The to vaccinate or not to vaccinate controversy is far from ended despite a recent statement from the CDC based on an Institute of Medicine (IOM) review that concludes, "the evidence favors rejection of a causal relationship between thimerosal–containing vaccines and autism". I have seen this statement repeated in many recent news items including one in USA Today yesterday. (That just doesn't sound right....USA Today yesterday). I do not profess to have any expertise on this subject other than what I hear and read. Which means I am as confused as you are since the truth does not seem as black and white as the IOM would have us believe. I also, do not think there is any conspiratorial process going on between big Pharma and big Government.
So, when asked my opinion recently by a client I was happy to be able to refer them to Jennifer Margulis' new book, "The Business of Baby". Its subtitle talks of what doctors won't tell you and what companies try to sell you and how to determine what's truthful. She presents an extremely well researched and referenced discussion without a personal agenda. Vaccines have performed miracles in the 20th Century, eradicating polio and small pox and minimizing risks from a variety of illnesses from mumps to measles to tetanus. When I traveled to endemic areas I did not hesitate to get vaccinated for yellow fever.
But, as will all aspects of life and, as I have related to pregnancy, there is nothing that is risk free. In my career I have seen a case of Guillain-Barre Syndrome related to a routine vaccine. We know that if the threat of a small pox epidemic from bioterrorism were ever to occur that the vaccine would save millions of lives but a few people would have an allergic reaction and die. Because of our ridiculously litigious American society this predictable and medically acceptable risk would result in lawsuits and has scared so many small pox vaccine manufacturers that only one company remains. Not having the capability of having this vaccine mass produced could be devastating. But I digress.
Whether to vaccinate or not is a personal decision that each of us has to make for ourselves and our children. What I can say is that in healthy women I see no reason to give universal hepatitis B vaccine to a newborn as is the policy in many hospitals. Always ask about this one. It makes absolutely no sense in families who are not active hepatitis B carriers. And almost every pregnant woman is routinely screened for this. Measles, mumps, Rubella, chicken pox and such options as Guardasil for HPV and the flu shot are never mandatory so do your own research as to the pros and cons. (One article out of Japan has shown that high doses of daily Vitamin D has been more effective against the flu than vaccination. Reminder: This study does not end that debate, either.)
I will end this blog with one last example of the rigidity of the academic-medical model taught to most pediatricians. A story related to me by one of my current pregnant clients and one that I hope most pediatricians would abhor. While searching the area for a supportive pediatrician she asked his position on routine vaccination. He stated that he recommended the standard vaccine regimen but that he would still accept her baby into his practice if she chose not to. This sounded most reasonable until he added that if she chose not to vaccinate her baby that he and his associates would only be available for her phone calls during business hours. He would not care for her baby after hours and on weekends should her baby become ill! Seriously, that is what she was told and I believe her. Off to the emergency room with you! As I think about it I am still shaking my head. How does a person say something like that? Does it not seem a bit unethical to that physician? It would be much more honorable to suggest she go elsewhere. I guess this is the new ethics and there is no vaccine against it. Caveat Emptor!
Wednesday, August 14, 2013
Friday, August 2, 2013
DrStusPodcast.com
Ok, so many of my colleagues have noted that I always have an opinion and usually a strong one and a relevant one. They say, and I agree, that I should get out there more and advocate for the good things we do to counter so much of the bloviating that goes on from those against reasonable ideas and choices in birthing. Finally I have taken this advice to heart. It is with excitement and a big smile that I am announcing the creation of my very own podcast with original name of Dr. Stu's Podcast with Brian Whitman at www.drstuspodcast.com
Brian is my friend and an accomplished radio personality currently on morning AM radio 870 in Los Angeles and brings his expertise and wit to the show. We discuss timely medical issues and current events. No topic is off limits from the medical world to politics to current events and, of course, LA Kings hockey. Its an informative, informal conversation and banter so come join us. Your support, as always, is appreciated.
Listen online or download for free on iTunes as Dr. Stu's Podcast. The first 3 episodes are up. I will be adding at least 2 new ones every week. Please pass it on, give it a high "5" ranking. Comments and questions are welcome at drstuspodcast@gmail.com
Brian is my friend and an accomplished radio personality currently on morning AM radio 870 in Los Angeles and brings his expertise and wit to the show. We discuss timely medical issues and current events. No topic is off limits from the medical world to politics to current events and, of course, LA Kings hockey. Its an informative, informal conversation and banter so come join us. Your support, as always, is appreciated.
Listen online or download for free on iTunes as Dr. Stu's Podcast. The first 3 episodes are up. I will be adding at least 2 new ones every week. Please pass it on, give it a high "5" ranking. Comments and questions are welcome at drstuspodcast@gmail.com
Monday, July 29, 2013
Truth v. EDA, Preparing Ourselves Part 1
This is a longer version of a letter to the editor I had published in the AJOG in response to an opinion piece by a physician and ethicist who has previously stated his dislike for all things home birth. Should a home birth antagonist whose name shall not be spoken quote these opinions as fact in some future presentation, say in Hawaii, maybe in the end of September then it will be good to have honest, coherent counter arguments. Hope this is helpful, Dr. Stu
Redefining Ethics.
Truth or Tyranny?
In a recent opinion piece published earlier this year in the
AJOG, “Planned Home Birth: The Professional Responsibility Response”,
Chervenak, et al(1) argue against the ethics of home birthing stating that advocates
of planned home birth have emphasized 4 selling points: patient safety, patient satisfaction, cost effectiveness, and respect for
women’s rights. “{The Authors} provide a critical evaluation of each of
these claims and identify professionally appropriate responses of obstetricians
and other concerned physicians to planned home birth.” Most of what followed in the rest of his article was neither
inductively or reductively logical.
As to point 1,
patient safety, he says, “Maternal and fetal necessity for transport during
labor is often impossible to predict.” Home birth women by
definition are cherry picked for their health. They are allowed to labor as
nature intended without interventions. In experienced hands, transport is rarely
“impossible” to predict. He states the most common reasons for transport are
pain relief and prolonged labor, neither being unsafe. He continues his
argument against home birth in America by presenting safety data from South
Australia, a system that has no resemblance here.
He summarizes his
anti-safety position this way: “It is antithetical to professional responsibility
to intentionally assign any damaged or dead pregnant, fetal, or neonatal
patient to this category, even if the number is small.” Yet ample evidence
exists that similar cohorts of normal women delivered out of hospital vs.
hospital have c/section rates of 6% and 24% respectively (2). By the author’s very
own words then, the increased morbidity of the hospital model if held to the
same standard would be professionally irresponsible.
As to point 2, patient satisfaction, he assumes the high rates of transport
undercut the raison d’etre of planned home birth. He cites a Dutch study from
2008 showing persistent levels of frustration for up to 3 years in 17% of
transported women. Conversely, that would seem to imply an 83% satisfaction
rate. A fairer comparison would be the satisfaction rate of American women with
successful home birth vs. hospital birth, but none was made. His solution of
supporting “homebirth-like” environments in the hospital setting, sadly, shows
a complete lack of understanding of mammalian birth.
As to point 3, cost effectiveness, he cites minimal savings in cost comparison
data from Britain. Again, the author is using foreign data from a country with single-payer, socialized medicine when a simple Google
search easily produces reliable American cost comparison data. This tactic is most concerning in its dishonesty.
The cost of a typical home birth here is about a third of that in hospitals.
Savings over a cesarean birth approach 85% (3). When c/section rates
approaching 35% in the hospital setting are factored in the cost savings is
significant.
Finally, as to point 4, respect for women’s rights, Dr. Chervenak makes the classic straw man
argument. He avoids altogether using the beneficence based model of
ethics which, as with VBAC, supports a woman’s reasonable choice (4). Instead he states, “From the perspective of
the professional responsibility model, insistence on implementing the unconstrained
rights of pregnant women to control the
birth location is an ethical error and therefore has no place in professional
perinatal medicine.” But home birth advocates don’t support unconstrained
rights or rights based reductionism. Dr. Chervenak has created a whole new
theory of ethics, “professional responsibility ethics”, which in his opinion
trumps beneficence based ethics and respect for patient autonomy.
Skewed evidence, selection bias, straw men and anecdotes do
not equal data but that is what is presented by the authors as an ethical argument
against home birthing. This group of well credential authors has written an
article that is more propaganda than evidence based opinion. They might as well
have said, ACOG thinks home birth is very, very bad and asked us to make up an
argument on their behalf.
