My response to another rant by Dr. Tuteur

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

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.

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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

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?

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

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

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

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