACOG

Stand & Deliver Offers Breech Skills Workshop

2011-03-25T08:49:00.000-07:00

www.rixafreeze.com/pdf/breechflyer.pdf.

I received this e-mail from my colleague, Rixa Freeze, of the great web site Stand & Deliver. Please pass on this info to anyone you know who might be interested in learning or relearning these skills. Good stuff! Dr. F

Hi Dr. Fischbein,

I am thrilled to announce a vaginal breech skills workshop coming to Indianapolis this July! Participants will perform and observe simulated vaginal breech deliveries with Canadian obstetrician J. Peter O'Neill and learn upright (hands & knees) breech techniques from Canadian midwife Betty-Anne Daviss. She will also be giving a free public lecture about upright breech birth on Saturday, July 16th.

I have attached the flyer & registration form (PDF). You may also access it at www.rixafreeze.com/pdf/breechflyer.pdf.

Please circulate this to other physicians or midwives who might be interested in updating their vaginal breech skills. Don't forget to take advantage of the early registration discount before April 15th.

I hope to see you there!

Rixa Freeze, PhD

Rainy Day Philosophy

2011-03-20T22:34:00.000-07:00

Living in Southern California has many advantages. One is the absence of snow days and another is the rarity of rainy days. Life slows down for me on a rainy Sunday morning. No place to run to. Horseback riding cancelled. Cat asleep at my feet. The sound of the wind and rain on the roof all cozy in bed with my book momentarily unhooked from the world. It is wonderful to slow down in today’s buzzing world of instantaneous information overload and short attention spans.

Then I open my computer to read the amazing notes of my midwife colleagues at Sanctuary attending 4 separate births in the last 24 hours. Maybe there is something to the super moon thing! They post on the board of the natural progress of labor that comes in so many different forms. With calmness born of wisdom they describe what the families are doing at home. Some resting quietly while others are up walking and talking. Some sit or stand in water while others forage in the kitchen for the perfect nourishment to suit their craving. Fathers and doulas and midwives and apprentices and hypnosis experts and children and pets all are choreographing this dance of life. I was speaking to my great friend and colleague, Heather, in the comfort of The Sanctuary Birth & Family Wellness Center, this past week and the following realization just flowed forth.

I have now attended more than a dozen home births and have noticed many differences from my 28 years of attending hospital births. But none is more striking than how the environment affects the traditions and attitudes of the practitioners. In a hospital based birth the primary care giver is almost always a nurse or possibly a CNM. They are bound by policies and procedures that limit individualization. No matter what the desire of the family dictates there is pressure on the staff to complete forms and data entry. They must document “progress” and even encourage intervention when it does not conform to some standardized norm. To not push the process along can bring the scorn of their supervisor. Nurses are encouraged to monitor all sorts of bodily functions and even the most caring have to deny food and interrupt the primordial place a woman should be for the sake of documentation.

Documenting what and for whom? When and why then? Likely for administrative policy, litigation mitigation for that worst case scenario fear, for the next nurse and doctor coming on in the shift practice model or just one of those long habits of not thinking a thing wrong, thus making it seem right. But that is all the consequence of the dominant trend to look at pregnancy and labor as illness, not wellness.

In this model there is rarely a doctor present until called by the nurse to come in. From experience I think many nurses fear this for woe be unto them for calling the doctor too soon or too late. From my past experience I vividly recall arriving to the labor room from home or office. Invariably, all eyes would now focus on me and I would be expected to do something. Many doctors would feel as if they must do something because they are now there. And so there would be vaginal exams and commands to push when no urge was felt. The nurse would receive orders for pitocin and pressure catheters because labor was not following the curve fast enough. Discomfort is difficult for doctors to observe so the wonders of an epidural would be lauded.

It would almost be inconceivable for the doctor to arrive, sit quietly in the corner observing for a while, whisper a few words of encouragement and then quietly leave the woman and her partner alone. The “I am here now so I must do something” mentality is pervasive. It may be the rescuer in us, the fixer or it could just be an impatience born of long hours, frustration, poor rewards and fear. Whatever the reason it is pervasive and is a startling contrast to the calm, nurturing approach of my experiences with home birth.

When I arrive at a home birth after a gentle knock on the door I quietly enter the space with a whispered greeting to the father or other caregivers. I observe the room, listen to the sounds and look at the faces of those present. There is so much vital information there that no machine can tell me. There is an honoring of the process and the woman in labor is on a pedestal. She is a person not an object. The goal of all those around her is to keep her feeling safe and nurtured and in whatever zone will keep her focused on the primitive, instinctual processes of labor. There is no timetable and no hustle and bustle of disturbances. There are only the sounds of nature and family linking us to all those that came before. We are calmly waiting for another generation to enter the world.

The conversation with Heather clarified what had been just a feeling since joining the home birth community and made it a revelation to me. My midwife colleagues have heard me say that no matter how I am feeling before I enter that sacred space of the nurturing birth world I always leave feeling better then when I came in. That was almost never the case when entering even the parking lot at a hospital. It is a striking difference to enter the world of the laboring woman and not feel like I am obligated or entitled to do something. Trusting birth makes it a better world for everyone involved and returns the joy to my work.

We have all created a safe and cozy space for ourselves. We call it home. On this windy, rainy Sunday there is no place better to be. I am surrounded by familiar sounds, sights and smells and it feels wonderful. It is a metaphor for life and certainly for birth. Building a secure, nurturing support system is good for your life and better for your birth. There is much to be said for returning to the pleasures of sociability and being intentionally unproductive. I would encourage my fellow practitioners to take a deep breath, look about them, walk more slowly and rethink the model which has become so normal and yet so detrimental to the enjoyment of their lives.

Warm Greetings To You All, Dr.F

NY Times article on NICU Costs

2011-03-20T14:29:00.000-07:00

Sometimes you have to weed through a pile of junk to find a few pearls of wisdom. Thats my feeling about the majority of junk, called news, in the NY Times. However, this article was forwarded to me from my colleagues at D4PC.
(www.docs4patientcare.org) It has some good points including support for ones of profit motive that I have mentioned in the past when discussing some of the policies of the NICU and its director at St. John's Regional Medical Center in Oxnard. Whatever your take it is food for thought. Dr. F

http://www.nytimes.com/2011/03/20/us/20ttnicus.html?hpw

Scientific American Article worth reading.

2011-03-18T22:49:00.000-07:00

Please check out this link to an article in Scientific American that discusses The Wax Meta-analysis Paper that ACOG relied on as justification for its position against home birth and certified professional midwives. It fairly presents an unbiased view that, at best, many experts question its veracity.

http://www.scientificamerican.com/article.cfm?id=home-birth-study-investigated

Garbage in, garbage out. Science is not served when there is an agenda first and then data is cherry picked to bolster that agenda. I have no knowledge of Dr. Wax's agenda but ACOG diminishes themselves by showing theirs in choosing this paper as its sole basis for justification of its opinion on home birth. Readers should do their best to decide for themselves what the evidence and common sense tells us. Dr.F

Collaboration at work

2011-03-11T12:39:00.000-08:00

2 Days ago I was asked by one of my midwife colleagues to come to their clients home and assess the mom for a prolonged second stage. The mom had reached that "wall" and could no longer push effectively. After about 4 hours of trying different things in an otherwise healthy, nurturing environment they were talking transport as the standard option. However, now that I am contributing to the out of hospital birthing community we had another choice. I arrived to find the baby doing well and mom leaning on an exhausted but incredibly supportive husband. After talking it over with dad and the amazing team we decided that a vacuum delivery was a good option for them as they did not want to go to the hospital after such heroic efforts at home and for financial reasons. I examined mom and felt the baby to be OA, slightly asynclintic and +2 station. Not much molding or caput. We repositioned to the sofa and with a cooperative baby and a revitalized mom they gave birth by vacuum assisted vaginal delivery to a beautiful baby girl in their living room illuminated by the late afternoon sun. Beautiful relief on parents faces. Birth team, too. It was a great example of combining the skills and knowledge of the midwife-OB-doula in a collaborative effort to give families another choice. Love to Molly, Heather Anne, Kim and the trusting family. Dr. F

Followup Letter to ACOG President

2011-03-11T12:33:00.000-08:00

I have found Dr. Waldman to be sincere and I hope I am right. It has been 2 months since I wrote to ACOG regarding Committee Opinion 476 on Home Birth. This e-mail is a followup to my correspondence with ACOG's president and is self explanatory.

3/11/2011

Dear Dr. Waldman, Hope this note finds you well. In your email to me from January 25th you mentioned that Dr. Hale would be passing my letter on to the committee for what I had hoped would be some honest answers to my serious doubts about their science and motivation in releasing Opinion 476. Sadly, my expectations of receiving a response from them were very low from past experience and it seems that low expectations of your Opinion Committee were appropriate. I have the energy, knowledge, evidentiary support and willingness to discuss these issues with my esteemed colleagues who make up this committee. I am disappointed that a committee from my college is assigned the awesome responsibility to make statements that have a powerful effect on practice and policies in America but ignores legitimate questions and dissent from one of its own members. I hope you will accept my offer to contribute to any future discussions inside of or publically made by ACOG regarding the safety of home birthing, licensed midwives and patient's rights to true informed consent with the same sincerity that I voice my concerns to you. I am one of but a very few professionals in the country who have the legitimacy and wisdom of experience living and working in both worlds. Opinion 476 should never have been released based on the Wax paper. It damages the credibility of the College. If we as obstetricians really do care about honesty and truth towards the women we serve then there should be no other motive but those from an organization like ours.

Sincerely, Stuart J. Fischbein MD FACOG

A Comparison - You Decide

2011-03-06T23:01:00.000-08:00

When I was on staff at my local hospital in 2009 I posted this data. Needless to say, I got yelled at and was ordered to remove it because it somehow violated confidentiality. No explanation given. Actually, I believe it was too revealing of the differences in practice styles and therefore embarassing to some. Well, I am no longer under threat of administrative retribution and therefore, once again, I feel this data deserves to be discussed. What it does show is that in a population of low risk mothers in 2008, comparing apples to apples, the midwifery collaborative model practiced by The Woman's Place for Health, Inc. had a primary c/section rate of less than 5% while another local large group of doctors adhering to the obstetrical model of medicalizing birth had a primary rate near 17%.
In this group of over 300 women an almost 4-fold risk of having a first time c/section in a comparable group of low risk pregnant women exists when birth is "treated" as a medical problem. In order to respectfully and honestly share the information of my collaborative practice and quell the naysayers I am in the process of compiling data from more than 10 years. I hope to publish "The Experience of an OB-Midwife Collaborative Practice" using statistical analysis and an evidenced based approach this year.
What those of us with common sense and the powers of observation have known for a long time about low risk birthing will benefit from as much objective data as we can get. Patients deserve as much truthful information as they can get to make an informed choice. I look forward to sharing my findings with you and with them. Dr. F

Small Community Hospital Deliveries from 12/1/07 to 11/30/08
Practice Total / # / Rate
Doctor A 75 / 10 / 13.33%
Doctor B 37 / 4 / 10.80%
Doctor C 51 / 12 / 23.50%
Doctor D 20 / 5 / 25.00%

Doctor E 14 / 3 / 21.40%

TWP 124 / 6 / 4.84%(Dr.F & midwives)
Other Large Group Total:
MDs A-D 183 / 33 / 16.9%
Deliveries and c/sections performed at a hospital that cares for almost exclusively low risk patients.

Gotta love Dr. Fogelson

2011-03-06T21:01:00.000-08:00

My colleague, Dr. Nicholas Fogelson writes a blog called "Academic Ob/Gyn" at www.academicobgyn.com (see supporters). He is a strong supporter of delayed cord clamping and takes a common sense approach to decision making in our field. He has recently penned a column that expresses one of those pet peeves that nags at those of us who care for pregnant women. With his permission I have posted it below. Dr. F

An open letter to the dentists of the world
March 3, 2011
Nicholas Fogelson
22 comments
Dear Dentist-

Thank you for being there for patients around the world, fixing and cleaning their teeth and gums. Thank you for your training and your wonderful set of skills which we all need.

But today I have a bone to pick with you.

For the one thousandth time today I was asked to write a note for a patient with an obviously infected tooth, giving my permission for you to treat her. For the one thousandth time, I sat before my suffering patient, cursing your name, and wrote this ridiculous note. And now my patient can go back to you, and now you can do the job you should have done when she first came to you with her painful tooth.

As an obstetrician, I am expected to be expert in all things pregnancy. Not only that, but I am expected to understand how all things not pregnancy affect all things pregnancy. It was for this that I went to medical school and trained long in my field.

You are much the same.

As a dentist, you are expected to know all things oral cavity, and furthermore how all things not oral cavity affect all things oral cavity. It was for this that you went to dental school and trained long in your field.

And in this training, you no doubt learned something about the dental care of pregnant women. You probably learned that local anesthetics are not harmful to a pregnancy, and that the narcotics you prescribe for pain and the penicillin based antibiotics you use for infection are also safe. You probably learned that the millirads of radiation your oral films use are trivial compared the amount of radiation it would take to harm a fetus, and if you’re really on it you might even know that an obstetrician would do a 3 rad cat scan right through the fetus if he or she thought it was important enough. At the least, you know that the big lead apron you use is going to block anything that might get to the fetus anyway. You might have read that obstetricians are actually quite interested in oral health, and that we think that chronic oral disease may ironically be a contributing factor to the preterm labor you hope to avoid involvement with by refusing to treat oral disease in pregnancy women.

At the very least, you know that a fetus is kept in the uterine cavity, not in the oral cavity.

Since you already know these things, really what is going on is that you want your ass covered if under some strange coincidence something bad happens to a pregnancy after you treat a patient.

This is bullshit, and I am tired of it.

So forever more, here is a note for all the pregnant ladies of the world.

1. There is nothing you can do under local anesthesia that will hurt a fetus.

2. Penicillin antibiotics are safe in pregnancy

3. Local anesthetics are safe in pregnancy.

4. Narcotics are safe in pregnancy.

5. Oral xrays are safe in pregnancy. Shield the baby like you would any patient.

If after reading this you ever again send away a pregnant patient in pain because they need a note from their obstetrician, I have only this to say:

Grow a pair. You are doing your patient a disservice. Excercise the wonderful skills you spent years cultivating, and help your patient.