1. Chervenak,
FA, et al. Planned Home Birth: the professional responsibility response. Am J Obstet Gynecol. 2013 Jan;208(1):31-8
4. The Hastings Center Report:
“The Ethics of Vaginal Birth After Cesarean”, Sonya Charles http://www.medscape.com/viewarticle/767504_3
Stuart J. Fischbein, MD FACOG
Medical Director, Sanctuary Birth & Family Wellness
Center
Los Angeles, CA
Monday, July 1, 2013
A Letter to Sacramento
Dear California Representatives:
I am writing to express my support for the independent practice of midwifery in California and the reasonableness of the choice of home birth. I am a practicing obstetrician, trained at Cedars-Sinai Medical Center, board certified in 1989, a Fellow of ACOG for more than 20 years and co-author of the book, “Fearless Pregnancy, Wisdom & Reassurance from a Doctor, a Midwife and a Mom”. The American College of Ob/Gyn (ACOG) frequently does not represent the majority of its members when it takes a position, and their motivation is not always patient centered. A recent paper published in their own journal reported that 2/3rd of their practice guideline bulletins are based on Level C evidence.(1) Level C evidence, by definition, is not based on the best science and represents only consensus opinion. Truth and ethics should be everyone’s overriding concern. Consensus is frequently assumed to be based on truth when, in fact, it often is not.
Requiring licensed midwives who assist California women with the reasonable choice of home birth to have supervision from obstetricians who are reluctant to do so or are prevented from doing so by their malpractice policy, without first mandating physician supervision in the same law, is essentially a de facto way to eliminate home birth without lawmakers having to overtly come out against choice. I have worked with both Certified Nurse Midwives and Licensed Midwives over the last 27 years as a back-up physician, supervising physician, direct employer, and in collaboration assisting pregnant women with delivering their babies both in the hospital and home setting. This experience makes me uniquely qualified over my academic and administrative colleagues to give perspective to this debate. I am hopeful that what I have to say will cause you to take a moment to reconsider long held positions about the very nature of human birth.
Licensed midwives (LMs) are highly educated, dedicated and nurturing specialists trained in the art and science of normal birth. Physicians are trained as specialists in abnormal or problem pregnancy. LMs spend an hour at each prenatal visit, which allows them to use their expertise in preventative care. Physicians are limited by the medical model to short prenatal visits and are experts at treating disease. Normal pregnancy is not a disease and my physician colleagues do not receive adequate training in normal birth and, therefore, fail to recognize the natural mammalian process of birth. I am certain that a great degree of the friction between these professionals comes from a lack of understanding of what midwives do and how they are trained and the perpetuation of the myth by organized medicine that they are somehow substandard.
My experience with midwives has shown me that they want the best for their clients and are not anti-medical zealots. They seek consultation and transport when appropriate. Ideally, both midwives and physicians would benefit if the supervision requirement was removed altogether and transport was made less stressful. For one of the large concerns of physicians is their vicarious liability as a “supervisor.” Malpractice tort reform would be a benefit to all of California’s health professionals but until that day comes the supervision requirement provision should be removed to protect doctors willing to support midwives and possibly allowing for more to come forward. This might make access to choice for California woman more available and that is a good thing. The countries with the best statistics have home birth supported by midwives and the smoothest collaboration with physicians and hospitals for transport. It is in this area that California has failed.
Medical ethics dictate that patient autonomy and decision-making is to be respected. And not all patients who are given unbiased and true informed consent should be expected to reach the same decision. Physicians have a fiduciary duty and an ethical obligation to discuss the risks and benefits of all reasonable options. In the skewed argument against the safety of home birth the benefits are never discussed. And the counseling given by doctors almost never reflects equally on the safety and risk of birthing in the hospital. The assumption that hospital birthing and the high rate of medical interventions resulting in a 33% cesarean section rate is safer than home birth for low risk mothers should be challenged. A very large and recently published Dutch study in the prestigious British Medical Journal showed home birth of properly selected women to be safer than hospital birth.(2) Women who have been given true informed consent may well choose a home birth and a midwife as the best option for their family. Sometimes, due to restrictive hospital policies or complete bans on certain evidenced based reasonable options, a woman’s choice of a home birth is all she has as in the cases of a vaginal birth after cesarean and breech birth.
I would also like to bring your attention to the argument often given by physicians with contempt for home birth transports because of the occasional bad outcome. Almost all transports from a home birth are for the common issues such as pain relief and exhaustion. All too often the term transport is equated with emergency and that is simply not the case. While it would be wonderful if bad things never happened we should learn from history that trying to legislate absolute safety is impossible and only leads to one size fits all policies which are ethically incompatible with patient autonomy. And while a bad outcome in a home birth gets spread all over the internet, a similar bad outcome in the hospital is hushed up and protected by a veil of confidentiality and HIPPA regulations. Hospitals are not always the safest place to be and certainly not the most nurturing and any honest obstetrician can relate numerous disasters, some preventable and some not, that occurred under the watch of an obstetrician and labor and delivery staff. Hospitals and newborn intensive care units can do wonders when needed and my intention would never be to diminish that. However, we must begin to rethink how we look at normal birth and a woman’s free exercise of all reasonable choices and that is where your leadership is most needed.
In summary, I am hopeful that you will take these points into consideration when you deliberate. Home birth and licensed midwifery are reasonable options and therefore ethically sound. While collaboration between doctors and midwives in many western countries has led to better outcomes and statistics the United States continues to lag way behind. Putting our midwives at the mercy or pleasure of reluctant obstetricians is not a constructive idea. Home birth is here to stay. It is a choice many women want and restricting access to the best professionals through medically unfounded legislation will not serve our citizens well. Collaboration and congenial consultation and transport are what is needed. Please allow licensed midwives the freedom to practice and remove the burdensome obligation of direct physician supervision. The status quo only leads to fear and mistrust because of the overwhelming legal concerns facing every doctor forcing them to make decisions that do not put patients first. I would relish the opportunity and be delighted to discuss any aspect of this issue with you, your distinguished colleagues and any members of the medical community holding an alternate point of view.
Sincerely,
Stuart J. Fischbein, MD FACOG
Home Birthing Specialist
1: Wright JD et al. Scientific Evidence Underlying the American College of Obstetrics and Gynecologists’ Practice Bulletins. Obstetrics & Gynecology, September 2011; Volume 118; No.3; Pages 1-8
2: de Jonge A, et al. Severe adverse maternal outcomes among low risk women with planned home versus hospital births in the Netherlands: nationwide cohort study. BMJ 2013;346:f3263 doi: 10.1136/bmj.f3263 (Published 13 June 2013)
I am writing to express my support for the independent practice of midwifery in California and the reasonableness of the choice of home birth. I am a practicing obstetrician, trained at Cedars-Sinai Medical Center, board certified in 1989, a Fellow of ACOG for more than 20 years and co-author of the book, “Fearless Pregnancy, Wisdom & Reassurance from a Doctor, a Midwife and a Mom”. The American College of Ob/Gyn (ACOG) frequently does not represent the majority of its members when it takes a position, and their motivation is not always patient centered. A recent paper published in their own journal reported that 2/3rd of their practice guideline bulletins are based on Level C evidence.(1) Level C evidence, by definition, is not based on the best science and represents only consensus opinion. Truth and ethics should be everyone’s overriding concern. Consensus is frequently assumed to be based on truth when, in fact, it often is not.
Requiring licensed midwives who assist California women with the reasonable choice of home birth to have supervision from obstetricians who are reluctant to do so or are prevented from doing so by their malpractice policy, without first mandating physician supervision in the same law, is essentially a de facto way to eliminate home birth without lawmakers having to overtly come out against choice. I have worked with both Certified Nurse Midwives and Licensed Midwives over the last 27 years as a back-up physician, supervising physician, direct employer, and in collaboration assisting pregnant women with delivering their babies both in the hospital and home setting. This experience makes me uniquely qualified over my academic and administrative colleagues to give perspective to this debate. I am hopeful that what I have to say will cause you to take a moment to reconsider long held positions about the very nature of human birth.
Licensed midwives (LMs) are highly educated, dedicated and nurturing specialists trained in the art and science of normal birth. Physicians are trained as specialists in abnormal or problem pregnancy. LMs spend an hour at each prenatal visit, which allows them to use their expertise in preventative care. Physicians are limited by the medical model to short prenatal visits and are experts at treating disease. Normal pregnancy is not a disease and my physician colleagues do not receive adequate training in normal birth and, therefore, fail to recognize the natural mammalian process of birth. I am certain that a great degree of the friction between these professionals comes from a lack of understanding of what midwives do and how they are trained and the perpetuation of the myth by organized medicine that they are somehow substandard.
