Tuesday, September 1, 2009

The Patient's Best Interests? Not Anymore

Check out Rixa's recent interview with Dr. Stuart Fischbein, a VBAC- and breech-supportive doctor in California who is in trouble with his hospital for supporting Vaginal Birth After Cesarean (VBAC) and vaginal breech births.

It's an interesting summary of the sad state of birth in hospitals these days.....ruled not by the patient's best interests, but by the hospital's best interests, along with doctor convenience, insurance rules, ease of staffing, and fear of litigation.

As a feminist, I am particularly upset at how a woman's right to decision-making about her own health, her own body, and her baby is currently being taken away from her. And yet there is a stunning lack of recognition or caring about this fact in our society.

Dr. Fischbein at least is talking about this issue. He recognizes the tension between hospital concerns and patients' rights as one of the major ethical dilemmas of our time.

He has some interesting and frustrating things to say about hospital and insurance decision-making. He also discusses home birth, the midwifery model of care, tort reform, malpractice and litigation, among many other things.

I don't agree with everything he says but overall it's a very interesting interview with many important points. And it's so refreshing to hear of a doctor who is actually fighting for the patient's interests (not just his own or the hospitals' interests), and who is trying to stand up for the patient's right to make her own medical decisions.

Here are a few excerpts, edited for clarity, length, and sometimes rearranged a bit from the original.

On the Use of Certified Nurse-Midwives (CNMs) in the hospital:
About 5-7 years into my practice...I was approached by a couple of midwives and a good friend about opening a collaborative midwifery practice with hospital deliveries. We looked for a hospital on the west side of Los Angeles that would allow midwives to do deliveries and we couldn’t find one. None of them were allowing midwives to do deliveries...So we opened a practice out in Ventura County and called it the Woman’s Place for Health.

Even there we were met with a lot of suspicion and resistance, despite the fact that the track record for midwives is excellent, despite the fact that they take care of low-risk patients and have very strict protocols that they follow, despite the fact that they have excellent outcomes and a very low c-section rate, even compared to other obstetrical models that take care of low-risk patients. It’s always been a battle.

...We follow the midwifery model of care, which exhibits a lot more patience than the obstetrical model of care. It treats pregnancy as a normal function of the body. In contrast, the obstetric model treats pregnancy as a disease that needs to be treated, as opposed to something that just needs to be nurtured.

About VBACs and Patient Rights:
If you go on [ACOG's] website—the back part, where members can go—they have paragraph after paragraph about patient’s rights, patient’s autonomy, the right to informed consent and refusal, the right not to be harassed or threatened if they make a decision that is different from what the hospital would want, the right to sanctity of their bodies free from fear of reprisals.

...The problem with VBAC bans is that it puts the needs of the hospital and the other health care workers ahead of the rights of the patient.

I understand why they do that, but I just think they are misguided. They ban VBACs under the guise of patient safety. But patient safety is a euphemism for “we don’t have a good evidence-based reason to do it, other than we don’t want to get sued, it’s more expedient, and we make more money from c-sections...so we’re going to ban it because it’s easier for us, and we’re going to say it’s for patient safety because of the risk of rupturing the uterus.”

But you know what? That risk should be something that the patient decides. Patients have a right to be given informed consent, free from misinformation or coercion, free from skewing information that benefits the practitioner or the hospital. And they have the right to consent or refuse to accept the treatment that’s offered. That right is frequently being denied.
On the Lack of Truly Informed Consent:
There’s a study that came out in the American Journal of Obstetrics & Gynecology last December that found the morbidity of a repeat cesarean section is higher than a successful VBAC.

A successful VBAC occurs about 73% of the time. If a hospital bans VBAC, they’re basically telling 73% of women that they have to undergo a surgical procedure that carries more morbidity than if they had a vaginal birth. That’s outrageous to me. It leaves me speechless, and for me that’s no small thing!