Special Delivery

2011-03-01T07:31:00.000-08:00

With permission from the family, it is with great joy and pride that I can announce my first home twin delivery. On Valentine's day my multiparous client went into labor at 37+ weeks with known breech/breech twins. The family had previously had 2 successful home VBACs and knew that no hospital would have allowed her desire to deliver breech twins vaginally. She approached the Sanctuary Birth and Family Wellness Center in Los Angeles several months ago and we agreed to care for her. She was a wonderful candidate, well-informed and highly motivated with a background in the natural birth community. Her labor started with ruptured membranes about 3AM. She finally kicked into high gear just after dinner. The little girls behaved smashingly in utero giving mom her opportunity. Baby A was born breech on all fours in water at 10:05PM on February 14th, 2011. Things then settled down with contractions spacing out and Baby B happy as a clam. Meanwhile mom tried nursing and dad and big sister took turns skin to skin with Baby A when mom needed a break. Shortly after midnight labor kicked back in and at 12:20 AM on February 15th Baby B was born breech on all fours on land. The family was amazing as was the birth team assembled. Much is possible with an informed patient with the right attitude and confidence in her body. Trusting the birth process and allowing nature to do its thing will often win out if we let it. I have to admit it feels wonderful to be freed from rigid policies and restrictive protocols, often void of common sense or evidenced based support. If hospitals will not allow women the right of true informed consent and refusal, I and the Sanctuary Midwives are proud to give them another option. Regards to all, Dr. F

"Fearless Pregnancy" - Spread the Word

2011-03-01T07:26:00.000-08:00

Facebook Post

A reminder to all that fears and anxieties are a barrier to a joyous birth. "Fearless Pregnancy" is now in its second addition and available for purchase or download. Expousing midwife philosophy while explaining medical issues, this book alleviates doubts that interfere with a natural birth. Please consider recommending our book. Your clients will thank you for the reassurance it provides and your thoughtful wisdom. Thanks, Dr. F

www.fearlesspregnancy.net

“I am such a huge fan of yours — have bought your book for every pregnant friend since someone gave it to me when I was expecting. It is by far the best book out there!!" – Beth Lipton, mom, cookbook author and blogger at Cookie Pie

Talk at Yoga Works, El Segundo

2011-02-21T22:28:00.000-08:00

Patricia Grube, an extraordinary doula and yoga instructor invited me to come and speak to her prenatal yoga class today. I talked about my journey to the present enlightenment and explained the differences between the midwifery and obstetric models of care, birth choices and the definitions of true informed consent and refusal. We discussed home and birthing centers as well as hospital births. Stressed was the normality of birth and how trust in the process often leads to a successful outcome. This was followed by some good Q and A and I handed out 10 copies of my book, "Fearless Pregnancy...". I was honored to speak to this group and give them a resource for all options. Sipping a cup of tea and listening to these women sing to their unborn babies made for a joyous event. Thank you, Patricia.
With affection, Dr. F

A Year Without Midwives

2011-02-20T09:32:00.000-08:00

Anniversaries are usually celebrated in honor of a positive life event. Weddings, first dates, career successes to name a few. They mark a milestone of sorts in our lives and are the means by which we keep track of those meaningful moments. Sometimes, however, they recall more tragic or sad events such as Pearl Harbor, yahrzeit in the Jewish religion for the loss of a loved one and, of course, 9/11. On a much smaller scale but still quite significant here in Ventura County it has now been more than a year since, by the stroke of a pen, the certified nurse midwives were banned from Pleasant Valley hospital.

While rumors have circulated for a while now as to whether or when they will return the fact remains that nothing has changed and no plausible explanation has ever been offered. One rumor has it they are trying to figure out how to have NICU coverage at PV. If they were really motivated to get this done there is no way it would drag on so long. Really does not seem that hard to solve. But since doctors still deliver there it can't be pediatric or anesthesia "safety" anyway as was the bogus reason given last year. Still veiled in secrecy, the process and motives baffle the mind. You don't need me to try to explain the inexplicable. When something defies common sense and the reasoning just doen't add up to all of you then it has to have some ulterior motive. If it looks fishy it probably is.

Some of the newer PV hospital administrators seem to support the return, however, nothing happens. Why? Maybe time for supporters of midwfery and honesty to write once again a letter to Ann Kelley, MD Chief of Staff or Laurie Eberst, the not so new anymore CEO. Call the Ventura County Star and wake them up while you are at it. Don't expect much from any of them in return. This is a anniversary that should never have happened. Dr. F

A must read!

2011-02-16T08:49:00.000-08:00

http://www.mercatornet.com/articles/view/taking_childbirth_home/

John Bambanek, husband of a woman who desired out of hospital birthing has written a terrific piece titled "Taking Childbirth Home" in mercatornet.com (see link above). Please read and enjoy and comment there and here. Thanks, Dr. F

Defining the Straw Man

2011-02-09T05:36:00.000-08:00

Dr. Amy Tuteur continues her crusade against home birthing. She offered a challenge that no one will debate with her. As you know, I have accepted her offer to speak in a public forum however she has never responded. Instead she publishes this last night:

10 Illogical Arguments in Favor of Home Birth
Opinion by The Skeptical OB
(16 Hours Ago) in Health / Women's Health
In addition to the problem of possessing inaccurate information, homebirth advocates have another, more serious problem, the tendency to construct illogical arguments. It is apparently such a pervasive problem that a brief review of these arguments is in order.

Let's look at the various types of illogical argument constructed against my core claim "the death rate at homebirth is higher than the death rate at low risk hospital birth." To make this exercise easier to understand, lets substitute a claim of the same form that is obviously true, so we will not get sidestepped by issues of truth or falsity and can focus only on whether an argument is logical or illogical. This is important because illogical arguments are automatically invalid arguments. We'll use the claim "there are more black cars in the US than lime green cars."

I say: There are more black cars in the US than lime green cars.

Don't say:

I saw a lime green car. - Can you understand how the fact that you personally saw a lime green car tells us nothing about the relative number of black cars and lime green cars in the US? That you saw a lime green car is perfectly consistent with black cars outstripping lime green cars 100 to 1, or even 1,00,000 to 1? Similarly, the fact that babies die in the hospital tells us nothing about whether the death rate is greater at homebirth.

I know ten people and not one of them has a black car. - This is an illogical claim based on an unstated assumption. The assumption is that the small slice you observe accurately represents the whole. However, tiny samples are often unrepresentative. Knowing 10 people who own black cars is perfectly consistent with the number of black cars exceeding lime green cars, BUT it is also perfectly consistent with lime green cars exceeding black cars, so it can't be used to support a specific claim. Similarly, the fact that you know ten women who had homebirths and not a single baby died tells us nothing about whether the homebirth neonatal death rate exceeds the low risk hospital death rate.

Lime green cars are prettier than black cars. - I hope it is obvious why value judgments about lime green cars tell us nothing about whether there are more or less black cars than lime green cars. Therefore, it should be obvious that claiming that women are more satisfied with homebirth tell us nothing about homebirth death rates.

You say that because you sell black cars. - Whether or not I sell black cars is immaterial; it has absolutely no effect on the number of black cars or lime green cars. This is essentially an accusation that I am lying and offering as "proof" the fact that I have a reason to lie, but a reason to lie is not proof of lying. So don't tell me that the fact that I am an obstetrician means that I am lying about neonatal death rates.

The people who make black cars have oppressed the people who make lime green cars. - Maybe yes, maybe no, but in either case, it does not affect how many black and lime green cars are on the road. Similarly, whether doctors have oppressed midwives has no bearing on whether the neonatal death rate at midwife attended homebirths is higher than hospital births.

There is a conspiracy against lime green cars. - We are supposed to believe that the number of lime green cars would equal black cars except for a public relations campaign designed to make lime green cars less desirable. It is theoretically possible that there is a conspiracy against lime green cars, but it is far more likely that other factors account for the difference in numbers. And in any case, it doesn't tell us anything about the relative numbers of black and lime green cars. So when confronted with the fact that homebirth death rates exceed hospital rates, it is illogical to counter with a claim that a conspiracy against homebirth exists.

There would be more lime green cars if the makers of black cars helped out. - That might be true, or it might not. In either case, it tells us nothing about the truth of the claim that black cars exceed lime green cars. And while it might be true that the death rate from midwife attended homebirth would be lower if doctors were more supportive of midwives, it doesn't change the reality of the current situation.

The Association of Lime Green Car Makers say that there are more green cars than black cars. - Cherry picking certain claims and ignoring all others is likely to lead people to the wrong conclusion. A lobbying group that disagrees with almost everyone else is not a reliable source of information. Similarly, professional NCB advocates and organizations are not reliable sources of information when they disagree with the bulk of the scientific evidence.

The color of cars is influenced by culture. - That is a non sequitur. It does not oppose the claim; it simply attempts to pin responsibility somewhere else and it is irrelevant. That's why the claim that hospital birth is culturally favored is irrelevant to any argument about homebirth death rates.

There are more important things about cars than the color. - That is what is known as "reframing the debate". It is a tacit acknowledgment that there are more black cars than lime green cars and a barely concealed effort to divert everyone's attention. That's why when someone announces that there are more important things than whether babies live or die, I know they have accepted the fact that homebirth leads to preventable neonatal deaths.

My Response posted this morning:

Dear Dr. Tuteur,
Your whole lengthy analogy is based on the assumption that home birth advocates possess inaccurate information and construct illogical arguments. You have yet to prove that either of these are true making your car anaolgy cute but meaningless. When you make a statement that you have failed to support and then build on that foundation you have a tottering structure. You have constructed a canard, the only purpose of which is, to confuse readers to accept your "core claim" and unsupported positions. The largest and most respected studies on Planned Home Birth vs. Hospital Birth do not show an increased neonatal death rate. In fact, in every measure of outcome and satisfaction, low risk planned home birth with a qualified attendant is equal or superior to comparable hospital based experience. And with less interventions which likely explains why.

Until you come out from behind your keyboard and defend your vitriol against midwives and alternative birth choices in person you have no credibility. We know this and your readers must be starting to wonder about the motives behind your fanaticism. Debate publically and we can respectfully discuss point by point all the lime green analogies you want. Sincerely, Dr. Fischbein

A Homebirth Story by Dena Moes

2011-02-05T18:11:00.000-08:00

I have invited Chico Midwife Dena Moes to post a guest blog. You can read more of her thoughts at:

http://www.chicomidwife.blogspot.com

I hope you enjoy this touching story and consider visiting Dena's site. Thanks, Dr. F

Special Delivery: A Homebirth after a Previous Stillbirth
This post is written with permission from the family involved. My intent is to inspire others to think through their choices and have courage. Deep thanks are given to Rachel and her family.

Eight years ago, Rachel was twenty-two years old, in a troubled marriage, and pregnant. Young, poor, and in a challenging life situation, Rachel did her best to take care of herself and eagerly awaited her baby. She used hospital-based midwives for her care, and had a normal pregnancy. Two weeks before her due date, her water broke. She called her midwives who advised her to come over to the hospital to be checked. She showered, got dressed, and came to the hospital. When she arrived, the heart beat of the baby could not be found. The baby had died. Rachel labored heroically and gave birth naturally after many hours to her stillborn son David. The cause of his death was never found, and the diagnosis of "unexplained stillbirth" was given to him.

The birth of David changed Rachel's life. She describes the changes as positive, because she used her grief as a catalyst for transformation. She began a profound spiritual journey, left her unhealthy marriage, and basically started a new life, listening deeply into her heart to find what was good and true for her. Rachel says "I believe that David and I had an agreement, made many lifetimes ago, that in this lifetime our time together would only last as long as it did. For whatever reason, that was what was meant for us. If it weren't for him, I would not be the person I am now."

Several years later, Rachel met Henry, a gentle, compassionate man who shared her spiritual approach to life and love of the wilderness. They married and bought property in the mountains together, to homestead and live "back to the land" . Rachel says "the urn of David's ashes stayed with me for years. I didn't know what to do with them. I often dreamed of a mountain, where I was to place his ashes, but I couldn't find that mountain. When we walked onto our property for the first time, I looked out and could see the mountain from my dream. I knew we were home." That summer Rachel climbed the mountain and scattered his ashes. A few months later, she was pregnant.

Rachel went back to the same hospital-based midwives for her care. She had felt well cared for with David, despite the outcome. The midwife explained that this pregnancy would be considered high-risk, due to her history. She outlined a plan that included multiple ultrasounds, non-stress tests for the last six weeks, and an early induction of labor. Rachel was surprised, and went home to think about all she had been told. She was now a wise, strong, healthy mother. She ate all organic, whole foods, and lived an active mountain life. Her life was full of love and joy. She listened deeply to her heart and discovered how strongly she knew that this pregnancy was entirely different from the last, that this baby was a healthy and strong girl, and that she would be born alive.

At the next prenatal visit, Rachel attempted to explain this all to her midwife. She says "With the last pregnancy I did everything I was told. I had every lab test, I had the ultra-sounds. I did all the medical stuff, and still ended up with a dead baby. Whether the baby lives or not has nothing to do with your lab tests and ultra-sounds. I intend to decline them all. The baby will live because the baby is meant to live." The midwife became tense at this response, and Rachel feared that a hostile disagreement was about to take place. But then the midwife took a deep breath, centered herself, and gave Rachel a gift. The gift was in the form of these words "I think you would be happier with a homebirth midwife. Let me give you a couple names."

Rachel came to me at the beginning of her third trimester. She shared her story, and we connected right away. She wanted me to help her have this baby, and I felt honored to assist. I was awed by her strength and clarity. We carefully selected some lab tests for her - blood type, iron, HIV, blood sugar. We did not do an ultrasound. We talked a lot about feeling fetal movement, and tuning in with the baby. We talked about her previous birth, and shed tears together. Henry came to most of the appointments, nervous but open to learning. They read Ina May's birth stories to each other at night. Again and again, Rachel clearly communicated her feelings; with a different father, her own self so evolved and changed , and everything about her life so different, she did not fear another stillbirth.