My experience with midwives has shown me that they want the best for their clients and are not anti-medical zealots. They seek consultation and transport when appropriate. Ideally, both midwives and physicians would benefit if the supervision requirement was removed altogether and transport was made less stressful. For one of the large concerns of physicians is their vicarious liability as a “supervisor.” Malpractice tort reform would be a benefit to all of California’s health professionals but until that day comes the supervision requirement provision should be removed to protect doctors willing to support midwives and possibly allowing for more to come forward. This might make access to choice for California woman more available and that is a good thing. The countries with the best statistics have home birth supported by midwives and the smoothest collaboration with physicians and hospitals for transport. It is in this area that California has failed.
Medical ethics dictate that patient autonomy and decision-making is to be respected. And not all patients who are given unbiased and true informed consent should be expected to reach the same decision. Physicians have a fiduciary duty and an ethical obligation to discuss the risks and benefits of all reasonable options. In the skewed argument against the safety of home birth the benefits are never discussed. And the counseling given by doctors almost never reflects equally on the safety and risk of birthing in the hospital. The assumption that hospital birthing and the high rate of medical interventions resulting in a 33% cesarean section rate is safer than home birth for low risk mothers should be challenged. A very large and recently published Dutch study in the prestigious British Medical Journal showed home birth of properly selected women to be safer than hospital birth.(2) Women who have been given true informed consent may well choose a home birth and a midwife as the best option for their family. Sometimes, due to restrictive hospital policies or complete bans on certain evidenced based reasonable options, a woman’s choice of a home birth is all she has as in the cases of a vaginal birth after cesarean and breech birth.
I would also like to bring your attention to the argument often given by physicians with contempt for home birth transports because of the occasional bad outcome. Almost all transports from a home birth are for the common issues such as pain relief and exhaustion. All too often the term transport is equated with emergency and that is simply not the case. While it would be wonderful if bad things never happened we should learn from history that trying to legislate absolute safety is impossible and only leads to one size fits all policies which are ethically incompatible with patient autonomy. And while a bad outcome in a home birth gets spread all over the internet, a similar bad outcome in the hospital is hushed up and protected by a veil of confidentiality and HIPPA regulations. Hospitals are not always the safest place to be and certainly not the most nurturing and any honest obstetrician can relate numerous disasters, some preventable and some not, that occurred under the watch of an obstetrician and labor and delivery staff. Hospitals and newborn intensive care units can do wonders when needed and my intention would never be to diminish that. However, we must begin to rethink how we look at normal birth and a woman’s free exercise of all reasonable choices and that is where your leadership is most needed.
In summary, I am hopeful that you will take these points into consideration when you deliberate. Home birth and licensed midwifery are reasonable options and therefore ethically sound. While collaboration between doctors and midwives in many western countries has led to better outcomes and statistics the United States continues to lag way behind. Putting our midwives at the mercy or pleasure of reluctant obstetricians is not a constructive idea. Home birth is here to stay. It is a choice many women want and restricting access to the best professionals through medically unfounded legislation will not serve our citizens well. Collaboration and congenial consultation and transport are what is needed. Please allow licensed midwives the freedom to practice and remove the burdensome obligation of direct physician supervision. The status quo only leads to fear and mistrust because of the overwhelming legal concerns facing every doctor forcing them to make decisions that do not put patients first. I would relish the opportunity and be delighted to discuss any aspect of this issue with you, your distinguished colleagues and any members of the medical community holding an alternate point of view.
Sincerely,
Stuart J. Fischbein, MD FACOG
Home Birthing Specialist
1: Wright JD et al. Scientific Evidence Underlying the American College of Obstetrics and Gynecologists’ Practice Bulletins. Obstetrics & Gynecology, September 2011; Volume 118; No.3; Pages 1-8
2: de Jonge A, et al. Severe adverse maternal outcomes among low risk women with planned home versus hospital births in the Netherlands: nationwide cohort study. BMJ 2013;346:f3263 doi: 10.1136/bmj.f3263 (Published 13 June 2013)
Legislative Alert - AB 1308
Greetings to all of you and hoping this finds you and your families well and expecting of a fun summer. I am writing to ask your help in fighting a provision in a bill currently making its way through the California Senate that could severely affect the ability of licensed midwives to practice in the state. AB 1308, if passed and enforced, would make it a violation of law for a midwife to practice without physician supervision. It has already been passed by the state assembly and is, in part, sponsored by ACOG. The physician supervision provision has been in the statute since 1993 but has never been enforced because it has previously been seen as unworkable. Most physicians are either unwilling to supervise or are prevented from doing so by their malpractice insurance carrier and/or a hostile hospital administration.
AB 1308: http://leginfo.legislature.ca.gov/faces/billTextClient.xhtml;jsessionid=5c82f256d9253d2e4326c4312ddf?bill_id=201320140AB1308
Last Thursday, Adeola Adeseun, the attorney for CFAM (California Families for Access to Midwives) and I met with the aide to state Senator Ted Lieu in Redondo Beach. It is his committee that is currently reviewing the bill. The Senator was in Sacramento but we had a very productive meeting with his aide, Veronica, for over an hour. We need to send a lot of emails over the next 24 hours to senator.lieu@senate.ca.gov
They need to briefly state their support for licensed midwifery, the choice of home birth and then give a little anecdotal story about their experience. Positive tone is preferred but those who had issues with transport, hospital staff and physician reception can also speak up. They should reference AB 1308 and their concern that enforcement of physician supervision in light of modern day realities is likely to be stifling to the reasonable choice of a home birth with a licensed midwife and lead to less, not more, access to a reasonable choice for the women of California. We would prefer they do away with the physician supervision clause altogether in much the same way the chiropractors and acupuncturists are licensed and free to practice independently of orthopedic surgeons. My good friend and associate, Howard Mandel, MD, felt that another analogy might be more appropriate. Family practice physicians often have far less training in pregnancy and birth than a midwife and yet, once licensed and credentialed, are able to practice their trade without supervision. Like midwives, they rely on appropriate consultation. Consultation, not supervision, makes sense. Striking the supervision requirement altogether in the bill would also benefit obstetricians by removing the vicarious liability that some fear when supportive of a local midwife.
Can you please take a moment to email the Senator today? senator.lieu@senate.ca.gov
Also, can you bombard your contacts, friends and supportive family, especially if they live in the 28th district but any will do, and ask them to send an email to their state senator?
It is really important to get this out today.
Below are a few logical and passionate letters written by some wonderful people. I can’t thank them and you enough for the support shown for the reasonable choice of licensed midwifery as an option for the women of California.
Dear Senator Lieu,
I am writing in support for licensed midwifery, and the right for a choice of home birth. I have learned of Assembly Bill 1308 and that if passed and enforced, it would make it a violation of law for a midwife to practice without physician supervision. That provision is completely impractical and unnecessary, as a licensed midwife is fully capable of providing the support needed for the natural delivery of a baby without having a physician present.
I am the mother of two young boys ages 6 and 2. The birth of my first son in June 2007 was a delivery by C-section at Santa Barbara Cottage Hospital after a 30-hour labor due to what the hospital staff determined was "failure to progress." There were no medical issues with me or my baby other than I had been in labor "too long" and I was convinced to have a C-section to give birth to my baby. Fortunately, everything went well and I had a healthy baby boy weighing 6 lbs., 10 oz. A few years later when I found out I was pregnant again, my only birth options where I live in Santa Barbara was to have a repeat C-section, which I did not want to endure again, knowing that my body was fully capable of a normal vaginal birth. No doctors, hospitals, or midwives in Santa Barbara were able to provide me support for a VBAC (Vaginal Birth After Cesarean). To my great fortune, I learned of Dr. Stuart Fischbein who has a practice in Camarillo that would support a VBAC home birth with a midwife present. I had a successful home birth of my second son in April 2011 weighing 7 lbs., 14 oz. after only a 4 1/2 hour labor. Dr. Fischbein and the midwife, Karni Seymour-Brown, were present along with my husband, my parents, and my older son. It was beautiful, it was happy, and it was safe. It wasn't just safe because Dr. Fischbein was there, although he is a well-skilled and knowledgeable medical doctor, but I trusted and knew my body could do it, and I was also supported by the knowledge and nurture of the midwife, Karni. Before I had children, home birth sounded like a radical idea to me, but after becoming educated about it, and about my ability to have the right to choose the birth experience that I wanted and was good for me and my baby, I have realized that home birth is the most natural and beautiful way to bring a child into this world. There is of course a time and a need for medical intervention and transport to a
hospital in certain situations, but that is rare, as are the situations that would arise to cause the need for a transport. Midwives know just as well when medical intervention and transport to a hospital is necessary, therefore requiring a physician to be present is unnecessary. I have experienced first-hand the wonderful care, support, and wisdom that a midwife provides to a mother before, during, and after birth, and I fully support the practice of independent midwifery. I encourage you, and everyone to do the same.