The same model applies to breech deliveries. Some women are being told to have a procedure that carries more morbidity than a vaginal delivery. But they are never being told the numbers or given the option.
About Why Many Hospitals Ban VBACs:

The reason that a lot of hospitals ban VBACs anyway—and this isn’t very well known to most people—is because their insurance carrier will tell them that if they allow VBACs, their premium will be much higher. Rather than pay higher premiums, they just ban VBACs and do so under the guise of patient safety.

The hospital lawyers, the insurance company lawyers, the insurance company executives, and the hospital administrators are making decisions for patients and then lying about why they’re doing it.

Again, they use the idea of the 24-hour anesthesia as a reason not to allow VBACs. Most emergency c-sections, the ones that occur suddenly, have nothing to do with a uterine rupture. They are for placental abruption, prolapsed cord, or prolonged fetal heart rate decelerations. And somehow the hospital can manage to take care of those situations. If hospitals can take care of those things, why can they not take care of VBACs? If they can’t do VBACs, should they be doing obstetrics at all?

On Vaginal Breech Birth:
Decisions for breech delivery should be based on the experience of the practitioner and the desire of the patient.

I understand that breech delivery is not for everybody. Certainly there are a lot of people who will never do breech deliveries because they’re not trained any more. Unless we bring vaginal breech delivery back into residency training programs, we will soon find that that skill is gone forever.

Having that skill gone is more than just a c-section problem. Every now and then, a woman is going to show up in labor, come in completely dilated with a butt in the vagina, and no one is going to know what to do...They’re going to be rushing to push the baby’s body back up and do a c-section. Quite frankly, the morbidity of that is so much higher. So it is going to be a major loss, because women are going to show up complete and breech in labor & delivery, and no one is going to know what to do.

In Canada, the SOGC is no longer recommending routine c-section for breech babies. Part of it’s for cost savings, probably. But part of it is because the evidence does not support sectioning every breech patient. The evidence is there to give patients the choice. This gets back to my primary issue, which is informed consent. This should not be a decision where the doctor tells the patient what to do.

If the doctor does not know how to do breeches, they should say to the patient “I can’t do your breech delivery but I really think you are a good candidate for it. Why don’t you see doctor X for a second opinion.” That’s the honorable thing to do. But of course that would cost doctors money, and a lot of doctors don’t want to give up the money.
On the Lack of Attention to Birth Politics:
I don’t know why maternity issues like these are not more popular, because every family in America is affected by what’s going on. It’s off the radar screen.We have an abortion rights movement in this country that, the minute anything happens regarding abortion, they’re up in arms about it. Yet women are losing the choice of how they give birth, and no one seems to care.
There's much more to the interview; I hope you will go check out the whole thing. You can read it at Rixa's Stand and Deliver blog:



Nat said...

So happy to see your blog! I love your website. I have a question ... I read very briefly in a book about lifting your stomach when you have contractions to help the baby move through when you are in labour. Do you know anything about this? Can't find any info online, but maybe I am not looking in the right place. I'm due in two weeks and anxious about how it will go!


Well-Rounded Mama said...

Yes, I do know about this technique, but I can't recall offhand the name of the book. It might be cited in the FAQ on my website on malpositions, though...check and see.

It was a book about fixing a posterior labor (where the baby is facing your front instead of your back). If I remember the technique correctly, you are supposed to flex your knees (like a plie in ballet) and tilt the bottom of your pelvis forward (i.e. tuck your butt under) as you lift your belly up.

This is supposed to help the baby navigate your pelvis more easily and hopefully rotate to anterior (which is usually easier to birth).

I think some of the best things to do in labor include staying home for as long as possible (really drops the cs rate), not letting them induce you or augment you unless truly medically indicated, stay as mobile as possible (don't be flat on your back; stay upright or lie on your side or get on all fours), move as your body dictates in labor (listen to your intuition on how to move it, even if it seems weird), don't let them break your waters if at all possible (or not until late in labor), and be flexible and go with the flow of the birth...whatever needs doing at the time. You can do this.

Best wishes to you!! Keep us posted on how things go!! Blessings on you and your baby.