Rachel gestated away happily, and her due date came and went. She was taking evening primrose oil and a birth preparation tincture to encourage a timely labor. Her last prenatal visit was three days after her due date. This visit was different. She was starting to feel anxious, and with so much time "waiting", thoughts about the stillbirth were creeping in. I acknowledged her feelings and gave her reassurance that her feelings were normal. It is hard to wait and wait! We listened to the baby for a long time and heard the heart-rate accelerate with fetal movement, which is a sign of well-being. We decided I would come and listen to the baby every couple days until labor begins. I told her I thought she would have her baby soon.

That same night, Rachel went into labor. My assistant Amber and I arrived at her home around midnight. Rachel was sitting in a comfy chair, eyes full of tears. We sat down beside her, listened to the baby's heart beat, and then listened to her. Between contractions, she wept and told us how excited she was, overwhelmed with gladness. She told us she had been holding her excitement back all this time, just keeping that little piece of her heart safe by not getting too excited. But now that she was in labor, and was still feeling the baby move, she was suddenly feeling all the anticipation of having her real, live baby. The tears rolled down her face, and I told her how good it was to cry, and share her feelings.

Rachel labored beautifully through he night. She cuddled with Henry on a mattress on the living room floor for a long time. She was quiet and tuned inward , and we just listened to the baby every half hour and let her be. Each time we went to listen to the baby's heart, I felt a little extra charge, and then relief at the sound it beating away perfectly. I focused on taking slow calming breaths in those moments, in order to maintain a calm, peaceful atmosphere for Rachel. We gently reassured her how well it was going, how good the heart beat was. When her labor got intense, I asked her how she was doing and she said, "excited". She never complained, and seemed to enjoy the whole labor. I checked her once, and at three a.m. she was 8 cms. At four a.m. her water broke with nice clear fluid, and a half hour later she felt like pushing. She lay on her side for a while just lightly pushing as her body told her until I could tell the baby had moved way down into her pelvis. I invited her to sit on my Amish birthing stool and ten minutes later her nine pound baby girl was born. Zoe Elizabeth was born pink and healthy, and was contentedly nursing by the time she was thirty minutes old.

Rachel had been right- her baby was strong and healthy, and meant for this world. As her midwife, I trusted both her inner wisdom and her body's ability to birth. During her birth I was careful to respect who she is and what her personal process entailed. She was not just "another patient". This very personal, individualized approach is a hallmark of homebirth midwifery. I am very grateful to her for inviting me to be her midwife, and now for her generosity in allowing me to share this story with others. May it be healing to those that need healing, and inspirational to those that need inspiration!

Even on Vacation....

2011-02-02T07:41:00.000-08:00

Darn those Goolgle alert search engines. While on vacation I was browsing my email and was alerted to a post by The Skeptical OB (Amy Tuteur)claiming MANA is trying to hide death statistics. Many of you know of this blogger from her vehement stance against VBAC, homebirth and midwives. I don't think she likes me much either. In her current blog at:

http://www.opposingviews.com/i/midwives-alliance-trying-to-hide-high-infant-death-statistics

she says,"I have been hammering away at this issue in the past 4 years in every possible forum and with every professional homebirth advocate I could find ... and the silence has been deafening".

Well, I believe that most of us do not take her seriously so do not bother responding. However, since she has somewhat of a following and has the ability to confuse and upset many readers I decided to accept her challenge and offer to debate her in an open forum. I guess I just found relaxing in a tropical paradise too peaceful and so I responded to her as follows:

Dear Dr. Tuteur, You seem to be very passionate and knowledgeable in your blogs. I am happy to respond to you and break the silence you claim is deafening. Who are you really and what is your background and expertise in this subject? You have been pounding away at midwives, VBAC, homebirth and me from a place of anonymity for 4 years. Many professionals dismiss you simply as an agitator who likes to see herself in print. I am happy to give you the benefit of the doubt and accept your challenge. Lets have an open debate. I am inviting you to accept an opportunity to debate me on this subject at a public venue of your choice. Or, if you prefer, I will ask ACOG or MANA to set up a public forum in the next year where you and I can debate face to face and respond to questions from attendees. You can reach me via email at stuart@thewomansplace.com. Lets stop the hyperbole and name calling and debate our differences like professionals and like adults.
Sincerely, S. Fischbein, MD FACOG

I will let you know if I hear anything. For those on the east coast, please stay safe and warm. Dr. F

Support for Delayed Cord Clamping

2011-01-30T21:38:00.000-08:00

Watch Dr. Nicholas Fogelson's talk on evidence based support for delayed cord clamping from Grand Rounds at the University of South Carolina this month. Its a good resource should any institution or professional challenge the idea and argue that clamping of the cord immediately is "just what we do". Thank you Dr. Fogelson.

I love when science finally catches up to common sense. The burden of proof should be on those that support the intervention and not on proponents of what evolution has provided. Dr. F

http://www.youtube.com/watch?v=cX-zD8jKne0&feature=youtu.be&a

http://www.youtube.com/watch?v=t5CelB63QR8

Story on Home Births

2011-01-29T21:29:00.000-08:00

I happened across this story from England in the Guardian by writer/author Joanna Kavenna and thought it well written and worth passing along. It seems the uniqueness of each labor is an idea that is speading. Please send me your comments.
Thanks, Dr. F

http://www.guardian.co.uk/lifeandstyle/2011/jan/30/home-births-womb-of-my-own

Response to ACOG Committee Opinion #476

2011-01-25T20:21:00.000-08:00

The American College of Obstetrics & Gynecology has released a new opinion paper on the "dangers" of home birth and the questionable qualifications of those that attend them. Just writing these words leaves me speechless....or keyboard frozen....or whatever! If you have a chance to get a copy of this document please read it critically. It is proprietary so I cannot copy it here but I have written a letter to ACOG president, Richard Waldman, responding to this embarassing, biased, unscientific and inconsistent opinion piece. (see below)
It has been 2 1/2 years since my first letter to ACOG on the subject of home birth. Sadly, they have learned nothing.

January 22, 2011

Richard N. Waldman, MD, President
The American Congress of Obstetricians and Gynecologists
Department of Executive Board Affairs
409 12th Street, SW
PO Box 96920
Washington, DC 20090-6920

Re: Committee Opinion Number 476

Dear Dr. Waldman,

I am an obstetrician who has collaborated with both certified nurse midwives (CNM) and licensed midwives (LM/CPM) in California for more than 25 years and I am a Fellow of the American College of Obstetrics & Gynecology. I, myself, also attend home deliveries. I use my knowledge and experience to make safe, evidenced based decisions and provide true informed consent to my patients. I feel qualified and obligated to, once again, comment on the position taken by ACOG against home birthing in Committee Opinion #476 and on the data from which it seems to be based. It seems from the very outset to be a document biased against home birth choices and those who provide support for them. This paper prefaces its conclusions with claims to support a woman’s right to make a medically informed decision about her birth path but evidently has an agenda to obstruct that right.

In the text of this paper it clearly states that in every measurable parameter of morbidity, except neonatal death, home birth is superior to hospital birth (page 2, paragraph 1) in comparable low risk women. Yet, in the abstract, this conceded fact is minimized in the words, “Specifically, they should be informed that although the absolute risk may be low…” No, the absolute benefits are, indeed, well documented as every reputable study shows. The college does not recommend informing patients that these are hard facts yet goes out of its way to say that “Specifically, they should be informed that…….planned home birth is associated with a twofold to threefold increased risk of neonatal death...” which is an assumption based on very controversial data.

It seems the College relied heavily on a paper by Joseph R Wax, MD in formulating its opinions. I have written the college before regarding the use of level C evidence (consensus opinion) to dictate policy and recommendations. Those of us who truly support a woman’s right to choose her own path based on true, not skewed, informed consent know the damage that can be done by a legitimate organization like ours when it puts out an opinion. The paper by Wax and colleagues is an extremely flawed article. It has been reviewed extensively by many who express legitimate criticisms. None of which ACOG chooses to address. This study demands a critical reading. The meta-analysis of Wax, et al is the weakest type of data and should never be used as an exclusive measure of a topic. The fact that the authors cherry picked this data, including the use of one tiny study with 11 women, to prove its point while ignoring the largest studies from North America and Europe on planned homebirth demonstrates the clear bias. His paper compares apples to oranges. He goes back 40 years, mixes matched cohorts with prospective cohorts and record reviews, mixes urban and rural statistics and admits to many difficulties in interpreting this information including whether an attendant was even present and excludes many legitimate studies that do not fit his theory. His bias is evident throughout his comment section and it seems his sole negative conclusion, of a higher neonatal death rate, from this flawed study is simply mirrored and emphasized by ACOG in Committee Opinion number 476.

Oddly, it seems that combining data from more than 40 years ago to the present time is accepted for the purpose of denigrating midwives and home birth. Would you be so eager to accept that sort of chronology for a conclusion on hospital obstetric practice? Wasn’t it just 25 years ago that ACOG was pushing VBAC so much that their influence led the insurance industry to mandate trials of labor for every woman? And didn’t that lead to an increase in morbidity for mothers and babies resulting in the more draconian ACOG endorsed (but NIH Consensus Statement of March, 2010 refuted) policies that so many hospitals have now embraced to ban VBAC? Would we consider including all those years of ignorance in formulating a consensus opinion paper today to be good science? Let’s be honest here. Of course not! So why is ACOG wedded to the controversial Wax article? In it he also quotes a transfer rate of 25-37% for nulliparous women. This, with modern day selection protocols, is simply untrue. In my extensive experience as a backup physician I can state it is far closer to 10% and only a tiny fraction of those are for anything close to an emergency.

In the ACOG opinion paper the limitations of any meaningful data interpretation are outlined (page 1, paragraph 2). Yet, it seems this awareness is totally disregarded when one analyzes the language of certainty used against home birth in the text. When facts favor homebirth it is written off as “selection bias”. From my decades in the role of a physician backup to Licensed Midwives here in Southern California I can tell you of the excellence of this group of professionals. These midwives go through an extensive training program and apprenticeship, have ongoing education and regular peer review and do wonderful work. Patient satisfaction from the midwifery model of care is consistently rated higher than from care given under the obstetric model. In California, they are licensed by the State Medical Board. This is the same body that licenses physicians. It is simply wrong and rather malicious to state that for “quality and safety” reasons ACOG does not support care given by licensed midwives or certified professional midwives. They deserve far more respect than our organization grants them. I think you know this.

In a letter I wrote to your predecessor in 2008 I asked for an explanation as to the actual experience with regards to home birthing of those who make up the opinion committee. For it defies common sense to believe that anyone on this panel who has actually spent a lifetime supporting or attending home births could condone this paper. In respectful correspondence with Dr. Ralph Hale I received no answer to my question about that nor about why the College felt obliged to so vehemently pursue or support potential legislation against the informed choice option of about 0.6% of pregnant women. It is not that ACOG puts out an opinion that matters to me. It is that this opinion lacks any foundation of solid evidenced based medicine. Truth is our most important value. ACOG should never lower its standards of excellence in research to accept evidence against home birth, HBAC and selected twin or breech vaginal delivery simply because they may disagree with these choices. And where can a woman turn to when her local hospital bans these options and then defends its position citing ACOG opinions and recommendations?

These sorts of opinion documents are biased and self-serving. Physicians and midwives share the same noble goals. The College’s continuing crusade against home birth only serves to hurt its reputation amongst our colleagues in the midwifery, nursing and alternative medicine professions and damages the confidence of the patients we are avowed to care for. It is divisive, unnecessary and fear based. It is especially so when those positions taken are based on flawed data and the motives for doing so remain unexplained. If it looks suspicious it probably is. The College often hides behind the canard of “safety” in its reasoning. It is a bit arrogant to think that only ACOG considers safety a virtue. Albert Camus said,” The welfare of humanity is always the alibi of tyrants”. Ironically, the modern experience and majority of current literature does not support your safety argument when low risk women choose home birth with qualified professionals. There is so much damage being done to women in the hospital setting through interventions that we know to be harmful all in the name of safety and, yet, there you remain silent. Separating mothers from babies, policies prohibiting VBAC and breech, continuous fetal monitoring, immediate cord clamping and unnecessary inductions of labor are but a few. Cesarean section rates of 35-40% are an abomination and inflicting, as yet, untold physical and emotional damage on an entire generation of women and babies.

ACOG committee opinions such as number 476 are misguided at best and will only further restrict options and choice and lead some low risk pregnant women to forced hospital based birthing and its tendencies toward interventions and morbidity that even ACOG agrees often occurs unnecessarily. It may also force informed mothers committed to experiencing their birth plan to have no option but an out of hospital birth. Is this really where our organization’s energy is needed? I consider it my professional, moral and ethical responsibility to write to you in adamant opposition to the questionable conclusions stated in committee opinion 476. For they do not serve us or our patients well and should be reconsidered. I would hope to have the courtesy of a personal response and to an honest dialogue with you.

Sincerely and with respect,

Stuart James Fischbein, MD FACOG

ACOG opines again!

2011-01-21T00:19:00.000-08:00

The American College of Obstetricians and Gynecologists, of which I remain a member, has once again issued an opinion regarding the safety of home births. Needless to say, they remain fervently against the practice in general. Furthermore, they go on to state that a prior c/section is an "absolute contraindication" to birthing at home. This does not come as a surprise and once again sacrifices their principle of patient autonomy and choice. My only comment here is my ongoing wish that they would come out as strongly in condemning hospitals and their members who won't allow women the choice of a VBAC, therefore, in a major way, forcing them, in many communities, to choose an out of hospital birth rather than an unnecessary repeat c/section. I will read over committee opinion number 476 and see if I can decipher what their "opinion" is based on. The previous statement was based solely on opinion (level C evidence) and not on evidenced based data. In many past condemnations of home birth the trend has been to lump planned and unplanned and attended and unattended into one group which completely skews the data to support their theory. I will let you know. Dr. F

http://www.acog.org/from_home/publications/press_releases/nr01-20-11.cfm

More on the c/section debate

2011-01-09T09:50:00.000-08:00

Here is an article from Portland, almost a year old, before the NIH consensus statement but seemingly caught in a timeless loop. Nevertheless, the timing, it presents the differing points of view and so I felt worthy of sharing.

http://www.portlandtribune.com/news/print_story.php?story_id=126644252863826200

And here is a response to the first article in support of the midwifery model in low risks birth. Always good to see the spread of logical, common sense based, evidence supported information. Slowly, nationwide, this information is making a difference and informing families of their true choices. Baby steps in the right direction.
Dr. F

http://www.portlandtribune.com/opinion/story.php?story_id=126946379588406800

Interesting news from Jackson Hole, Wyoming

2011-01-09T08:43:00.000-08:00

Even peaceful little Jackson Hole does not seemed spared from controversies in that most natural of functions: Birthing.