I am concerned about AB1308 enforcing physician supervision of a home birth with a licensed midwife, as the practicality of that does not make sense. A midwife is able to provide full support for a home birth without the need for a physician to be present. Access to this reasonable choice in California to have a home birth with a midwife would be limited with AB1308 in place. Please consider doing away with the physician supervision clause altogether in much the same way the chiropractors and acupuncturists are licensed and free to practice independently of orthopedic surgeons.
Sincerely,
Briana Villasenor
Santa Barbara, CA
Senator:
As the father-in-law of a State licensed midwife, I believe I can speak with some authority on the requirement of AB 1308 to make physician supervision mandatory for home births by midwife.
As my daughter (in-law) completed the rigorous training required by the State of California to qualify for her certification I asked the questions you are no doubt pondering as you consider your vote. Is the training sufficient? Please, if this is not something you can answer in the affirmative, take a close look at the program the State requires midwives to master. Not just complete, but master. There is a comprehensive test involved here, as well as sworn statements by supervising and qualified midwives of hundreds of hours of hands-on experience.
Is there reasonable back-up in the event of a problem beyond the scope of a midwife’s expertise? I do not know the law, but I have spoken to my daughter about my concern. She told me that as the pregnancy progresses she makes contact with the future mother’s doctor and with the hospital the mother would use in case of emergency. Further, she told me that she makes certain emergency transport is available if it is needed. Nothing—nothing—if left to chance. Be assured that no responsible midwife wants a surprise if she has to seek the assistance of a physician. My daughter does not do this to boost her own ego. She is totally caring, devoted to the safe delivery of the child and the health and well being of the mother. The instant a delivery goes outside her comfort zone; she will have the mother transported to a hospital waiting with all required information.
I have a close friend who years ago delivered two children some years apart. I talked with her at some length about those deliveries. The first child was delivered in the same manner as I was. She was in a surgery, she was a patient, and there were masked nurses and a doctor. The labor was a bit slow so she received an injection to speed things up. The doctor used a scalpel. She recalled it being cold, sterile, and not at all fun.
Her second child was delivered at her home in Fresno under the supervision of a midwife. I spoke with her the next day. She was up, feeling fine, very happy, and eager to tell me the details of the delivery, mainly that the experience took place pretty much at her own direction. She was able to assume a position that was most comfortable for her. She was able to choose the music—yes, music. She asked for and was given a cup of tea. Her husband, of course, was present and assisted her with the midwife’s gentle direction. In short, the second birth was pleasantly memorable, unlike the first, which she told me she tried to forget.
The State of California has in place a system which works—works for mothers, for children, for fathers. The State, in it wisdom, has given healthy, responsible adults the right to a birth experience of their choosing while insisting on well trained, licensed professionals to assist. For the State to insist on the direct supervision of a physician over the midwife is to increase cost, needlessly consume physician time, inconvenience all concerned, especially the mother and the father (partner). Given the safeguards presently in place, this legislation is not unlike erecting a speed bump—a BIG speed bump—on a smooth roadway where everyone is smiling an obeying the laws.
Respectfully,
Christopher Burnett
Mariposa, CA
Hello Senator,
My name is Brooke Kochel and I'm writing to in support of the midwives of California. I'm lucky enough to have had 2 midwives care for both my pregnancies. It was the most proficient, knowledgeable and compassionate healthcare I have ever received. And giving birth at my home near LA 3 months ago with licensed midwives was the safest I've ever felt.
I am also a Certified Professional Midwife and understood the level of competence of this group of women, at The Sanctuary Birth and Family Wellness. I was trained as a midwife in the state of Texas, where physician supervision is not required. It was the general consensus there that California was way behind the times to be limiting midwives ability to practice and women's ability to choose who cares for their bodies. I attended hundreds of births in Texas, witnessed normal complications and saw competent midwives firsthand. Their outcomes where outstanding, better than the physicians when low risk births were compared.
I had my first baby in Arkansas. I remember the day my midwife told me I had to go to an OB for 2 visits. I felt belittled and that my decisions about my own body were being undermined. I was mad that the government had interfered with this private, personal decision. I felt hurt, scared and anxious knowing that the social climate was unfavorable in this small town. I felt defensive because I knew the physicians were uneducated about midwifery much less supportive of it. I was questioned, scorned, put on hold for long periods of time while the doctor's office figured out "what to do with me". I had to plead with many doctors’ offices to take me, see me. My midwife told me there were no doctors that would voluntarily see me. My only choice was to be seen at a public health clinic that the state set up for low income citizens. I somehow felt that society had shunned me for making what I thought was an outstanding health choice for my unborn child. In the end, an OB saw me as a favor to a friend. Her practice had a regulation to not allow their OBs to see midwives clients when they got wind of it. I wanted to share this story so you understand the social and emotional ramifications of this law. Clients of The Sanctuary are lucky enough to have Dr Fischbein, but many are not.
If you support midwives needing supervision then it's like supporting a form of inequality.
Thank you for hearing my voice. I assure you it's the voice I've heard a hundred times firsthand from my midwife clients and the group of educated families I surround myself with here in LA.
Feel free to contact me.
Brooke Kochel
Topanga
Good morning Senator Lieu,
I am writing you this morning to express my overwhelming support for Midwives to practice in California. I am a 38 year old teacher who chose to use a midwife for my prenatal care and the births of all 3 of my children. I cannot say enough about the positive experience I had throughout my pregnancy, delivery and postpartum care. Both of my licensed midwives, Leslie Stewart and Beth Cannon, provided me with exceptional care. Their care went above and beyond the care of any obstetrician. I know this because I saw a licensed obstetrician concurrently during my second pregnancy with twins.
My midwife, Beth Cannon, would spend over an hour with me at each appt. She would help me with my nutrition, exercise, my stress level, and coaching me on how to incorporate my new babies into my already existing family. She answered all of our questions, took time examining me and the babies and prepared me and my husband for the birth of our twins. She was never rushed and always very thorough. As a result, my babies were born healthy and without complications. Dr. Stewart Fischbein, OB, was also at the birth of my twins and provided me with concurrent pre and postnatal care.
During this pregnancy I also saw, Dr. Rusalna Kadze, OB. Her care was very different from that of my midwife. At each appointment I saw her for less than 5 minutes. She never discussed nutrition, my stress level, or asked me any questions about how I was doing emotionally. On a few occasions, she didn't even measure the babies.
During both of my pregnancies I had a back-up physician, should anything arise and I needed to be transported to a hospital. My midwives always took the upmost care to make sure that I would be cared for and the babies would be safe in any situation. My husband and I felt extremely confident in our decision to have home births because we knew our midwives were working with the support of licensed obstetricians. We never needed to transport, but if we had, I am fully confident that my midwife would have, without hesitation.
I feel extremely fortunate that I was allowed a choice when choosing how and where to birth. I would not have had this experience without my very dedicated, knowledgeable, patient, loving, supportive and trained midwife. I am asking that you do your part to help keep midwifery legal in California so that many other women and families have the CHOICE on how and where they birth their children.
Thank you for listening.
All the best,
Jennifer Cole
Home birth Mother
Dear Senator Lieu,
I write in support of licensed midwifery and the choice of home birth. I had a simple pregnancy without complications and a straightforward delivery at my home attended by a midwife 5 1/2 years ago. I was glad that safe, legal home birthing is an option in California and hope it will remain so. I am concerned that enforcement of physician supervision in light of modern day realities is likely to be stifling to the reasonable choice of a home birth with a licensed midwife and lead to less, not more, access to a reasonable choice for the women of California. I would prefer to do away with the physician supervision clause altogether in much the same way that chiropractors and acupuncturists are licensed and free to practice independently of orthopedic surgeons.
Please amend AB1308 to exclude the requirement of physician supervision.
Thank you,
Vanessa Frank Garcia
Ventura, CA
Senator Lieu:
I am writing to express my concern regarding the above-referenced bill and how it affects a woman's right to choose her practitioner and model of care for childbirth.
I am an attorney and six years ago I gave birth in a birth center with the supervision of two highly competent midwives. While they had physician backup, I never met the physician and never needed to. I realize this is not always the case but my personal knowledge of the practice of these two midwives is that they are competent and when physician assistance and hospital transfer has been required, it has been accomplished.
