If a tree falls in the forrest...

Douglas H. Kirkpatrick, MD
The American College of Obstetricians and Gynecologists
PO Box 96920
Washington, DC 20090-2188

Dear Sir:
I am a practicing OB/ GYN in southern California and Fellow of ACOG and
recently was informed by midwife colleagues of your recommendation and
encouragement for the AMA to lobby Congress for a law banning out of
hospital birth. Funny that I had to hear of this decision from outside
sources and was never approached by my college to see how I or my local
colleagues felt about it. I have grave concerns regarding my organization
taking such a stand. I think we are all agreed that ACOG has a statement
regarding patients' rights to informed consent and informed refusal. Yet, it
seems with every decision our organization moves further away from that
basic tenet. ACOG's little "guideline" paper on VBAC in 2004 where the word
readily was changed to immediately has had the chilling effect of doing away
with VBAC options at hundreds if not more hospitals. Not due to patient
safety, or the ideal of giving true informed consent but really, let's be
honest, to fear of litigation. I have seen how patients have become
counseled by obstetricians at facilities where VBAC has been banned. They
are clearly given a skewed view of the risks of VBAC but rarely told of the
risks of multiple surgeries. If you think this is untrue you are, sadly, out
of touch with real clinical medicine.

As to out of hospital birthing, please give me the courtesy of an
explanation as to the data you used and the process by which an organization
which is supposed to represent me came to this conclusion. Any statement
saying that it is as simple as patient safety and that one-size fits all
hospital birth under the "obstetric model" of practice should be applied to
all patients is, putting it nicely, not really in line with what best serves
all our patients. In many instances, hospitals are not safe, certainly not
nurturing and have a far worse track record for disasters than home birth.
Even when emergency help is nearby this is true. The focus of all of us in
medicine should be on reigning in trial lawyers and tort reform and lobbying
Congress for that. The best interest of the college members and the patients
we serve would be for my organization to spend its time and energy on
something that has true benefit. Removing choices from well-informed
patients and caring doctors and midwives is wholly un-American.

So please send me detailed information on how ACOG decided outlawing home
birth was a wise thing to do. You must have scientific data to take such a
drastic stand. Please make it available to me so that I may share it with
like-minded colleagues. I would also like to know the process by which this
came to pass. Who first raised this issue and why? What committee reviewed
all the data and did its due diligence in interviewing those of us with
long-standing experience in backing midwives who perform out of hospital
births. There must be a fine, non-confidential paper trail you can share
with your members. Specific names of committee member who voted for this
would be enlightening and I am requesting this information. I would like to
know the background and expertise regarding out of hospital birth for each
member who had a hand in the decision to go to the AMA.

We live in an odd era where once something is said or recommended by a
legitimate organization such as ACOG it has deep ramifications never
intended such as becoming fodder for trial lawyers trying to squeeze the
lifeblood and dignity out of your members. Or forcing women to travel
hundreds of miles in labor to find a supportive facility. Or even worse, to
have them arrive in a VBAC banned hospital and refuse surgery. Can this be
the best we can do for our patients? Remember, your VBAC statement was meant
to be only a recommendation but quickly became the rule by which hospital
administrators, risk managers and anesthesia departments of smaller hospital
banned this option for thousands of women. An option, that in proper hands,
was the safe and accepted standard of care for 30 years. In fact, you still
have an ACOG VBAC brochure that recommends this option! For those of us
working at smaller hospitals where VBAC was banned due to lack of emergency
help (anesthesia, OR crews, etc.) there is a big question that has perplexed
us that no administrator seems to be willing or able to answer. That
question is: "If a hospital cannot handle an emergency c/section for VBACs,
and most emergency are for fetal bradycardia, hemorrhage (ie. abruption) or
shoulder dystocia not for ruptured uteri, then how can they do obstetrics at
all?" For they seem to still be able to have a maternity ward without in
house anesthesia. Will someday ACOG, in their great wisdom but seeming
disconnect from reality, make a "recommendation" that little hospitals stop
providing obstetric services? Will this better serve women and their
communities throughout America?

I am frightened and angered by what you have done in my name. Now I ask you
to defend your position in encouraging the AMA to lobby Congress for another
restriction on the freedom of choice that belongs to women and their
families. Those choices include midwifery and the right to have the most
beautiful and life changing event occur wherever best fits their desire.
Midwives are well trained and required to have obstetrical backup. They have
very special relationships with their patients and want the very best
outcomes for them. They do not need me or you to police them. We have a
habit in our country over the past 40 years of thinking we can legislate out
stupidity. All that has done is erode the individual freedoms that belong,
by birthright, to each of us. I would hope you trust your Fellows to know
their specialty, their colleagues, and what is best for the patient as an
individual. These decisions do not belong to politicians or faceless
committees. You should have more faith in your members to give balanced
informed consent. Again, my recommendation to you is to put all your
considerable energy into changing our legal malpractice system. Those of us
actually practicing medicine and caring for patients know this to be the
greatest threat to the mission and responsibility we have chosen to
undertake.