Please read the 2 articles below. 1 positive, 1 distressing, and feel free to comment. I would love to dialogue on these stories.

http://www.jhnewsandguide.com/article.php?art_id=6852

http://www.jhnewsandguide.com/article.php?art_id=6859

As for me, I am finding much joy and satisfaction in homebirthing and the time and pace the midwifery model allows me to attend to clients. I have been laying low through the holidays and had a wonderful time with my family in Utah. I have great faith that good things will get even better for those with optimism in their hearts in 2011 and bad things will find their just dessert. A happy new year to all. I look forward to returning to the blogosphere with much to share in the days ahead. Dr.F

The Other Side of the Glass

2010-12-22T11:35:00.000-08:00

Janel's wonderful new film is now up for sneak preview viewing. Please watch, comment and pass it on.

http://www.theothersideoftheglassthefilm.blogspot.com/

Also, wishes for a merry Christmas and a very exciting and productive new year. Lots of good things going to happen in 2011 in the realm of birth choices. The public is waking up to know they have rights and options beyond the limitations of the medicalized hospital approach to birth. Dr. F

Cal State Northridge Jounalism Student Project

2010-11-24T18:22:00.000-08:00

By Andrew Lopez

It was 3:00 p.m. on June 23, 2007, when Emory Rivas, 27, arrived at St. Joseph Hospital in Orange, CA, to give birth to her first child, Davian. Throughout her pregnancy, Rivas, a Costa Mesa resident, has had a clear idea of how she wants her birthing experience to unfold, yet over the course of the next several hours, nothing works out quite like she wanted. First, the doctor she has put all her trust into delivering her child is not available because it’s the weekend. Secondly, she is talked into both an epidural to decrease pain and Pitocin to speed up her contractions, though she had planned all along not to take any medication during labor. Finally, at 6:00 a.m. the next day, her hope to give birth vaginally is no longer possible. The nurses tell her that she is failing to progress and starting to develop a fever. Feeling the decision was never truly in her hands, Rivas agreed to give birth by C-section.

At 6:34 a.m., Davian Rivas is born. Instead of being able to spend time with her newborn, Emory holds him for only a few minutes before he is taken to the nursery while she is taken to a recovery room. The anesthesia is causing her to vomit and she is crying for her baby. Though she was glad that the surgery was successful, the experience of having a C-section and the hospital policies that kept her from Davian was deeply upsetting.

“It was the worst feeling ever,” Rivas said. “They didn’t respect my birthing plan. I felt like I was by myself. It was horrible.”

Rivas is not alone. According to the CDC National Center for Health Statistics, 32.3 percent of babies born in the United States were by cesarean delivery in 2008. This number is at odds with a 1965 analysis of births in the United States, when just 4.5 percent of babies were born by cesarean. These rising numbers are alarming to those who advocate against unnecessary C-sections.

“The healthy rate (of C-sections) is between 8-15 percent for industrialized nations,” Chelsea Shure, chapter leader of the International Cesarean Awareness Network, West Los Angeles, said.

While critics of unnecessary C-sections point to a hospital’s bottom line as the primary reason for such high rates, those closest to the trend believe that it’s much more complex than that.

“There are many legs to this,” Dr. Stuart Fischbein, who practices in Southern California, said. “The big three are expediency, economics and malpractice.”

Dr. Gary Nishida, whose office is located in Oxnard, CA, lists “failure to progress” as the most common reason for first time C-sections. The term itself means that the laboring process has come to a standstill. There are a variety of reasons for this, including the woman’s pelvis being too small for the baby, according to Nishida. Nishida points to the one and a half lb. increase in baby weight since the 1950s and the unchanged size of an average woman’s pelvis.

However, certified birth doula (a trained person in childbirth who provides non-medical support before, during and after labor), Patricia Grube, believes that there is more to it than just that. “Failure to progress?” Grube asked rhetorically. “Doctors just don’t want to wait around.”

Shure believes that more than a failure to progress, C-sections are increasing due to a lack waiting by medical professionals. She believes that the unpredictable nature of vaginal births cause doctors to act quicker than necessary.

“A normal vaginal birth is so wildly inconvenient,” Shure said. “Doctors won’t sit on their hands. They can’t wait.” Shure also believes that obstetricians opt for C-sections because they haven’t been properly exposed to unmedicated births in their training. Fischbein agrees. “Obstetricians are high-risk surgeons,” he said. The medical model is that of intervention, he explained. Fischbein believes that the fear of a lawsuit rather than finances, dictates how obstetricians are taught.

Nishida disagrees that the bigger bills generated by C-sections is the primary reason they occur. “It has nothing to do with finances,” Nishida said. “I’m getting paid one-third what we got paid 15 years ago,” he said. It is the fear of a malpractice suit that facilitates swift action. “None of us (doctors) get sued for doing a C-section, we get sued for not doing a C-section,” Nishida said. “If they (those who oppose the high C-section rates) want to pay my malpractice suit, they can go ahead.” Fischbein also points to the fear of a malpractice suit as a driving force for unnecessary C-sections. “No one wants to work with an anvil over their head,” Fischbein said. “It’s a huge burden.”

In 2008, Rivas found out she was pregnant once again. This time she did research on VBAC’s (vaginal birth after cesarean) and switched hospitals and doctors, hoping to fulfill her wish of giving birth naturally. To her dismay, her new doctor thought it best not to try for a vaginal birth. He explained to Rivas that her body shape wasn’t ideal for a VBAC. “He was basically saying I wasn’t fit for it,” she said. Not until she was seven-and-a-half months pregnant did she decide to once again go with a surgical birth for her first daughter, Daya. Once again, she felt pressured and regretted her choice. “With Daya I felt I made the wrong decision,” she said. “I kind of got screwed over.”

Nishida points to the strict guidelines that must be met to perform a VBAC as the reason so few actually take place. Not only must a doctor be on-call throughout the process, an anesthesiologist and a team of nurses must also be waiting around the clock as labor takes its course. Nishida finds these guidelines to be unrealistic, as neither he nor the anesthesiologist would be getting paid to wait for the laboring process. “There are cost issues and practical issues,” he said. “If someone wants to pay me to sit around they can go ahead,” he said. Nishida also cites the American College of Obstetricians and Gynecologists (ACOG) stance on VBAC’s, which states the risk of uterine rupture that could take place during labor might be catastrophic. Once again, Nishida fears a lawsuit if something were to go wrong in performing a VBAC. “You’d lose everything you got,” he said.

Shure doesn’t agree that the risks of a VBAC are any more dangerous than performing multiple C-sections on a healthy woman. “The risks of major complications from a second C-section is one-in-23,” she said. “That’s a huge problem,” she said. Shure does agree with Nishida that the strict guidelines for VBAC’s are unpractical and in place so no one can blame the hospital for an unsuccessful attempt at a vaginal birth. “It’s not fueled by doctors. Hospitals have policies that make it hard for vaginal births,” she said. “They’re covering their ass,” she said. Shure believes that the prohibition on VBAC’s reflects a combination of hospital policy, unnecessary inductions fueled by poor information to obstetricians and simple impatience.

Fischbein looks to the executives of insurance companies to explain why these contentious policies exist. Politics and bureaucracy, according to Fischbein, are the motivating factors behind many of the problems he sees in the healthcare system.

“None of these decisions are health-based,” said Fischbein, who summed up his distrust of those with the most authority in the healthcare system by quoting French philosopher, Albert Camus: “The welfare of humanity is always the alibi of tyrants.”

Just as Fischbein attributed three causes for the increase in C-sections, he sees three solutions as being the only ways those rates will decrease. First, he suggests that the cost of vaginal births go up to account for the high cost it takes to staff the delivery process. Secondly, he proposes some kind of tort-reform to limit the damages that may be sought in malpractice suits. Thirdly, Fischbein envisions a freestanding maternity center run by midwives, free of the bureaucracy that rule hospitals. He doesn’t see a reason for low-risk pregnancies to end up in a hospital at all.

“Hospitals are for sick people,” he said. “Pregnancy is not a disease. Labor is not an illness,” Fischbein said. “Midwives do regular births better than obstetricians.” Grube agrees. “For non-complicated pregnancies, a midwife should be the model,” she said. “Midwifes deliver babies naturally and healthily. They are very patient.”

Rivas is visiting her parents’ home in Fillmore as she sits on the front porch on a warm, Sunday afternoon. She looks out onto the quiet street as Daya rests against her chest, nodding off. She smiles from time to time during the interview, but there is an unmistakable air of regret that surrounds her as she revisits the past.

“I feel like I missed out,” she said. “I was robbed.” She doesn’t rule out the possibility of another baby in the future, and if she does, she plans on looking into the issue much closer. “I’m going to definitely prepare myself,” she said. She plans to look into hospitals and their C-section rates, as well as doctors’ tendencies to perform surgical births. She also plans on looking into the possibility of having a midwife deliver her baby. As she weighs her options for the future, Rivas becomes more at ease. It’s as though she realizes for the very first time that her desire to give birth naturally need not be tangled up in the problems of a defensive, bureaucratic healthcare system.

.....Hope this story struck a nerve. I would appreciate feedback which I will forward to the student writer. Happy Thanksgiving, Dr. F

Joy on the Job

2010-11-10T08:13:00.000-08:00

Once again, I had the amazing honor of attending a beautiful home water birth in Tarzana last night. What a sweet, nurturing life event I bore witness to. Nice to know some decisions in life lead to a joyous new path. I am having fun in my profession again. Thanks to all the forces, good and bad, who have led me here. All have a great day. Dr. F

Panel Discussions and Thank Yous

2010-11-07T22:17:00.000-08:00

So many people to thank for their efforts this weekend. Saturday, the Sanctuary Birth and Family Wellness team sponsored a panel discussion after viewing 3 films, Laboring Under an Illusion, Guerilla Midwife and Orgasmic Birth, at the Santa Monica Library. The Q and A session was vigorous and well received. Thanks to Clara for her excellent work putting it together and to the staff at the library.

Today, I spoke on a panel discussing pregnancy, birth and child development in the context of nurturing the next generation of leaders at the Leaders Causing Leaders Conference at the Long Beach Convention Center. A very inspiring group joined me in sharing our stories and insights. Thanks to Cecily, Karen, Anna, Susan and Ishmael for their selfless and amazing contributions to the betterment of future generations. I was honored to be included amongst these visionaries.

Oh, and lastly, thanks to TIVO, Bret Farve and The Minnesota Vikings for finally pulling one out after making me a nervous wreck. And to beautiful sunsets like the one we had this evening. And to my daughter, Madeleine, who did a great job singing a Guns and Roses song at her recital this evening. It was a great weekend. Dr. F

Demystifying Birth Myths this Saturday in Santa Monica

2010-11-02T23:12:00.000-07:00

Santa Monica Public Library and the Sanctuary Birth & Family Wellness Center present this enlightening look at the myths and cultural ideas of birth. Clips from the documentary films Laboring Under the Illusion, Orgasmic Birth and Guerrilla Midwife will be followed by a panel discussion with licensed midwives and doulas on the birth options available to parents today.

http://www.facebook.com/event.php?eid=117696424958345

Time Saturday, November 6 · 3:00pm - 10:00pm

--------------------------------------------------------------------------------

Location Santa Monica Public Library
601 Santa Monica Blvd
Santa Monica, CA

The Sanctuary midwives, doulas, staff and I will make up the panel. I look forward to seeing all of you locals there. Dr. F

Dr. F at Leaders Causing Leaders Conference this Sunday

2010-11-02T23:03:00.000-07:00

You are invited to attend a panel discussion moderated by Cecily on November 7, 2010.

Leaders from Birth: Our leaders 25-years from now are in the womb!
JOIN US for an inspiring, empowering panel discussion amongst interdisciplinary pioneers connecting the dots between shaping our future and serving our children well.

http://bit.ly/Leaders2010

Panelists:
Karen Gordon wholechild.org/home.html
Susan Kaiser Greenland susankaisergreenland.com/
Anna Getty pregnancyawarenessmonth.com
Dr. Stuart Fischbein supportdrfischbein.com/index
Ishmael Beah beahfound.org/Beah_Foundation/Home.htm

November 7th 2pm / Leaders Causing Leaders Conference / Long Beach Convention Center / Moderated by Cecily Miller http://baby-welcoming.com/

The Peanut Butter Syndrome

2010-11-01T19:15:00.000-07:00

Of Peanut Butter, Birth Choices and Politics
November 1st, 2010

This is a peculiar trinity at the very least. While having nothing in common with or the monumental importance of the well known trinities of Christianity and the American trinity of e pluribus unum, liberty and in God We Trust, there is something very important to be said about the connection between these three subjects. Let me be very clear that I am a big fan of peanut butter and birth choices. Politics, well that leaves much to be desired. I have distaste for intellectual dishonesty and the nanny state so that gives you a clue as to my leanings in the political arena. Many of my friends and colleagues choose to ignore or avoid this subject because they find it exhausting or irrelevant in their day to day lives. But to ignore the reality that politics affects all of us is to live in denial. There is an election tomorrow that will have a great deal of affect on how we and those we care about will live our lives here in America.

I am a big supporter of true informed consent and birth choices as are all my wonderful colleagues in the birthing community. That is not a surprise to anyone who knows me. But many of my friends and supporters do not share my political views. I am not writing to try to convince anyone that one side is better or worse than the other. What I would like to do is make a logical argument in support of smaller government and personal responsibility and individual liberty. And, then let each of you decide what is best for you and your family.