My understanding is that physician backup is already required but not enforced and that the current bill will strengthen this provision effectively making it more difficult for women to choose midwifery over obstetrics when giving birth. Like chiropractors and acupuncturists, midwives are skilled medical professionals and requiring backup of a physician is a slap in the face to the professionalism of the practitioners. The licensing of midwives should be sufficient to ensure qualified practitioners, as in the case of chiropractors and acupuncturists, two professions that I have also elected to use.
I have professional experience that has enlightened me to the fact that the general medical community and more particularly the obstetric community is hostile toward midwives so it is difficult to find any physician willing or able to backup midwives without fear of reprisal from hospitals and insurance carriers.
I strongly urge you not to take away the choice of medical care that is the right of all mothers.
Best Regards,
Sandy Lipkin
Sandra Lee Lipkin, A Law Corporation
Ventura, CA
Dear Senator Lieu –
I am writing to you to express my concerns over a provision in Bill AB1308 that could severely affect the ability of licensed midwives to practice in the state of CA. AB1308, if passed and enforced, would make it a violation of law for a midwife to practice without physician supervision. This requirement for physician supervision would effectively limit the birthing choices for many women in the state.
Having a licensed midwife as one of the options available for women and families to choose is important as both a personal and public policy decision. I am not an advocate for, nor an opponent against, any specific type of birth option, but I do strongly believe that a woman should be allowed to make those choices that are right for her family, her baby, and herself. This includes not only hospital births with a doctor or midwife, but also births in birthing centers and home births with the support and care of a licensed midwife.
I delivered my first child in a hospital setting under the care of a physician who respected the decisions I had made for my labor and my son’s birth: no interventions, no epidural, the freedom to choose a birth position, bonding time immediately after birth, and rooming-in with my son. I was fortunate to have a physician and hospital who respected those choices.
When I discovered I was pregnant again, my husband and I were thrilled. When we discovered that I was pregnant with twins, we were doubly thrilled – but also terrified. Most doctors and hospitals across the state (and country) have very specific protocols in place for twin deliveries, including requiring an epidural and delivering in an operating room. Additionally, few doctors either know how to deliver a breech baby or are allowed to do so by their insurance or hospital: my otherwise wonderful physician from my first child’s birth was one of those doctors. If both babies were not head-first (<50 a="" be="" c-section.="" i="" labor="" of="" pregnancies="" present="" prior="" required="" this="" to="" twin="" undergo="" way="" would="">
I began to evaluate my options, because being forced to have a potentially biologically unnecessary C-section was terrifying for me. A birthing center or home-birth with a midwife was out: being pregnant with twins automatically deemed my pregnancy “high-risk”, despite all signs pointing to a normal and healthy pregnancy … with an extra baby. I was very fortunate to find a physician who will attend home births. He and a licensed midwife (or, in my case, a licensed midwife and her assistant) come to provide support – medical and emotional – at a woman’s home, where she is able to deliver in the way that she desires, surrounded by whatever and whomever gives her comfort. And that was exactly my experience: my twins were successfully delivered at home, happy and healthy, and I could not be happier with the decision I made to choose that option for myself and my family.
I know that my case was very outside of the norm inasmuch as I required and was able to have a physician present at my homebirth. Under normal homebirth circumstances, a licensed midwife and her assistant would be the ones to whom a woman would turn. I am not aware of any other physician in the state who does what my doctor did, so if AB1308 passes, it will effectively force women who do not want a hospital birth to either go without the support and expertise of a licensed midwife or it will force midwives to risk losing their licenses and livelihoods in order to attend a homebirth. Neither of these options is acceptable.
Women and families should, within sound medical guidelines, be able to exercise any and all options for the birth experience they choose to pursue: hospital, birth center, or homebirth; intervention-heavy or natural. This is a choice that should not be denied any family, and the requirement for physician supervision of a midwife in this bill effectively does just that.
I urge you to do away with the physician supervision clause altogether in order to continue to provide choice surrounding birthing options for women and families in the state of California.
Sincerely,
Elizabeth A. Nack
Good morning Senator Lieu,
I have recently become aware of the new provision AB1308 that is making its way through the California Senate. It is my understanding that this new provision could severely affect the ability of licensed midwives to practice in the state and if passed would make it a violation of law for a midwife to practice without physician supervision. Senator I cannot tell you how much of a step backwards this would be to women's health care. Midwives have been in practice for hundreds of years because of their never wavering support of those who they humbly serve. My mother and aunts were born by that fine tradition of midwifery and so was my daughter Eva Victoria Fleming. I chose to have my daughter at home with a midwife after having my son at UCLA Santa Monica with a physician. This is considered one of the best hospitals with some of the very best physicians and if I could do it over I would have had a midwife for both pregnancies and births. The amount of care, understanding and willingness to help were incredible. I was able to express concerns as if talking to an older wiser grandmother/aunt, where as calling to speak with my son's physician I often found myself speaking with the nurse after leaving a few messages.
My home birth cost our insurance significantly less than my birth at UCLA. The care given by Karni and Dr. Fischbein were unparalleled to the UCLA doctors. My contractions started at 10am and everyone was at my home by 1. I was guided through one of the toughest days of my life by two angels. My husband had already been through one birth but he was amazed by the detail and care given by these two professionals. My daughter Eva was born at 5:45 that day and I was never rushed or pushed to give her over so someone could take down weights or measurements. As both Karni and Dr. Fischbein had been a part of my birth from start to finish they could see how strong this little girl was. In contrast, my son's doctor literally ran in as I was getting ready to push. I was told to "blow air" so we could wait a little longer for her to arrive. At home my daughter was weighed and measured a few hours after the birth without a timetable and then she was handed to my husband as I was tenderly and respectfully cared for. I was bathed, fed, and generally "put back together". Dr. Fischbein and Karni did not leave my house and my side until 12 o'clock AM. Not because I was an emergency or that I may have been some possible liability but because it is a mark of whom they are and what they do. Dr. Michel Odent, OB/GYN - "We are completely lost and we have forgotten to raise the most simple questions. What are the basic needs of women in labor? The fact that midwives have disappeared is a symptom of the lack of understanding of the basic needs of women in labor."
Please let's work to keep these wonderful people an option for my daughter's children and for the future generations to come. Thank you.
Sincerely,
Victoria Pinero Fleming
AB 1308: http://leginfo.legislature.ca.gov/faces/billTextClient.xhtml;jsessionid=5c82f256d9253d2e4326c4312ddf?bill_id=201320140AB1308
Last Thursday, Adeola Adeseun, the attorney for CFAM (California Families for Access to Midwives) and I met with the aide to state Senator Ted Lieu in Redondo Beach. It is his committee that is currently reviewing the bill. The Senator was in Sacramento but we had a very productive meeting with his aide, Veronica, for over an hour. We need to send a lot of emails over the next 24 hours to senator.lieu@senate.ca.gov
They need to briefly state their support for licensed midwifery, the choice of home birth and then give a little anecdotal story about their experience. Positive tone is preferred but those who had issues with transport, hospital staff and physician reception can also speak up. They should reference AB 1308 and their concern that enforcement of physician supervision in light of modern day realities is likely to be stifling to the reasonable choice of a home birth with a licensed midwife and lead to less, not more, access to a reasonable choice for the women of California. We would prefer they do away with the physician supervision clause altogether in much the same way the chiropractors and acupuncturists are licensed and free to practice independently of orthopedic surgeons. My good friend and associate, Howard Mandel, MD, felt that another analogy might be more appropriate. Family practice physicians often have far less training in pregnancy and birth than a midwife and yet, once licensed and credentialed, are able to practice their trade without supervision. Like midwives, they rely on appropriate consultation. Consultation, not supervision, makes sense. Striking the supervision requirement altogether in the bill would also benefit obstetricians by removing the vicarious liability that some fear when supportive of a local midwife.
Can you please take a moment to email the Senator today? senator.lieu@senate.ca.gov
Also, can you bombard your contacts, friends and supportive family, especially if they live in the 28th district but any will do, and ask them to send an email to their state senator?
It is really important to get this out today.
Below are a few logical and passionate letters written by some wonderful people. I can’t thank them and you enough for the support shown for the reasonable choice of licensed midwifery as an option for the women of California.
Dear Senator Lieu,
I am writing in support for licensed midwifery, and the right for a choice of home birth. I have learned of Assembly Bill 1308 and that if passed and enforced, it would make it a violation of law for a midwife to practice without physician supervision. That provision is completely impractical and unnecessary, as a licensed midwife is fully capable of providing the support needed for the natural delivery of a baby without having a physician present.