I look forward to your response and possibly the beginning of a meaningful
dialogue.

Sincerely,
Stuart J. Fischbein, MD FACOG
Medical Advisor, Birth Action Coalition

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The Doula - Wealth or Waste?

A randomized controlled trial of continuous labor support for middle-class couples: effect on cesarean delivery rates. SK McGrath and JH Kennell Birth, June 1, 2008; 35(2): 92-7.

"Conclusion: For middle-class women laboring with the support of their male partner, the continuous presence of a doula during labor significantly decreased the likelihood of cesarean delivery and reduced the need for epidural analgesia. Women and their male partners were unequivocal in their positive opinions about laboring with the support of a doula. "

So, there are more choices in childbirth. Those of us in the birth field know that this is true, but fact is fact. Whether a Doula, ChildbirthAssistant- whatever you call her (Mom?) - She's a valuable asset to the birth experience.

Trend Gives New Reason to Learn Ways to Avoid Unnecessary Cesarean

Insurance Companies Rejecting Women with History of Cesarean;
Some Companies Require Surgical Sterilization for Coverage;

- As reported in New York Times, ICAN has begun tracking an alarming new trend of insurance companies refusing to provide health insurance for women with a history of cesarean surgery. In some cases, women are being rejected for coverage outright and in other case they are being charged significantly higher rates to obtain the same coverage as women without a history of cesarean. With over a million women each year undergoing this surgery, this practice has the potential to render large numbers of women uninsurable.

This trend surfaces as the rate of cesarean surgery, including unnecessary cesareans, continues to rise. In 1970, the cesarean rate was 5%. In 2007, it was 30.1%. Experts often cite the incentives within the health care system for driving up the rate of cesarean unnecessarily, including physicians' medical malpractice fears, better reimbursement for surgery, and lifestyle conveniences for care providers and staffing efficiencies in having more "9-5" deliveries.

"Women are caught in the middle of a dysfunctional system. Doctors are telling them they need surgery, even when they don't, and insurance companies, who are tired of paying the bill for so many frivolous surgeries, are punishing women for the poor medical care of doctors," said Pam Udy, President of the International Cesarean Awareness Network (ICAN).

The trend is highlighted in the cases of women like Peggy Robertson of Colorado. When she applied for health insurance coverage with Golden Rule, her husband and her children were accepted, but her application was denied. After multiple inquiries directed to the insurance company, she was finally told that she was denied because she had delivered one of her children by cesarean. "It was shocking. I assumed that as a woman in good health I would be readily
accepted," said Robertson. "When I finally found someone who would explain why my application was denied, they had the audacity to ask me if I had been sterilized, stating that this was the only way I could get insurance coverage with them."

As the incidence of cesarean increases, the evidence of the downstream medical complications for women and babies, and the associated medical costs, becomes increasingly apparent. Risks of cesarean in later pregnancies include increased incidence of infertility, miscarriage, fetal deformities, overgrowth of scar tissue leading to bowel problems, and potentially deadly placental abnormalities in subsequent pregnancies.

And though most women with a prior cesarean are being encouraged and often coerced into having repeat cesareans by their doctors and hospitals that have banned vaginal birth after cesarean (VBAC), a pair of recent studies done by the National Institute of Child Health
and Human Development Maternal-Fetal Medicine Units Network demonstrates that women who deliver vaginally after a cesarean fare significantly better than women who deliver by repeat cesarean.
(Obstetrics & Gynecology 2008;111:285- 291, Labor Outcomes With Increasing Number of Prior Vaginal Births After Cesarean Delivery, Mercer et al, and Obstetrics & Gynecology 2006;107:1226- 1232 Maternal Morbidity Associated With Multiple Repeat Cesarean Deliveries, Silver et al.)

"Most women are looking to avoid cesareans. But physicians often make surgery difficult to avoid by insisting on non-evidence based practices," said Udy. Practices that fail to improve the outcomes for mothers and babies and increase the risk of cesarean section include inducing for going post-dates, inducing for suspected large baby, requiring fasting during labor, requiring women to be confined to bed for continuous fetal monitoring, and failing to offer continuous
support to a mother in labor. "These care practices serve the system well, but not mothers and babies" Udy added.

About Cesareans: ICAN recognizes that when a cesarean is medically necessary, it can be a lifesaving technique for both mother and baby, and worth the risks involved.

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