So, what do peanut butter and birth choices have in common? We live in an era where government wants to control “fairness”. They want to raise equality to the level of a right and to constantly try to legislate morality and eliminate failure. Strange, as there is no right of guaranteed equality of result in the Constitution. Only the rights to equality of opportunity are implied. This has morphed into an America where all the soccer kids get a trophy no matter what place they finished. There are no winners and losers. Standards are lowered or eliminated all together. But by shooting for an egalitarian paradise those that desire this must, by definition, restrict liberty. Liberty is the freedom to succeed or fail on your own merits. Many think equality and liberty are synonyms when, in reality, they are exact opposites. Whenever you impose equality you necessarily restrict liberty. When a child is allergic to peanut butter, the school board often bans peanut butter for all of the other children. One child cannot be around peanut butter so 800 children cannot have a peanut butter sandwich. This is a perfect metaphor for the equality vs. liberty debate. What seems fair and kind and protective to one individual restricts the freedom of the vast majority of so many others. I call this overreaction the “Peanut Butter Syndrome”.

We see the “Peanut Butter Syndrome” everywhere these days. Kids are obese therefore we ban snacks and mandate certain foods in schools. Smoking is considered a danger so because of second hand smoke we have laws prohibiting any private business from allowing smoking. Mylar balloons may cause a power line short circuit so lets ban them. A child falls off a teeter-totter so all teeter-totters must be removed from playgrounds. Ban incandescent light bulbs and big screen TVs. And on and on it goes. Overzealous activism, often good hearted but often shortsighted, leads to restrictions on personal choice and liberty. And often without any evidence other than it feels good.

Now sweet sensitive people, mainly on the left, who mean well will see these things and say it is good that we are looking out for the folks and the environment. We need government to protect the few, the weak and those that cannot help themselves. They need to keep us safe. A fair argument but at what cost to liberty? If you agree with this premise then voting for bigger government and the Democratic Party is what you should do.

But here is the problem as I see it. We are for a woman’s right to choose the path of her own birth. We strongly support the right to informed consent and refusal. If you take the same sort of liberal thinking as described in the previous paragraph then why get upset when hospital policies, lawyers and politicians want to control our choices. They constantly argue that restrictions on midwifery and VBAC and breeches are for safety purposes. They are just protecting the folks. It does not matter that their arguments may not be evidenced-based. They are just trying to legislate out the possibility of a bad outcome. This may be noble but foolish in that over time this has been shown not to work. Not with birth choices nor food choices. Ever since nutritional information has been mandated on food products the American populace as a whole has only gotten fatter. Can you see the inconsistency here? If you think it is OK for there to be laws that restrict our choices in how we live and to surrender some liberty for the sake of a greater good then how can you be upset when those same rules are applied to birth choices?

My point is simply that I am a believer in allowing people to make their own choices. I think what makes our country special is her founding desire to allow all of us to succeed or fail of our own accord. This is the greatness of America and this unique quality of American life has been slowly whittled away by often well meaning people who tend to be on the liberal left. Not all, but most. Of course there has to be some regulation when individual choices can have massive consequences. But what I eat or drive or watch should have no more control from the outside then how or where I choose to give birth. If you agree with the idea that peanut butter and birth choices should remain free of politics then I hope you will consider voting tomorrow for the candidates and propositions that best fit this premise. Look at the big picture and do not get hung up on letting one issue decide how you vote. I hope you will see the folly in voting for bigger government. At least as it pertains to the freedom we long for and the profession we love.

Stuart Fischbein, MD

A Must Read Alert

2010-10-18T21:53:00.000-07:00

I wish I had written this. The Big Push for Midwives has once again done great work in educating us in what goes on behind the scenes. Thanks to PushGirl Friday for her insight at:

http://www.theunnecesarean.com/blog/2010/10/18/a-tale-of-two-moms-acog-pulls-a-fast-one.html
Please read her blog.....
A Tale of Two MOMS: ACOG Pulls a Fast One on Groundbreaking Maternity Care Legislation

As many readers here know, last summer Congresswoman Lucille Roybal-Allard introduced the MOMS (Maximizing Optimal Maternity Services) for the 21st Century Act, a groundbreaking piece of legislation that has the potential to revolutionize our maternity care system. The bill makes increasing access to evidence-based care, reducing racial and ethnic disparities in birth outcomes, and bringing down maternity care costs national priorities by promoting a number of common-sense, low-cost solutions to addressing the maternity care crisis in the US, such as:

Creating loan repayment programs to increase the numbers of family practice physicians, nurse-midwives, and certified professional midwives, all of whom provide low-cost, high-satisfaction alternatives to traditional obstetrical care
Increasing access to culturally competent care and reducing disparities by taking measures to recruit more racially and ethnically diverse students into the maternity care workforce
Launching a public awareness campaign to inform women of the benefits of increasing access to evidence-based maternity care and reducing over-reliance on often unnecessary interventions, such as labor induction, electronic fetal monitoring, episiotomy, and cesarean section
Establishing an Interagency Coordinating Committee on the Promotion of Optimal Maternity Outcomes
The MOMS Act has attracted a broad-based coalition of advocacy and professional organizations, including Amnesty International, Childbirth Connection, The Big Push for Midwives Campaign, the American College of Nurse-Midwives, the National Association of Certified Professional Midwives, the American Association of Birth Centers, and the Midwives Alliance of North America, all of whom have been working together with Representative Roybal-Allard’s office to build support for the bill both within Congress and among the general public.

Notably absent from the list of MOMS Act supporters is the American Congress of Obstetricians and Gynecologists, which is already busy lobbying Congress about its own forthcoming legislation. Not to be confused with the MOMS Act, ACOG’S proposed Making Obstetrics and Maternity Safer bill, which in the interests of clarity has been dubbed—wait for it—the MOMS Initiative, will, as ACOG President Dr. Richard Waldman stated, “lead the way” in making maternity care safer by promoting research into the causes of premature birth, obesity, and racial disparities in outcomes. Because as we all know, the problem with maternity care in the US is with the women who receive it, not with the care they receive.

Perhaps a better title for ACOG’s MOMS legislation would be the Making Obstetricians More Satisfied Initiative, because the proposal contains absolutely no provisions that encourage obstetricians to abandon current practices in favor of evidence-based care or to give up an inch of turf in their ongoing battle to protect their virtual monopoly on the maternity care market in the US—a monopoly that is responsible for creating the need for the Real MOMS Act in the first place. ACOG laid the groundwork for its sabotage of the bill in a recent letter that has been circulating in DC, assuring Congress that the organization has already put many patient safety measures into place and that their own MOMS legislation “can lead to direct measurable improvements in patient safety and quality of care, and to healthier births.” No promises that the Misleading MOMS Act actually will lead to improvements, but hey—it’s a start, right?

As for the Real MOMS Act? According to Dr. Waldman it is unacceptable because a) it promotes “the wholesale adoption of delivery models that have not yet been proven safe and effective, including doula support, group prenatal care, and home-birth,” and b) it “questions ob-gyns’ ability, compared to certified nurse-midwives, family physicians, and certified professional midwives, to deliver care that supports physiologic birth.” In other words, the Real MOMS Act told the Emperor he has no clothes, he took offense, and now he’s busy knitting himself a new Naked Suit.

Watch this blog for further developments on the Real and Fake MOMS legislative front as we head into a new Congressional session in January. In the meantime, please spread the word about Congresswoman Roybal-Allard’s brave stance in support of real maternity care reform. We need more champions like her who are willing to speak up on behalf mothers and babies and who won’t be fooled by ACOG’s bait-and-switch tactics.

As one who has seen pregnancy from both sides of this "debate" my wish is that ACOG and academic medicine would stop maligning evidenced based midwifery as in doing so they only malign themselves. There is a role for collaboration between the models but it is time for ACOG to realize that more medical intervention may not be the solution to the rising intervention rates. Nurturing care, individual attention and prevention do work and have been the way of the midwife for centuries. Dr F

Midwife Celebration at Golden Bridge

2010-10-10T16:24:00.001-07:00

Just a heartfelt thank you to the wonderful people at Golden Bridge and to Debbie, Carrie Anne, Ricki, Peggy, the choir and all the wonderful speakers whose names I can't even begin to remember. It was a joy to see so many smiling faces in that most friendly of places. A special thank you to Congresswoman Roybal-Allard for her advocacy. You all said so eloquently what we all know to be true. It is a marvelous feeling to be associated with you and I am proud to also carry the banner for normalcy and choice. I know now as much as ever that midwifery is the best choice for those low risk women who desire it. I came directly from the airport and the sadness of burying my beloved uncle in Minnesota to the warmth and nurturing of all of you. What a healing talent you all have. Thank you, thank you, thank you!!

Love, Dr. F

Midwifery Week Blog

2010-10-10T06:41:00.000-07:00

http://www.rhrealitycheck.org/blog/2010/10/04/state-midwifery-pushing-legalization
This is Rebecca Spence's blog this week. Please check it out.

Today is the Midwife Gathering at Golden Bridge Yoga at 1:30PM in LA. I will be traveling back from Minneapolis this morning and hope to arrive in time to pay tribute to my midwife colleagues. Continuing to promote access to midwifery and birth choices is an honor and joy and every little thing helps. Please support the Big Push with letter writing and spreading the word client by client. Dr F

Time Magazine Cover

2010-10-02T22:13:00.000-07:00

Just a quick thought on the recent time cover story about the significance of external factors during intrauterine life that may play a much more significant role in our health and wellbeing than previously thought. Traditional teaching about how we end up has always been nurture v. nature, heredity v. environment. Well, it appears that there is growing data to support the idea that exposure to many things in utero may play just as big a role in determining our physical and mental health later in life. This comes as an interesting "discovery" to those of us brought up in the medical/scientific world but is well known to my colleagues trained in the more natural world of midwifery and common sense. The midwifery model emplores women to be in a healthy state of mind and body before and during pregnancy and has known the benefit of this knowledge for centuries. It is nice to see the science catch up with the empirically obvious and kudos to Time for a nonpartisan story that is beneficial to all. Dr. F

Internet TV interview

2010-09-27T22:25:00.001-07:00

Here is a link to my interview on the Dr. Cassie Show on local KADY TV here in Ventura, CA. Dr. Cassie does great work with children and for the community and it was an honor to be a guest on her show. Check out what's happening with her at The Children's Therapy Network. Having good prenatal care and a nurturing birth will get babies off to a good start. Dr. F

http://www.ustream.tv/recorded/9737013

First Waterbirth

2010-09-27T18:29:00.000-07:00

Well, I am happy to announce I had the privilege of assisting on my first home birth in water. After 27 years of the lithotomy position it was really enlightening to experience another way. I was honored to be present for the birth of Eva and want to thank her parents for their trust. I also want to thank Karni and all my midwife and birthing advocate colleagues for their support during this transition. It seems the demand for information and alternatives to hospital birthing is growing. I am getting quite a few inquiries from women looking into all options. It feels really good to give them an open and honest discussion about choices. I have been contacted by women with previous c/sections, twins, breeches and medical issues. All seeking just an honest discussion about risks and benefits of their individual situation. It is with great respect that I thank those of you who send potential clients my way. While out of hospital birthing is not for everyone, the choice of how and where to give birth belongs to the woman and her family. All good things, Dr. F

C-section rates higher at for-profit hospitals

2010-09-12T13:41:00.000-07:00

From todays San Francisco Chronicle. This link below was sent to me by Brian Gilmore of Rumi Baby.
Looking only at low risk birth, women were 17% more likely to have a c/section at a for profit hospital than at a non-profit one. Each of us can draw our own conclusions but knowing what we know about what motivates many hospitals and physicians these days it is not surprising. In 2008, our practice in Camarillo at The Woman's Place had a 6% primary c/section rate compared to a greater than 20% primary rate at our local hospital overall in low risk women. I believe the difference is using the midwifery model vs. the obstetrical model for labor management.
This information has to rely on reporting of birth rates and methods by each institution. This may raise some question about honesty in reporting. I suspect the data comes from birth records so there is likely to be some credibility here. Just another reason pregnant women need to be educated and informed of choices, benefits and risks so keep spreading the word to your clients, family and friends.

Thanks, Dr F

http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2010/09/12/MNSS1FA3LH.DTL&feed=rss.news

Good Feelings

2010-08-26T19:43:00.000-07:00

I just left the new client meeting at The Sanctuary Birth & Wellness Center in Mar Vista, CA. It is so nice to enter a space where nurturing and collegiality are the rule. What a breath of fresh air. We meet every Thursday afternoon to introduce the Center and its staff and our philosophy to potential new clients. All topics of home and the new birthing center births are touched upon in an open forum of discussion and Q and A. It is a time to describe pregnancy care in the true midwifery model and the way it should be. I believe I am in a great position to observe and comment on the amazing differences in low risk pregnancy care between the two competing models of care available in the U.S. And I can safely say there is no comparison. Little by little the word about true informed consent and birth choices is spreading. Kudos to my colleagues for their passion and success in the dream and, once again, congratulations on the opening of the beautiful new Sanctuary Birth Center. The only one of its kind in Los Angeles. Dr. F

ACOG review panel report

2010-08-24T16:16:00.000-07:00

Hello to all and especially to those readers from the medical staff office at St. John's. Word on the street is that the ACOG panel that reviewed the policies, procedures and antics of the OB department at our local hospitals last June has issued its final written report. If I were to make an educated guess based on experience I would presume that this report will never see the light of day in its entirety. I hope I am wrong and would be the first to congratulate the new administration on their bravery if they were to release it. If this review was meant to be a learning experience for the department on evidenced based medicine and improving patient care then it should be shared with the medical staff without censorship. In fact, it should be shared with the community as a whole in the spirit of cooperation and transparency. I encourage all to call the new CEO at 805 988-2500 and ask if she intends to share the findings of this independent panel with the medical community and the residents of Ventura County. While I am no longer on the staff at these institutions I am still an active member of this medical community, and like many of my colleagues, must remain vocal when patient safety and quality of care issues need attention. Let us see what the American Congress of OB/Gyn thinks has been going on here. Dr. F

Rediscovering the joy in childbirth.

2010-08-12T20:15:00.001-07:00

As you must have heard by now, I am no longer attending deliveries at the hospitals in Ventura County (See previous blog). Turns out that things have evolved as they should and I am much happier for it. It is a liberating feeling to be away from such a toxic environment and find myself looking to the future with great optimism. Life is made up of the choices we make and I choose to look to the positive.