I am the mother of two young boys ages 6 and 2. The birth of my first son in June 2007 was a delivery by C-section at Santa Barbara Cottage Hospital after a 30-hour labor due to what the hospital staff determined was "failure to progress." There were no medical issues with me or my baby other than I had been in labor "too long" and I was convinced to have a C-section to give birth to my baby. Fortunately, everything went well and I had a healthy baby boy weighing 6 lbs., 10 oz. A few years later when I found out I was pregnant again, my only birth options where I live in Santa Barbara was to have a repeat C-section, which I did not want to endure again, knowing that my body was fully capable of a normal vaginal birth. No doctors, hospitals, or midwives in Santa Barbara were able to provide me support for a VBAC (Vaginal Birth After Cesarean). To my great fortune, I learned of Dr. Stuart Fischbein who has a practice in Camarillo that would support a VBAC home birth with a midwife present. I had a successful home birth of my second son in April 2011 weighing 7 lbs., 14 oz. after only a 4 1/2 hour labor. Dr. Fischbein and the midwife, Karni Seymour-Brown, were present along with my husband, my parents, and my older son. It was beautiful, it was happy, and it was safe. It wasn't just safe because Dr. Fischbein was there, although he is a well-skilled and knowledgeable medical doctor, but I trusted and knew my body could do it, and I was also supported by the knowledge and nurture of the midwife, Karni. Before I had children, home birth sounded like a radical idea to me, but after becoming educated about it, and about my ability to have the right to choose the birth experience that I wanted and was good for me and my baby, I have realized that home birth is the most natural and beautiful way to bring a child into this world. There is of course a time and a need for medical intervention and transport to a
hospital in certain situations, but that is rare, as are the situations that would arise to cause the need for a transport. Midwives know just as well when medical intervention and transport to a hospital is necessary, therefore requiring a physician to be present is unnecessary. I have experienced first-hand the wonderful care, support, and wisdom that a midwife provides to a mother before, during, and after birth, and I fully support the practice of independent midwifery. I encourage you, and everyone to do the same.
I am concerned about AB1308 enforcing physician supervision of a home birth with a licensed midwife, as the practicality of that does not make sense. A midwife is able to provide full support for a home birth without the need for a physician to be present. Access to this reasonable choice in California to have a home birth with a midwife would be limited with AB1308 in place. Please consider doing away with the physician supervision clause altogether in much the same way the chiropractors and acupuncturists are licensed and free to practice independently of orthopedic surgeons.
Sincerely,
Briana Villasenor
Santa Barbara, CA
Senator:
As the father-in-law of a State licensed midwife, I believe I can speak with some authority on the requirement of AB 1308 to make physician supervision mandatory for home births by midwife.
As my daughter (in-law) completed the rigorous training required by the State of California to qualify for her certification I asked the questions you are no doubt pondering as you consider your vote. Is the training sufficient? Please, if this is not something you can answer in the affirmative, take a close look at the program the State requires midwives to master. Not just complete, but master. There is a comprehensive test involved here, as well as sworn statements by supervising and qualified midwives of hundreds of hours of hands-on experience.
Is there reasonable back-up in the event of a problem beyond the scope of a midwife’s expertise? I do not know the law, but I have spoken to my daughter about my concern. She told me that as the pregnancy progresses she makes contact with the future mother’s doctor and with the hospital the mother would use in case of emergency. Further, she told me that she makes certain emergency transport is available if it is needed. Nothing—nothing—if left to chance. Be assured that no responsible midwife wants a surprise if she has to seek the assistance of a physician. My daughter does not do this to boost her own ego. She is totally caring, devoted to the safe delivery of the child and the health and well being of the mother. The instant a delivery goes outside her comfort zone; she will have the mother transported to a hospital waiting with all required information.
I have a close friend who years ago delivered two children some years apart. I talked with her at some length about those deliveries. The first child was delivered in the same manner as I was. She was in a surgery, she was a patient, and there were masked nurses and a doctor. The labor was a bit slow so she received an injection to speed things up. The doctor used a scalpel. She recalled it being cold, sterile, and not at all fun.
Her second child was delivered at her home in Fresno under the supervision of a midwife. I spoke with her the next day. She was up, feeling fine, very happy, and eager to tell me the details of the delivery, mainly that the experience took place pretty much at her own direction. She was able to assume a position that was most comfortable for her. She was able to choose the music—yes, music. She asked for and was given a cup of tea. Her husband, of course, was present and assisted her with the midwife’s gentle direction. In short, the second birth was pleasantly memorable, unlike the first, which she told me she tried to forget.
The State of California has in place a system which works—works for mothers, for children, for fathers. The State, in it wisdom, has given healthy, responsible adults the right to a birth experience of their choosing while insisting on well trained, licensed professionals to assist. For the State to insist on the direct supervision of a physician over the midwife is to increase cost, needlessly consume physician time, inconvenience all concerned, especially the mother and the father (partner). Given the safeguards presently in place, this legislation is not unlike erecting a speed bump—a BIG speed bump—on a smooth roadway where everyone is smiling an obeying the laws.
Respectfully,
Christopher Burnett
Mariposa, CA
Hello Senator,
My name is Brooke Kochel and I'm writing to in support of the midwives of California. I'm lucky enough to have had 2 midwives care for both my pregnancies. It was the most proficient, knowledgeable and compassionate healthcare I have ever received. And giving birth at my home near LA 3 months ago with licensed midwives was the safest I've ever felt.
I am also a Certified Professional Midwife and understood the level of competence of this group of women, at The Sanctuary Birth and Family Wellness. I was trained as a midwife in the state of Texas, where physician supervision is not required. It was the general consensus there that California was way behind the times to be limiting midwives ability to practice and women's ability to choose who cares for their bodies. I attended hundreds of births in Texas, witnessed normal complications and saw competent midwives firsthand. Their outcomes where outstanding, better than the physicians when low risk births were compared.
I had my first baby in Arkansas. I remember the day my midwife told me I had to go to an OB for 2 visits. I felt belittled and that my decisions about my own body were being undermined. I was mad that the government had interfered with this private, personal decision. I felt hurt, scared and anxious knowing that the social climate was unfavorable in this small town. I felt defensive because I knew the physicians were uneducated about midwifery much less supportive of it. I was questioned, scorned, put on hold for long periods of time while the doctor's office figured out "what to do with me". I had to plead with many doctors’ offices to take me, see me. My midwife told me there were no doctors that would voluntarily see me. My only choice was to be seen at a public health clinic that the state set up for low income citizens. I somehow felt that society had shunned me for making what I thought was an outstanding health choice for my unborn child. In the end, an OB saw me as a favor to a friend. Her practice had a regulation to not allow their OBs to see midwives clients when they got wind of it. I wanted to share this story so you understand the social and emotional ramifications of this law. Clients of The Sanctuary are lucky enough to have Dr Fischbein, but many are not.
If you support midwives needing supervision then it's like supporting a form of inequality.
Thank you for hearing my voice. I assure you it's the voice I've heard a hundred times firsthand from my midwife clients and the group of educated families I surround myself with here in LA.
Feel free to contact me.
Brooke Kochel
Topanga
Good morning Senator Lieu,
I am writing you this morning to express my overwhelming support for Midwives to practice in California. I am a 38 year old teacher who chose to use a midwife for my prenatal care and the births of all 3 of my children. I cannot say enough about the positive experience I had throughout my pregnancy, delivery and postpartum care. Both of my licensed midwives, Leslie Stewart and Beth Cannon, provided me with exceptional care. Their care went above and beyond the care of any obstetrician. I know this because I saw a licensed obstetrician concurrently during my second pregnancy with twins.
My midwife, Beth Cannon, would spend over an hour with me at each appt. She would help me with my nutrition, exercise, my stress level, and coaching me on how to incorporate my new babies into my already existing family. She answered all of our questions, took time examining me and the babies and prepared me and my husband for the birth of our twins. She was never rushed and always very thorough. As a result, my babies were born healthy and without complications. Dr. Stewart Fischbein, OB, was also at the birth of my twins and provided me with concurrent pre and postnatal care.
During this pregnancy I also saw, Dr. Rusalna Kadze, OB. Her care was very different from that of my midwife. At each appointment I saw her for less than 5 minutes. She never discussed nutrition, my stress level, or asked me any questions about how I was doing emotionally. On a few occasions, she didn't even measure the babies.
During both of my pregnancies I had a back-up physician, should anything arise and I needed to be transported to a hospital. My midwives always took the upmost care to make sure that I would be cared for and the babies would be safe in any situation. My husband and I felt extremely confident in our decision to have home births because we knew our midwives were working with the support of licensed obstetricians. We never needed to transport, but if we had, I am fully confident that my midwife would have, without hesitation.