I was fortunate enough to attend my first home birth this past Tuesday as the primary caregiver. Sharing the joy with a wonderful couple who opened their home to me, doula Jen and midwife Karni. This was a beautiful early morning delivery just after sunrise and for me it renewed the joy to be found in my profession. The path to this point has been rough and winding and full of obstacles but I am very lucky to have reached this point. I am grateful to all of you who have supported me in the journey to find a way to practice my trade and use my skills in the way nature and common sense intended.

I would hope that you will spread the word to your friends and clients that I am fortunate to be able to now offer an out of hospital birthing experience as a choice to women and families who are interested in having a doctor collaborating with a midwife. I will be working with Karni in Ventura and the lovely staff at Sanctuary in Mar Vista as well as continuing to practice in my 2 offices during the week. Anyone with questions can be referred to my Century City phone number 310 282-8613.

We know that normal birth deserves much more reverence and respect than it has been given. I am proud to be associated with all of you who undertand this and respect the wonders of the human body and the mounting evidence that supports our perspective. Ultimately, if hospitals and organized medicine will not evolve to meet this knowledge and demand then women will look elsewhere. We need to be there to meet these needs. Lets support the development of the birthing center model such as Sanctuary and Santa Barbara Birth Center, work toward the development of a freestanding maternity center model and continue to educate the next generation of care providers and pregnant women. Emphasize the "normal" in low risk birth and spread the knwoledge that childbirth is a time of great human joy. Dr.F

2010-08-06T19:30:00.000-07:00

Well, hello again. I apologize for being silent for so long. I was strategically waiting until things played themselves out here locally and now they have. Despite being vindicated by the ACOG review panel and in spite of the stellar record of care given by me and my Woman's Place colleagues over the years the administration at my hospital was still very unappreciative of my abilities and my worth in the community. Rather than face further ugliness and negativity I have chosen to withdraw my application for reappointment at my local hospitals. I am excited for all the positives the future has to hold for me as I now am free to head in the direction my long journey as an advocate of birth choices has meant for me to go. More on that to follow in the days to come. Below is a letter of explanation I have been distributing to patients this past week. I would be honored to hear your comments.

Dear Patients of The Woman’s Place,

Many of you are aware that I have long supported birth as a natural process and have advocated for changes in the current “birth as illness” medical model of obstetrics practiced at our local hospitals. The Woman’s Place, Inc. has been a haven for the collaboration between midwives and obstetricians and it has been a true joy to provide this option to so many of you. After much thought and consideration I have decided to stop delivering babies in the hospital setting here in Ventura County. This decision will allow me the opportunity to pursue new ventures including doing some birthing center and home deliveries while allowing me the freedom and time to create my dream of a free-standing maternity center run by midwives and supportive physicians. I will continue to work in the Camarillo office and perform ultrasound, office procedures, and gynecologic exams and see prenatal patients there in support of my colleagues, Michelle Marine, MD and Lynn Olson, CNM. Dr. Marine and I have been working together now for almost a year and I am confident in her dedication and ability to provide you with the same excellent standard of care you have come to expect from The Woman’s Place, Inc. My hope is that you will continue to rely on us for that excellence.

My presence in the office will remain and our great staff of Judy, Mimi, Wendy and Lynn, along with Dr. Marine and I are available if you should have any questions. For those of you who might like to have me attend your birth, that option will also be available. I have worked for 15 years with the Sunrise Birth Center in Ventura and its founder, Karni Seymour Brown, who has graciously agreed to collaborate with me should you desire an out of hospital birth at home or the birthing center with a licensed midwife and me in attendance. Please feel free to make an appointment with me to discuss this option.

Change is always unsettling and decisions like this can produce both anxiety and excitement. I know it will be difficult for some of you who expected me to attend your delivery but I hope you will come to see this decision as a positive in the long run. It will give me the time and freedom to advocate for normal birth options and choice here in Ventura County and nationally. It has been an honor to have delivered so many healthy Ventura county babies to happy and fulfilled Ventura County mothers these past 15 years. For me, the time is right to work towards the goal of giving women another choice of where and how to give birth. Thank you for your understanding and continued loyalty to The Woman’s Place, Inc.

Sincerely,

Stuart J. Fischbein MD FACOG

Next up is the open house this Sunday from 11 to 3 at the new Sanctuary Birth Center in Mar Vista. I will be there with my co-author, Victoria Clayton, signing copies of our newly released, "Fearless Pregnancy, second edition", while soaking up the warm and nurturing vibes from the wonderful people there. Please stop by and say hello. Info can be found at their website: www.birthsanctuary.com

It feels liberating to be blogging again. Good things are going to continue to happen if we choose them to be. Dr. F

Where's My Midwife?

2010-06-20T22:59:00.000-07:00

Check out this video by Kirsti Kreutzer!! Stay informed on what is happening around the country by viewing this 12 minute film from North Carolina. See if this story sounds familiar in your area. Support midwifery and never believe that a small voice can't change things. Dr. F

http://www.wheresmymidwife.org

Good News!!

2010-06-19T09:30:00.000-07:00

Hi All, have been off the radar for a few weeks as some important issues sort themselves out. For now I must remain silent but hopeful that things will be improving for women's birth choices in my community. Your voices have helped and there is no reason to stop now. I speak out when injustice appears in the birthing world and there has been plenty to talk about but now there are some voices of reason appearing and lets see where this goes.

In the really good news arena, the second edition of "Fearless Pregnancy" is now available on line as a book or a download. You can find it at

http://www.lulu.com/content/8624827

and soon it will be linked directly from our website at www.fearlesspregnancy.com as well. It continues to remind women that pregnancy is not a disease state and does not need to be treated as an illness in almost all cases. We have added some updates in new technologies, ideas and evidenced based approaches that are confirming what many of us knew as truth before. The book still has the easy reading wisdom it had in the first edition. It would make a great gift for loved ones who are pregnant or contemplating pregnancy soon as it would help them have a calm enjoyable voyage through one of life's greatest moments. Dr. F

Good news and Horrible news

2010-05-30T06:53:00.000-07:00

It seems there are some rumblings about ready to spill over at my hospitals in Ventura County. Wouldn't it be nice if everyone involved could speak honestly about what goes on there behind closed doors. With all the secrets and suspicions and threats one might think that national security was on the line. To me it is a ruse the powerful play to make what they do seem so almighty important. Its the doctors and nurses and midwives that are saving lives and yet its the administrators and lawyers that act as if only they carry the burden of righteousness.

This past week I was called into a meeting with the Chief of Staff and the Chairman of my OB/Gyn department. Four weeks ago and almost 10 months since the investigation into my practice which started me on this whole blogging thing began the decision was made as to whether further disciplinary action should end or continue. It took more than 2 weeks for their lawyer to draw up a letter and another 10 days before a mandatory meeting was called. So they knew for a month about my fate but because of the way an administrative system "works" could not express any humanity by letting me know sooner. I arrived for the meeting early while the other parties were 25 minutes late. No apology was offered. I was handed a letter exonerating me from any wrongdoing and ending any investigation. That was it!

Yes, they had me sign a piece of paper saying I received the letter. Ever heard of certified mail? No explanation or apology offered as to why they sat on this decision for a month. Clearly, to me a total lack of concern or empathy for what I might be dealing with. Then we had a discussion about making sure professional conduct rules were followed and the problems with our department came up. Clearly, the Chairman of my department and I see things differently and it was enlightening to see how little truthful information gets filtered through to the Chief of Staff. Hidden behind those rules of confidentiality is an ugly process by which the powerful can pick on and destroy those with which they take issue. Despite the lack of courtesy, I feel fortunate that I am now out from under their threat. At least for the moment. With the ACOG review panel coming in 2 weeks to scrutinize this OB Department there are some of us who hope a day of reckoning will come. And maybe, when the balance of power shifts to those who lead justly and with reason we may again see things like Midwives in Camarillo, breech deliveries and even a way to bring back VBAC.

Now, the horrible news. Sadly, the committee did claim one most wonderful and innocent victim this past week. After almost 3 years of tormenting one of my colleagues and a patient and nurse favorite they called her in to administration Thursday afternoon and suspended her from the staff. What I believe to be a series of lies, distortions, discrimination, pettiness, fraud and ethical violations by certain members of the OB Dept. all went against her. Complicit in the process are numerous administrators and other physicians who never took the time to look deeper and question the motivation and conflicts of interest of those that persecuted her. And to all of the staff not privy to the "confidential" information there is a feeling of sadness and astonishment that this could happen. Those of us that work with her know her to be caring, competent and appropriate in all she does. So we cannot understand the WHY? She has no greater incidence of complications or bad outcomes. In fact, compared to the members of the committee who led the charge to remove her she has a far better track record.

For reasons none of us can comprehend she now faces an inquiry from the Medical Board of California and will likely never again be able to perform hospital based deliveries. It is very unlikely that once you are kicked off a medical staff at one institution that any other will allow you onto their staff. However, on the positive side she has immense support and good friends. With ACOG coming to investigate we may have some light shown on what really happened. Interesting timing of suspending her 2 weeks before ACOG comes so that now she does not have a chance to speak to the panel as a member of the department. But her voice will be heard. Also, now that the one-sided administrative hearing process is complete she does have the opportunity to appeal in civil court where there will be an impartial judge, subpoena power and a jury made up of civilians free from subterfuge. Having sort of been through this type of process myself, my heart aches for the fear, anxiety, helplessness and unrequited anger she must be feeling. I think she knows how loved and supported she is and those that have hounded her will have their day of reckoning and right soon.

How I long for a simpler time where honest men went into medicine for a single purpose of helping others. How that time was lost is a subject for a great novel at some point. When I see what has happened to Dr. Biter, my colleague, many midwives and myself to a lesser degree I want to cry for a moment and then I am energized to fight back to reclaim common sense and hold those who would abuse their positions accountable and liable. The peer review system is so broken at my institution and the undercurrent of discontent with those that abuse it and support it in its current form is about to explode. Sad, that it will take outsiders and the civil court system to make transparency and honesty happen. But happen it must! Dr. F

The Industrialization of Medicine is Unhealthy for Patients

2010-05-26T18:49:00.000-07:00

Talk show host Dennis Prager has popularized the phrase, “The bigger the government the smaller the citizen”. Calm and thoughtful people should consider well this premise. It seems that following the news of the European union and from Washington to Sacramento to city councils we are seeing the demise of personal liberty. So it is with health care. As government intrusion and industrial micromanaging overwhelm my medical profession the individuality of patients and of doctors who care for them is crushed. You have heard me say many times that one size does not fit all when it comes to patient care. We are all different, with varied life experiences and unique personalities. Informed consent and refusal require a free flow of information free from coercive forces. Doctors should be free to advise patients of choices based on what is good for the individual. But as medicine has become the purveyance and money engine of government, businessmen and lawyers our choices are being funneled by processes not often born of reason or the spirit of Hypocrates. Individuality does not fit the business model of bureaucrats and cubicle workers. Too hard to count beans if we honor our differences! In plain language, it is too hard to control. So the solution becomes a takeover of our health care in every facet so that choices can be limited, a façade of liability protection created and a sense of order mandated. As the beast grows it devours everything unique and special that was once the sacred doctor-patient relationship.

Last week I attended the biannual OB/Gyn department meeting at St. John’s Regional Medical Center. I have tried for years to be left alone and allowed to use my skills and allow patients their right of self-determination. Treating patients with that sort of individual dignity has led to conflict with the larger controlling machine of industrial medicine. While we are supposed to follow evidenced based medicine and rely on outcomes data to determine good health care policy, this only gets in the way of those who prefer power over preference. This is true today on almost every scale. When it comes to my local hospital I see a clear distinction. While I want to be left alone to provide the right of informed choice to each and every patient and allow other doctors to do the same, the hospital chooses a narrow path laid down by an admittedly dysfunctional committee. They make what often seem to be arbitrary policies sometimes lacking any sort of sound medical reasoning and then force them upon the doctors and nursing staff with little or no input from the rank and file. These blanket, often kneejerk, policies are not thought out beyond the immediate false satisfaction gained by the creating institution. Thomas Sowell calls this Stage 1 thinking. There seems to be almost no thought for the, Stage 2, long term consequences that result in less choice, higher intervention rates and far more paperwork but no evidence that outcomes will be improved. In fact, as we have seen with premature policies surrounding fetal monitoring and VBAC based on opinion rather than hard evidence, outcomes often worsen. At this department meeting we were provided with a list of policies and protocols put in place at my institution in just the past year.

Delivery Privileges for Certified Nurse Midwives (new, restriction)
Professional Conduct (revised)
Emergency Privileges during a Disaster (revised)
Oxytocin Inductions/Augmentation
Epidural analgesia/anesthesia During Labor
Post cesarean section routine orders
Bakri tamponade balloon protocol
Obstetric hemorrhage protocol
Admission and discharge criteria-St. John’s Pleasant Valley Hospital (restrictions)
Vaginal Packing policy
HIV, Preventing perinatal transmission of
Vacuum assisted vaginal delivery protocol
Post c-section routine orders
Admission/Induction orders
Updated 1-page guide to OB hemorrhage protocol (added per anesthesia dept.)
Final OB hemorrhage policy
Foley catheter policy

Now, maybe some of these 16 new policies will do some good but I have never seen any reports that show they were ever proven to do anything prior to their adoption. And with all these policies now in place will there be any evaluation as to whether outcomes have improved? Were things that bad that we really needed 16 new policies?While not all of medicine is yet lost to this sort of micromanaging, it is becoming pervasive. What is essentially gone is the “Art” of medicine. It seems to me that the job of so many hospital administrators these days is to constantly find things to change. It makes them seem busy and important and justifies their salaries but they so often leap before they look. Their premise is always liability mitigation and economics and sometimes just meddlesome. And it is all under the guise of patient safety protocols. As you can see from the list above, as these policies become more massive and micromanaging there is little or no room for the individual. Sadly, in the current monolithic healthcare model there is no going back. Choices in childbirth, caregivers, prescription drugs, facilities and procedures will continue to shrink and the single patient as a unique person model will fade into history. I am still hopeful that creating smaller alternatives such as birth centers and free standing maternity centers unencumbered by massive government or insurance industry oversight will provide an oasis for those pregnant women who desire the freedom to educate themselves and choose their own path. There will be a cost to remain free but it will surely be small compared to the cost of giving up our individuality. Dr F

Laying Low and letting the process work

2010-05-25T07:17:00.000-07:00

I have not posted in nearly two weeks. But that does not mean things aren't happening out here in Ventura County. Some revealing events are taking shape but the details are protected by their veil of confidentiality. One important event happening next month is the arrival of an investigative panel sent by ACOG to review the policies, procedures and doings of the OB committee. Apparently, things have finally gotten so obviously bad with this committee that even the always complicit hospital administration had to do something. There was no hiding it anymore. So they have hired a group of ACOG physicians and nurses, at a price tag of more than $37,000.00, to come for 4 days and perform an "objective" investigation, chart, policy and meeting minute reviews and conduct personal interviews with all members of the department including midwives. At the OB department meeting I was specifically assured by one of the hospitals top administrators that anyone who wanted to be interviewed would have 30 minutes in private. Now, however, there are rumors that they may be backing away from this promise. There are many of us who would make a lot of noise if they even try something like that. I am hopeful that this will be the first step in returning honesty, common sense and reason back to our department. I would like to see those that have for so long abused their position of power be humbled to the point of apology and punishment and we can hope for a revamping of the committee model and a return to evidenced based medicine and national standards that benefit patients rather than a small totalitarian group of petty obstetricians forcing their will upon us.

Also, Joyce, Victoria and I have almost completed the final edits of "Fearless Pregnancy, 2nd edition" and hope to have a release date in early June. It will be available online in real soft-cover book form or as a download e-book format. Amy Tinney and I also have 2 meetings this week with persons possibly interested in helping with our maternity center idea. I see Laurel Phillips has some fundraising events going on up in Santa Barbara. Please check out the Santa Barbabra Birth Center web site for details. I may also soon be helping out with the Sanctuary birth team as a consultant in the Los Angeles office and I have heard exciting news that they will soon have a facility for midwife assisted out of hospital birthing on LA's west side. All the best, Dr. F

“There’s really been no change in anything,” said St. John's Chief of Staff

2010-05-12T00:26:00.000-07:00

And so it goes. Despite a petition from over 700 residents of Ventura County calling for an end to the midwife ban delivered by BAC chairperson, Kim Rivers, St. John's continues to refuse to explain the hypocrisy or release any supportive evidence for their decision to ban midwives from Pleasant Valley Hospital. The Ventura County Star, to their credit, has written a followup story which confirms the title of this blog but at least feels the issue is unresolved and worthy of continued scrutiny.

http://www.vcstar.com/news/2010/may/11/battle-continues-against-hospitals-ban-on/

Reading the comments section can be fascinating and frustrating as some just do not understand what midwives do. Others have the sky is falling approach to birth while voices of reason try to elucidate common sense. BAC is committed to keeping the issue alive. Here is a copy of their press release:

St. John’s Denies BAC’s Meeting Request to Discuss the
Community’s Response to Ban on Nurse-Midwives from Attending Births

Ventura, Ca. – On May 6, 2010 a representative from the Human Resources department at St. John’s Regional Medical Center canceled a meeting with Ms. Kimberly Rivers, President of the Birth Action Coalition (BAC), that was scheduled for 3:00pm on Friday May 7th. The meeting was set with Mr. John Bibby, Director of Human Resources and St. John’s Chief Medical Officer, Dr. Eugene Fussell. The meeting was requested and set in order for Mrs. Rivers to present BAC’s petition regarding the recent midwifery ban at Pleasant Valley Hospital in Camarillo. On Monday May 10th without an appointment Mrs. Rivers presented the petition to the Human Resources office desk at St. John’s and was told it would be delivered to Mr. Bebe.

BAC, a community organization focused on educating and advocating for supportive birth environments, has been calling for St. John's to respond to community member requests for access to midwives, and clarification over reasons for the recent ban on nurse-midwives at Pleasant Valley Hospital since the ban. Administrators at St. John’s Regional Medical Center, part of Catholic Healthcare West, cite “patient safety” and availability of a NICU (neonatal intensive care unit) at the facility as the reasons for approving the policy that prohibits certified nurse midwives (CNM) from attending births at Pleasant Valley Hospital.

BAC hopes to gain a response from St. John’s through its monthly protests in front of St. John's Regional Medical Center in Oxnard and is circulating a community petition The petition asks that St. John’s administrators immediately reinstate privileges for all CNM’s at Pleasant Valley Hospital, or, that St. John’s administrators provide evidence supporting their statements that the CNM’s have been removed from the Camarillo facility due to “patient safety” (we ask that this evidence show outcomes for all care providers who have attended births at Pleasant Valley Hospital), or that St. John’s administrators retract their claims that the midwifery ban is due to “patient safety”.

(See petition at: www.petitinonline.com/speakout)

On two separate occasions Ms. Rivers contacted St. John’s for a meeting requesting 5 minutes to present the petition signed by over 700 people. Finally on May 3 an appointment was confirmed with Mr. Bebe’s office for 3:00 pm on Friday, May 7 but was then canceled on May 6. When asked for a reason why the scheduled meeting with Ms. Rivers was canceled, it was suggested that Mr. Bibby and Dr. Fussell were advised not to speak with Ms. Rivers without further explanation. “St. John’s is now outright refusing to listen to a member of the community regarding a policy they have put in place that affects the birthing women of Camarillo,” says Rivers. “ BAC plans to notify Mr. Lloyd Dean of Catholic Healthcare West regarding this clear dismissal of the concerns of community members, and we will continue to speak out on this issue until the community receives a satisfactory response. ”

More absurd secrecy?

2010-05-10T08:11:00.000-07:00

First, I admit I only heard about this through an email blast this weekend from L. Janel Martin. The details are sketchy but all too hauntingly familiar for me to ignore. Dr. Robert Biter from the Carlsbad, CA area has apparently lost his admitting privileges at Scripps Encinitas Hospital:

As of 5 pm Friday, May7th, Dr. Biter's privileges to deliver babies at Scripps Encinitas Hospital have been suspended. He will still be able to see his current patients postpartum (after they deliver) in the hospital. He is hoping that this will be resolved quickly & is working hard to ensure that there is a backup plan for his patients that are due to have their babies soon.

Here's what I know: There have been no obstetrical malpractice issues against him---ever. The hospital, specifically some OBs, have been attacking him for the last 3 years for protecting women's rights for natural birth. I believe it''s all out of greed for money--less interventions means less money for the hospital. Other doctors were losing their patients to Dr. Biter because they wanted a doctor who would support them & that trusted birth as being a woman's birthright rather than a medical procedure.

An effort to support him is being organized by Carol Yeh-Garner at:

Carol Yeh-Garner
3192 Corte Tradicion
Carlsbad, CA 92009

awelllivedlife@hotmail.com.

My own experiences suggest that the rules of peer review and the convenient veil of confidentiality will prevent us from knowing the real reasons for the hospital committee's actions. However, I do suspect that Carol's suspicions are likely correct. What we can do, if Dr. Biter so desires, is contact and barrage the hospital administration with calls and letters asking them for explanations. The one thing that hospitals hate most is negative publicity in the media and having a light shone on their internal policies and politics. If you have any information, please comment here on my blog to educate the rest of us. Also, for those who care to write here is an address:

Write a letter to the CEO of Scripps Encinitas:
Chris Van Gorder--President & CEO of Scripps
4275 Campus Point Court
San Diego, CA 92121

I have heard that Dr. Biter is planning to open a free standing maternity center supportive of the midwifery birthing model. The timing of this latest absurdity against him cannot just be a coincidence. I am hopeful that we will know more soon. Although, he may be restricted from discussing this openly by the rules of the hospital set up to always favor the hospital. Through my own experience I find such secrecy, when not directly involving patient confidentiality, to always be suspicious of nefarious reasoning. Dr. F

Are we de-evolving as a culture?

2010-04-18T09:19:00.000-07:00

I was sent this link to an Australian Documentary being made about the possibility that home birthing may be outlawed there. We cannot stand idly by as these personal choices and birth rights are systematically attacked. Whether one agrees with home birthing or not, we should always allow for self determination when it comes to our bodies. There is an insidious and totalitarian trend that has been speading its tentacles into so many aspects of the liberty loving free world. I encourage you all to make your voices heard so that clarity on these issues spreads to the sleeping giant that is the freedom loving peoples of the world. Please demand that politics and lawyers stay out of your homes. For if we remain silent we will get what we deserve and what will be next. I am not surprised about much of anything anymore. But I remain pissed off!

http://www.youtube.com/watch?v=pFWH_IZWulE&feature=email

Thanks, Dr. F

Text of Tea Party Tax Day Speech

2010-04-16T07:09:00.000-07:00

Here is the speech I was to give at the Tea Party Tax Day Rally in Thousand Oaks, CA yesterday. I think it is better when I am speaking but wanted to share my thoughts, as usual. Warmest regards to all, Dr. F.

"A wise man, in a past time of wisdom, a patriot named Thomas Paine, author of the original “Common Sense”, was quoted to have said, “The long habit of not calling a thing wrong gives it the superficial impression of being right.” So it has been with American citizens not paying attention to their own government. Sadly, it has taken the passage of this monstrously corrupt health care bill to wake the sleeping giant that is American Values. It is time to stand up for our liberty and call what is happening just wrong.

I am so honored to speak here today. I have been asked to give a practicing doctor’s perspective on what is happening to our health care system. Now, despite what words may follow, I am very motivated to help fix what I consider to be a broken leftist ideology about health care as a right. For if it is a right then it implies that people have the right to my services for whatever value the current democratic leadership decide I am worth

“I observed that in all the discussions that preceded the enslavement of medicine. Men discussed everything—except the desires of the doctors. Men considered only the ‘welfare’ of the patients, with no thought for those who were to provide it. That a doctor should have any right, desire or choice in the matter, was regarded as irrelevant selfishness; his is not to choose, they said, only ‘to serve’.”
Ayn Rand, from Atlas Shrugged, 1957

Healthcare is not an inanimate commodity like oil or water. It is people!

What we will see as government and organizations and insurance companies begin to micromanage our lives are mandates based, not on evidence or the realization that each patient is an individual, but on ideological, nanny state one size fits all ideals that are determined by politically favored elites. Forcing behaviors upon us by any means possible is the fanatical religion of those on the secular left who are true believers in a society defined by what they think is best. You will begin to see laws and commercials and public service announcements, paid for by government stimulus money which entices you by reward or punishment to follow their advice. Advice based most often on emotion and not science. You will see more brainwashing type curriculum using your tax dollars in public schools with the purpose of indoctrinating our children early on towards the “correct” way to think. It is Orwellian and it is possible. No almost certain under this leftist administration.

You have seen it already. Crusades against second hand smoke (Have you seen the commercial about the little kid playing in the apartment building? C’mon, really?) or hetero-sexual aids or swine flu ( oops, where did those panics go?) and, now for Global Warming, excuse me, Climate Change and the need to go green no matter what the cost to our future generations.

The latest monkey business is legislation that will force restaurant chains to put the caloric content of their food on the menu. There is no evidence that this will do anything but increase costs to restaurant owners who will have to raise prices to us. In fact, there is evidence that exists that shows it will be pointless. But when you have a crusade and an ideology who cares about that little nuisance called facts. I submit that in the 20 years since we have been forced to put nutritional information on all grocery products Americans have gotten fatter, not thinner. I don’t go to a steakhouse because I care about caloric content. We need a congress that understands this and stays out of my pancakes!

Really, what we have now unleashed in our beloved country is a hostage situation to the American legal system. Whether it’s the local restauranteur, the small businessman, the ski resort, your family doctor or your local hospital or school we are all victimized by a lack of restraint on our legal tort system. Quite frankly, my biased opinion thinks that the biggest obstacle to American values returning is the American legal system. If any industry was in need of reform it is that one. Where are the future leaders who are willing to take on the trial lawyers? Now that would show real bravery. Dennis Prager and others have rightly labeled ObamaCare as, “The trial lawyers of America stimulus package”.

Recently, a midwife friendly hospital in Greenwich Village closed its doors due to its inability to stay financially solvent while trying to comply with all the mandates, regulations and legal protections required. The organization that runs residency training programs in the United States has predicted an increasing shortage of applicants in the next decade. Many doctors are already at the point where they cannot afford to continue to take on more patients for ever decreasing reimbursement. MediCal and medicare patients are going to find it harder to make appointments and are going to be waiting longer. The cost estimates in the ObamaCare bill are fictional. Everyone knows that or lives in denial. When costs cannot be contained there are only 3 choices. Raise taxes, lower reimbursement or ration care. Raising taxes will not solve anything as the well will run dry. And lowering reimbursement further will just push doctors and hospitals out of business, as it has in Greenwich Village and lead to rationing by default. This health care bill is unsustainable and un-American. Most doctors love our profession but hate what the business of medicine has become.

As for my practice: Carolyn asks whether I would consider giving it up and retiring early. The answer is really, can I afford to keep going? Is it worth it. Take the man who owns a horse. He adores that animal and derives much joy from riding and caring for it. But he can no longer afford to feed it. He cannot bring himself to sell it so he decides he will save money by cutting back each day on the amount of hay he feeds the horse. Each day he will feed it a little less and in that way save money. Finally, he reaches the day where he no longer has to feed the horse. He arrives for his joyful ride only to find the horse dead! What a shocker. (Horse and Hay story of Tim Conway Jr. from KFI Radio). Such is the analogy for this health care entitlement.

I have spoken about this many times before. Not only will doctors able to quit consider doing so but who in their right mind will become the future doctors in our country. Years of training, and sacrifice of social life. Loss of a decade of fun and earning power. Massive debt. Only to come out and see your expenses rising and uncontrolled but your earning power capped and regulated. The devastating threat of a career ending law suit hanging over your head like the sword of Damocles is no way to live. Having authorization for a test or procedure denied by some non-medically trained faceless cubicle worker who can’t even spell the diagnosis is maddening. Your decisions weighed and scrutinized by utilization review boards, government agencies and hospital committees. None of whom will ever bother to get to know the patient you are advocating for. How many of you would want to live like this? Would want your children to choose this?