I feel extremely fortunate that I was allowed a choice when choosing how and where to birth. I would not have had this experience without my very dedicated, knowledgeable, patient, loving, supportive and trained midwife. I am asking that you do your part to help keep midwifery legal in California so that many other women and families have the CHOICE on how and where they birth their children.
Thank you for listening.
All the best,
Jennifer Cole
Home birth Mother
Dear Senator Lieu,
I write in support of licensed midwifery and the choice of home birth. I had a simple pregnancy without complications and a straightforward delivery at my home attended by a midwife 5 1/2 years ago. I was glad that safe, legal home birthing is an option in California and hope it will remain so. I am concerned that enforcement of physician supervision in light of modern day realities is likely to be stifling to the reasonable choice of a home birth with a licensed midwife and lead to less, not more, access to a reasonable choice for the women of California. I would prefer to do away with the physician supervision clause altogether in much the same way that chiropractors and acupuncturists are licensed and free to practice independently of orthopedic surgeons.
Please amend AB1308 to exclude the requirement of physician supervision.
Thank you,
Vanessa Frank Garcia
Ventura, CA
Senator Lieu:
I am writing to express my concern regarding the above-referenced bill and how it affects a woman's right to choose her practitioner and model of care for childbirth.
I am an attorney and six years ago I gave birth in a birth center with the supervision of two highly competent midwives. While they had physician backup, I never met the physician and never needed to. I realize this is not always the case but my personal knowledge of the practice of these two midwives is that they are competent and when physician assistance and hospital transfer has been required, it has been accomplished.
My understanding is that physician backup is already required but not enforced and that the current bill will strengthen this provision effectively making it more difficult for women to choose midwifery over obstetrics when giving birth. Like chiropractors and acupuncturists, midwives are skilled medical professionals and requiring backup of a physician is a slap in the face to the professionalism of the practitioners. The licensing of midwives should be sufficient to ensure qualified practitioners, as in the case of chiropractors and acupuncturists, two professions that I have also elected to use.
I have professional experience that has enlightened me to the fact that the general medical community and more particularly the obstetric community is hostile toward midwives so it is difficult to find any physician willing or able to backup midwives without fear of reprisal from hospitals and insurance carriers.
I strongly urge you not to take away the choice of medical care that is the right of all mothers.
Best Regards,
Sandy Lipkin
Sandra Lee Lipkin, A Law Corporation
Ventura, CA
Dear Senator Lieu –
I am writing to you to express my concerns over a provision in Bill AB1308 that could severely affect the ability of licensed midwives to practice in the state of CA. AB1308, if passed and enforced, would make it a violation of law for a midwife to practice without physician supervision. This requirement for physician supervision would effectively limit the birthing choices for many women in the state.
Having a licensed midwife as one of the options available for women and families to choose is important as both a personal and public policy decision. I am not an advocate for, nor an opponent against, any specific type of birth option, but I do strongly believe that a woman should be allowed to make those choices that are right for her family, her baby, and herself. This includes not only hospital births with a doctor or midwife, but also births in birthing centers and home births with the support and care of a licensed midwife.
I delivered my first child in a hospital setting under the care of a physician who respected the decisions I had made for my labor and my son’s birth: no interventions, no epidural, the freedom to choose a birth position, bonding time immediately after birth, and rooming-in with my son. I was fortunate to have a physician and hospital who respected those choices.
When I discovered I was pregnant again, my husband and I were thrilled. When we discovered that I was pregnant with twins, we were doubly thrilled – but also terrified. Most doctors and hospitals across the state (and country) have very specific protocols in place for twin deliveries, including requiring an epidural and delivering in an operating room. Additionally, few doctors either know how to deliver a breech baby or are allowed to do so by their insurance or hospital: my otherwise wonderful physician from my first child’s birth was one of those doctors. If both babies were not head-first (<50 a="" be="" c-section.="" i="" labor="" of="" pregnancies="" present="" prior="" required="" this="" to="" twin="" undergo="" way="" would="">
I began to evaluate my options, because being forced to have a potentially biologically unnecessary C-section was terrifying for me. A birthing center or home-birth with a midwife was out: being pregnant with twins automatically deemed my pregnancy “high-risk”, despite all signs pointing to a normal and healthy pregnancy … with an extra baby. I was very fortunate to find a physician who will attend home births. He and a licensed midwife (or, in my case, a licensed midwife and her assistant) come to provide support – medical and emotional – at a woman’s home, where she is able to deliver in the way that she desires, surrounded by whatever and whomever gives her comfort. And that was exactly my experience: my twins were successfully delivered at home, happy and healthy, and I could not be happier with the decision I made to choose that option for myself and my family.
I know that my case was very outside of the norm inasmuch as I required and was able to have a physician present at my homebirth. Under normal homebirth circumstances, a licensed midwife and her assistant would be the ones to whom a woman would turn. I am not aware of any other physician in the state who does what my doctor did, so if AB1308 passes, it will effectively force women who do not want a hospital birth to either go without the support and expertise of a licensed midwife or it will force midwives to risk losing their licenses and livelihoods in order to attend a homebirth. Neither of these options is acceptable.
Women and families should, within sound medical guidelines, be able to exercise any and all options for the birth experience they choose to pursue: hospital, birth center, or homebirth; intervention-heavy or natural. This is a choice that should not be denied any family, and the requirement for physician supervision of a midwife in this bill effectively does just that.
I urge you to do away with the physician supervision clause altogether in order to continue to provide choice surrounding birthing options for women and families in the state of California.
Sincerely,
Elizabeth A. Nack
Good morning Senator Lieu,
I have recently become aware of the new provision AB1308 that is making its way through the California Senate. It is my understanding that this new provision could severely affect the ability of licensed midwives to practice in the state and if passed would make it a violation of law for a midwife to practice without physician supervision. Senator I cannot tell you how much of a step backwards this would be to women's health care. Midwives have been in practice for hundreds of years because of their never wavering support of those who they humbly serve. My mother and aunts were born by that fine tradition of midwifery and so was my daughter Eva Victoria Fleming. I chose to have my daughter at home with a midwife after having my son at UCLA Santa Monica with a physician. This is considered one of the best hospitals with some of the very best physicians and if I could do it over I would have had a midwife for both pregnancies and births. The amount of care, understanding and willingness to help were incredible. I was able to express concerns as if talking to an older wiser grandmother/aunt, where as calling to speak with my son's physician I often found myself speaking with the nurse after leaving a few messages.
My home birth cost our insurance significantly less than my birth at UCLA. The care given by Karni and Dr. Fischbein were unparalleled to the UCLA doctors. My contractions started at 10am and everyone was at my home by 1. I was guided through one of the toughest days of my life by two angels. My husband had already been through one birth but he was amazed by the detail and care given by these two professionals. My daughter Eva was born at 5:45 that day and I was never rushed or pushed to give her over so someone could take down weights or measurements. As both Karni and Dr. Fischbein had been a part of my birth from start to finish they could see how strong this little girl was. In contrast, my son's doctor literally ran in as I was getting ready to push. I was told to "blow air" so we could wait a little longer for her to arrive. At home my daughter was weighed and measured a few hours after the birth without a timetable and then she was handed to my husband as I was tenderly and respectfully cared for. I was bathed, fed, and generally "put back together". Dr. Fischbein and Karni did not leave my house and my side until 12 o'clock AM. Not because I was an emergency or that I may have been some possible liability but because it is a mark of whom they are and what they do. Dr. Michel Odent, OB/GYN - "We are completely lost and we have forgotten to raise the most simple questions. What are the basic needs of women in labor? The fact that midwives have disappeared is a symptom of the lack of understanding of the basic needs of women in labor."
Please let's work to keep these wonderful people an option for my daughter's children and for the future generations to come. Thank you.
Sincerely,
Victoria Pinero Fleming
Wednesday, June 12, 2013
The Tale of Two Transports: Trials, Tribulations & Happy Endings
Home birthing has its admirers and its detractors. We all know this. There is all too often a lack of respect by overzealous advocates of either side towards the other. My unique experience living in both worlds has shown me that for several reasons, most of them emotional but some of them understandable, those that oppose home birthing want to bully the other side into submission. Through oppression of supportive physicians and self-serving, ethically questionable policies they make it very difficult for the home birth practitioner and client. And once again they are taking their “safety” argument to the legislature to try to mandate physician supervision of licensed midwives even when we all know that most obstetricians are not interested in supervising or are restricted by their malpractice insurance policies from doing so. Thus, many midwives will become illegal in California if this is allowed to become law.
Too often there is a blurring of the lines between elective transport and emergency transport. To the on-call obstetrician the knee jerk idea of a homebirth transport is the train wreck. But to most of us in the homebirth world we understand the elective transport is nearly always for the same reasons that patients who plan a hospital birth come in for, only just a bit later in labor. Pain relief, exhaustion and inadequate progress are by far the most common reasons. What makes these women wanting rest, hydration and an epidural more “toxic” and any different from the 90% of women who get these things in the day to day practice of the average obstetrician anyway is simply their preference of home and midwife.
Some will say that these patients are unknown to them and therefore high risk. But that argument is specious for most obstetricians practice in large groups these days or they become laborists and so often have no acquaintance or historical relationship to the laboring woman. They will then argue that they can’t be sure these transports had adequate, if any, prenatal care despite records in hand. In reality, most of these women have had better prenatal care from their midwife than any obstetrician can possibly give and my experience tells me they are almost always better educated. But old habits, even misguided ones, are hard to break by those who find no reason to break them.
Enter a truly uplifting story of two very different obstetricians and their wonderful deeds of this past week. A testimony to the old adage that truly great men who do extraordinary things will often be despised. Courage is doing the right thing in the face of strong opposition. These two wonderful souls stand out in their compassion, humbleness and willingness to individualize care to patient desires using reasonable choices, true informed consent and sound medical practice.
R is a 24 year old, 5’ 9” primipara at 39 weeks who was in active labor for 16 hours. Despite many alternative attempts to rotate her baby he remained occiput posterior. She eventually reached her limit of exhaustion and pain tolerance at 7 cms. My usual back up physician at Cedars-Sinai was away so I put out a few calls to colleagues and was rewarded by two offering to accept her in transport. This may seem a simple thing but I am lucky in that I have choices for back-up when so many of my midwife colleagues are struggling in that arena as discussed above. They drove the 5 minutes over to Cedars while I drove separately. It had been awhile since I have had to transport so I was not quite prepared for the administrative and regulatory onslaught that followed. When I arrived, security would not let me in because R had not yet been admitted. It took a call to the charge nurse to bypass the woman guard with no eye contact to let me in. Upon arriving upstairs R was moaning loudly with every contraction while the nurse was attending to a laundry list of computer data entries, most of which were irrelevant to the medical necessity of an epidural. Admitting wanted the husband to sign all kinds of forms without reading them while R signed a consent form to be treated document between contractions that legally can’t mean anything when a person signs under such duress and pain. Dad refused to sign anything until his wife got her pain relief. A lesser man would have just signed but he knew his rights and pointed out a poster that clearly complied with the EMTALA statues that said “We cannot refuse treatment to anyone!” His point being, treat her first and then we can review documents. And despite much behind the back eye rolling and sighing they actually did. She got her IV and epidural, which still took over an hour, before she had her name band or lab results.
Once comfortable, the cascade of interventions began and baby gave all of us a few gray hairs but Dr. C was amazingly patient and trusting of his knowledge of labor and fetal heart patterns. R rested for about 90 minutes and then was feeling a lot of pressure. Dr. C checked her and found the head at plus 2 station but still OP and almost completely dilated. He then used his obstetric skills learned long ago. Putting his hand inside he reduced station, manually rotated the head to transverse and had her start to push. The cervix was reduced and she delivered over an intact perineum after 4 contractions! Baby M weighed in at 6 pounds 15 ounces. That cute little pipsqueak would have easily delivered if not for the persistence of his occiput posterior positioning. Sadly, in most other modern day obstetrician’s hands they may not have been greeted by a wonderfully accepting man and that little pipsqueak would most likely been born by cesarean section. We were all so grateful that there was an experience obstetrician who was trained in a different era in the skills that separate them from today’s obstetric surgeons.
J is a 34 year old, 5’ 6” Ventura County primipara at 41 weeks who went into labor the very next day. Her labor was strong and with the support of 2 marvelous doulas, Tracy & Tasha, she was doing great. After about 10 hours of 4 minute strong contractions J asked to be examined. Her sounds were consistent with early transition however her exam was only 2 cm./-1 and 40% effaced and, again, occiput posterior. Over the next 8-10 hours she remained at 4 cm with her cervix getting much more swollen. Despite her heroic effort to this point it was clear to all it was time to transport for an epidural and what follows. Our original backup plan was to go to a LA hospital with supportive backup but they did not want to drive that far and because she worked at the local hospital she knew her previous OB. Dad called and he told them to go to the ER and just tell them to use his name. He said there was no reason to call ahead.
So we packed up and all met at the ER. While sitting in the waiting area in a wheelchair the litany of questions began. Now, 2 days in a row for me makes a pattern. It is clear that administration rules the roost as paperwork comes before humanity. One particular question and response from the worker behind the bullet proof glass really stuck with me. It was 5:30 in the morning and J answered that she had ruptured her membranes 6 hours earlier. The woman’s response was so typical of the indoctrination to the one size fits all medical model, “Why did you wait so long to come in?” To those who only see medical birth this is their norm. The question, the timing of it and the tone from the person asking it were so inappropriate and lacking in social skills but we said nothing. In about ten minutes we were on our way up to labor and delivery.
Exhausted and in pain with contractions every 3-5 minutes J was, once again, subjected to consent forms and to an even longer laundry list of electronically generated, mostly irrelevant questions unrelated to her immediate need. (Tattoos? LMP? Family History?) And a plethora of questions that were all answered on her prenatal records which I brought with us but which were out at the desk being copied and stamped and posted in the chart but not in the room available to the nurse. I also learned that since I did not have the actual lab report on her negative Group B Strep that hospital protocol states she has “unknown” Group B strep status and therefore antibiotics were ordered (but could be refused). The hand written results and my presence were obviously not good enough for their risk managers but unnecessary antibiotics were fine. Ouch!
Next, the charge nurse came in to tell us that her admitting doctor did not want to take her and was passing her off to the on-call doctor. This was odd to me since they had a relationship and it was 6 AM already but it turned out to be the most fortuitous event of the day. For the doctor that was on call was likely the only one within 30 miles that would have allowed J the wonderful outcome that ensued. But I must digress for one last moment. We arrived at the ER at 5:30AM. She came for exhaustion and pain relief. She got her epidural about 7:20AM. That’s an hour and 50 minutes of pretty obvious suffering due solely to the administrative bureaucracy. She was begging for her epidural and all the wonderful nurses could say was that things were moving as fast as they can. It must be so hard for a caring nurse to watch that day in and day out. Tracy says she sees it 5 times a month. No one raises a stink for fear of retribution. There us little humanity in big institutions and it can only get worse.
J got comfortable and moved slowly going from 4 to 5 to 6 cm over the next 10 hours. Baby A was doing great, however, but even so it would be the rarest of obstetricians at a hospital with a nearly 40% c/section rate to allow her to crawl along like this in violation of Friedman’s Curve. Coming on 36 hours of labor and 24 hours of ruptured membranes modern obstetricians would become impatient, label this “dystocia or FTP” and proceed to a surgical birth. But Dr. W so honored this families wishes and followed evidence based medicine combined with knowledge of fetal heart patterns to allow her to labor. Sometime after 1AM the next day she was complete and although almost numb was able to push her baby out in 5 contractions at 8 pounds 7 ounces. Her 40 hour labor ended as it should with good collaboration and obstetric practice and joy all around. Will Dr. W get peer reviewed for going off the reservation? Possibly, but he did the right thing.
When I think of where my profession was and now is I get very sad. When I see attempts at bullying women and physicians by special interest groups like ACOG and the CMA I get angry. When my experience and wisdom have taught me that informed choice of options and not restriction of options under the façade of safety or the bias of economics are our right I get motivated. These stories of strong women, educated choice and wonderful support and collaboration deserve our attention. Californians need well trained midwives and these midwives and the women they serve deserve the support of our doctors and lawmakers and not their derision. My greatest admiration, almost to tears, goes out for these two women, their families and to the 2 very special doctors who still remember the humanity of our calling.
Dr. F
Saturday, June 1, 2013
The Impatience to Early Ruptured Membranes
Once again data comes out that may contradict longstanding thinking. Certainly, there is reasonable questioning of the practice of rapid induction for ROM prior to active labor. Strongly suggest reading this article brought to my attention by my midwife colleague, Heather S.
http://midwifethinking.com/2010/09/10/pre-labour-rupture-of-membranes-impatience-and-risk/
Some will scoff that this comes from a website called Midwife Thinking. I have gotten used to the knee jerk ridicule given to alternative sources by my colleagues in academia. But it is interesting that even the "prestigious" journals have lately had an abundance of published studies that are counter to the longstanding habits of the medical model. I, personally, have found the Cochrane reviews to carry validity and represent solid thinking. Old habits die hard but when they are questionable by reasonable alternatives or just plain wrong, die they must. Dr. F
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