And to this point I haven’t even mentioned the looming specter of Electronic Medical Records coming by 2014. Every detail of your medical history, and that of your children will be mandated to be online for bean counters of all shapes and motivations to peruse. Do you trust that it will remain confidential? I don’t! And there will be an amazing cost of installing the hardware, software and annual updates that will not be reimbursable to the practitioner. Adding another undo burden on the small, independent practice of doctor, midwife, chiropractor and therapist. Another not so subtle hammer to force doctors like me out of business or submit to joining large multispecialty impersonal groups run by large conglomerates or government agencies where the individuality and art of medicine I love will disappear.

Politics and politicians have no business invading the doctor patient relationship. The system is rotten to the core. We all saw this openly in the dirty tactics, special interests and bribery of all too eager politicians in the passing of Obamacare. People ask me why the AMA supported the bill. First, this may come as a surprise but less than 17% of America’s doctors belong to the AMA. And almost all of those are in academia, residency or retirement. Actually, I do not know any colleague who is a member. So the AMA does not represent the practicing doctor. The AMA represents the AMA. They do not care about you. They do not care about me. They do not really care about health care. They have a financial interest in this legislation just as does the AARP. They have made a deal with the devil, in my opinion. We have become a nation of deception by large special interests. The propagandists never say what they really mean.

Which brings me to the General Electric corporation, run by Jeffrey Immelt, one of president Obama’s biggest supporters and White House visitors. GE is apparently in line to be the major player in the EMR technology. Some say a 7 billion dollar deal. That’s our tax money, by the way! Numbers that are too big to really grasp. But here is an interesting tidbit. I was talking with a group of health care professionals about the legislation recently. Someone brought up an odd provision in the bill that increased payment to doctors for bone density studies. We all thought it odd that a bill that has few specifics would single out one procedure for increased reimbursement. How odd that in a 2700 page bill that this one test would be mentioned specifically! Well, here is my logical, yet cynical conclusion. With bone density payments diminishing over the last 5 years no one is buying bone density machines because it does not pay to own one. If reimbursement goes up, it may make sense for medical groups to purchase new machines again. Well, guess who is the leading manufacturer of bone density machines? Yep, General Electric.

So, we have come to a place where we have to decide who we trust. No longer can we be passive when it comes to something as important as health care. We have to take a stand. I trust the relationship I have with my personal physician. I trust my ability to judge him by his actions. I trust that he has my welfare as his primary concern. I trust that if he does not serve me well I can go someplace else. I do not trust big government or big business to have my back. I do not trust the nanny state to make decisions in my family’s best interest. I will do that and I want a country that allows me the freedom to succeed or fail. One size does not fit all. The government should not have the right to take my hard earned skills and demand of me to give them away for what they determine they are worth. I have never dreamed I would be before you all today making emotional speeches. All I wanted to do was to practice my profession as I was trained to do and love my family. But, I cannot sit idly by and watch this happen. I want my children to know that their dad stood up for self determination and personal responsibility.

I would close with this quote from Ayn Rand’s Atlas Shrugged. ““Let them discover the kind of doctors their system will now produce. Let them discover, in their operating rooms and hospital wards, that it is not safe to place their lives in the hands of a man whose life they have throttled. It is not safe, if he is the sort of man who resents it—and still less safe if he is the sort who doesn’t.”
Ayn Rand, from Atlas Shrugged, 1957

The best and the brightest should be going into noble professions like medicine. Sadly, unless we elect leaders who pledge to repeal this horrible health care legislation, medicine will no longer be noble and the best and brightest will seek other interests. Possibly becoming lawyers or government workers because that’s where the money and lifestyle remain.

Thank you for allowing me to vent and for your passion and love of country."

Stuart J. Fischbein, MD April 15, 2010

Good News from Ottawa!

2010-04-11T13:00:00.000-07:00

Very telling of the times we live in that a simple normal vaginal birth makes the news in Canada. But, still, its a turn toward common sense and evidenced based medicine and that should never be taken lightly. Congrats to the family and health care practitioners on this happy event. Dr. F

http://www.ottawacitizen.com/health/Giving%20birth%20natural/2788647/story.html

Another Casualty

2010-04-10T12:37:00.000-07:00

Here is an article sent to me by Laurel Phillips in Santa Barbara from today's NY Times. Another sad example of the loss of our inalienable rights due to economic forces and fears of litigation. Is this the Health Care Reform we desire? And "Tort reform is off the table" says our President and Congress.

We cannot feel despair. For me, this sort of story motivates me even more to take positive action. Reinforcing my belief that normal birth needs to be taken out of the hospital model. Market forces would support free standing women's health and maternity centers. There are enough midwives and supportive doctors around to make this a reality. What is needed are motivated patients and funding. Keep spreading the dream and the right circumstances will fall in to place.

Amy Tinney and I are working with some leads and putting a business plan in place for a Los Angeles site. Any support or expertise in this realm would be welcome. Thanks, Dr. F

N.Y. / REGION | April 10, 2010
Big City: With the Closing of a Hospital, Women's Childbirth Options Diminish
By SUSAN DOMINUS
Mothers-to-be will lose a midwife-friendly alternative after a decision by the board of St. Vincent's Medical Centers to close its flagship hospital in Greenwich Village.

http://www.nytimes.com/2010/04/10/nyregion/10bigcity.html?emc=eta1

No news is not necessarily good news

2010-03-30T00:45:00.000-07:00

Well, locally, there is no news to report. The BAC held it's third in the ongoing monthly protests against the indefensible banning of midwives from Pleasant Valley Hospital. No official word from the administration concerning a reversal of their blunder. Continued delays from apologizing to the midwives and those of us who support them are unacceptable. The local press has dropped the ball and there is the appearance of apathy. However, behind the scenes we are doing what we can to keep this travesty on the radar screen. Off the record sources have indicated that some in corporate CHW are not too happy with the St. John's administration. CEO Mike Murray is leaving for unknown reasons. Because they never tell the truth about such things we can only speculate as to why.

There has been no movement from the OB committee on its unwritten ban on Breech deliveries. In light of the NIH VBAC concensus concluding that the banning of VBACs at many hospitals around the country is not evidenced based one would hope that reasonable minds would rethink the banning of other evidenced supported procedures like Breech delivery. But then, fairness, logic, science and collegiality are not values of the current hospital committee. And, since, these defacto bans do not hinder their practices there is no need for them to be reconsidered. Every week that passes continues to hurt their reputation, their bottom line and the patients of our community as many are becoming informed and looking elsewhere for birth options.

My hope is to see a renaissance of common sense and return of birth choices which will include an eventual disbanding or reorganization of the committee structure in the OB department. I will continue to write, speak and try to work with those in the administration who still remember their mission statement. Please continue to make your opinions known to CHW through e-mails and letters and protests, when necessary. The BAC website has the contact information. I would also urge you to join and become active with the Birth Action Coalition at www.birthactioncoalition.org . Thanks, Dr. F

Micro vs. Macro:

2010-03-22T11:11:00.000-07:00

Some of my dear friends are excited about the events on Capitol Hill yesterday. There are parts of the massive health reform bill that suit their agendas. Such is the case with the Mama Campaign people who have done really good work in improving access and payment to CPMs. Or, the portion of the bill that improves access to health coverage for those in need. Worthy objectives, yes. While this sort of "Micro" thinking may be personally satisfying for a worthy agenda I would like to caution my friends from too much euphoria. For, in my opinon, the "Macro" of this bill, the corrupted process by which it came to pass and the inevitable intrusion by tax, mandate or yet to be determined legal quandries into our lives, will make America worse off. Those of you who know me, know I cherish personal autonomy and responsibility over the collective. Soon to follow will come the poison in this pill. Restrictions on choices and mandates on behavior with unforseeable costs and debt from a class of elites whose leftist philosophy believes, truly, that they know best. Watch for ads on TV frightening you or seducing you. Soon to come will be the tax incentives or punishment for behavior that they think is good or bad. One size fits all is not an American value. For me, this assault on our individuality transcends political bickering. I don't trust big government. But you guys know that. Their track record at ruining things they touch is pretty good. American education is a good example. My point here is not to suggest how you should think. Only that it is important to think. As we fight for the causes we believe in don't forget to look up and outside at the bigger picture of where this confusing, massive mandate is taking us. Thanks, Dr F.

New Facebook Page

2010-03-17T08:00:00.000-07:00

Hi All, One of you was energetic and thoughtful enough to create a Facebook page for me at:

http://www.facebook.com/home.php?ref=logo#!/pages/Stuart-Fischbein-OBGYN/364977701696?ref=ts

So now fans (and foes) have another place to check and see what I am up to or supportive of. Most of the news has been very positive towards what we believed all along. Nothing new to report at my local hospitals and it is doubtful that the NIH VBAC conclusions will cause even a ripple of remorse or guilt on the part of administrators and doctors who continue to uphold several policies without supportive medical evidence. I will continue to try to work respectfully for a return to common sense and patient autonomy out here.

Danielle from Momotics has posted a survey of 861 post c/section moms which looks at the feelings of the actual patient. What a novel idea! Asking the actual patients affected by the interventions modern medicine performs how it affects them. you can find it at:

http://momotics.com

Lastly, I believe the BAC is planning another rally at the corner of Rose and Gonzalez this Friday at 11 AM. Please check out the BAC website for details. Dr. F

Final NIH VBAC Consensus Report

2010-03-13T02:29:00.000-08:00

This is really welcome news. A government appointed panel has looked at the evidence objectively and concluded that VBAC should be a viable option for women. They also stated that in most instances it is as safe or safer than elective c/section, the opinions against VBAC were not evidence based and hospital policies that obstruct this option should be revisited. As always, they state more studies are warranted in several areas. Please read for yourself and forward to patients, colleagues and your institutions. Thanks, Dr. F

http://consensus.nih.gov/2010/vbacstatement.htm

Trust Birth Dinner & Upcoming VBAC class

2010-03-13T02:12:00.000-08:00

Julie and I had a wonderful time tonight at the Trust Birth Dinner in Redondo Beach. Thank you Carla, Heather and all the dedicated birth goddesses who honored me along with so many other deserving people. I am grateful for the energy you share that rejuvenates my drive for our common goals. So nice to meet Sara Buckley and see Paul Fleiss among the honorees, too.

Sunday from 1:30 to 5:30PM at my Century City Office is the VBAC education class led by Jen Kamel of VBACfacts. There is still room if anyone is interested. I will be attending and offering my 2 cents worth. Below is the information. If interested contact Jen through facebook or leave a comment here and I will get back to you. Dr F

There are still tickets available for the class this Sunday which will be the only class offered in Los Angeles for 2010. The class is close to being sold out, so if you are interested, don't delay!

Another reason to RSVP as soon as possible: I am printing up bounded books of the presentation and want to make sure I have enough for everyone.

Dr. Stuart Fischbein OB/GYN will be present to answer questions.

The latest couple who registered are driving 170 miles one way. Don't let distance hold you back from attending!

Warmly,

Jen

You are invited to the following event:
The Truth About VBAC - Los Angeles

Date:
Sunday, March 14, 2010 from 1:30 PM - 5:30 PM (PT)

Location:
Offices of Stuart Fischbein, MD
10309 Santa Monica Blvd, Suite 300
Los Angeles, CA 90025

Action Alert

2010-03-13T02:03:00.000-08:00

Please view the following message from Docs4patientcare and send to to everyone you know. For I believe a government takeover of healthcare is the purpose and inevitability of the current bill and would be detrimental to our patients and the individual right to autonomous decision making that we cherish. Rationing and limits on birth options and choice would certainly follow.

http://www.youtube.com/watch?v=8D_e1osuomg

We at docs4patientcare appreciate your attention at the vital time in history. Dr. F

Draft summary of NIH VBAC position

2010-03-10T18:00:00.000-08:00

Very good news and reassuring that at least at the academic level evidenced based reasoning and common sense have prevailed. Please read the initial statement from the National Institute of Health on VBAC:

http://www.nih.gov/news/health/mar2010/od-10.htm

The conference was a worthwhile experience and I believe the panel members have the most honest of intentions. I am so glad I went. I hope some of you followed the webcast and if not, it will be up soon through the NIH website. My take on the conference was that it is clear from the presentations and the panelist conclusions that there is no convincing evidence that VBAC is inherantly unsafe nor is it ethically a choice that should be denied to any informed woman. While I do not think there is a snowball's chance in hell it will cause any immediate effect on hospital policy, I do believe if disseminated to patients they can make a convincing argument to their local hospitals that they cannot be forced into surgery and have the right of informed refusal.

One of the most compelling points of the conference to me was the following. ACOG's 1999 statement No.5 changing the word readily to immediately available was not based on any evidence. It was likely done to give ACOG members legal cover in cases where compliance was maintained and still a bad outcome ensued. The result was no real protection against the fear or reality of a disastrous law suit and only fed the fear which led to VBAC bans at more than 30% of American hospitals. Amazingly, neither before ACOG came out with the "immediate" guideline or in the ten years since has there been any studies undertaken that have ever shown that having emergency help immediately available has done anything to lower the incidence of cerebral palsy, neonatal death or maternal morbidity over the "readily" available (30 minutes decision to incision) standard! It is horrifying for me to actually learn that so many of these repeat c/sections were inflicted on women based on nothing but fear and economics. My profession should be ashamed of our cowardice.

I will post a link to the final NIH consensus statement when it appears. The BAC website and VBACfacts are also a great resource to follow the story. Spread the word!

NIH VBAC Conference

2010-03-09T23:16:00.000-08:00

Hi All, Just home from Bethesda, MD and the NIH VBAC consensus conference. So much to tell but too late tonight. The evidenced based data presented was very supportive of VBAC and patient autonomy in decision making. Whether that will be the consensus and whether it will make any difference with the forces against it remains to be seen. I suggest for the greatest details and insights you look to Jen Kemel's site at www.Jen@vbacfacts.com

In the coming days I will do my best to summarize my thoughts and observations and report on the consensus statement due out tomorrow afternoon. The statement will be published online at www.consensus.nih.gov

Archived videocasts of the entire conference will be available in approximately 1 week at www.videocast.nih.gov

Dr. F