The following is from the May 11 Obstetric & Gynocology,
written by written by Annette Fineberg, MD (OB/GYN) and a response
that follows from David Hayes, MD (OB/GYN)
Obstetrics & Gynecology:
May 2011 - Volume 117 - Issue 5 - pp 1188-1190
An Obstetrician's Lament
Fineberg, Annette E. MD
article-box-text2',%20'img2')> Collapse Box
>From the Department of Women's Health, Sutter West Medical
See related articles on pages 1179 and 1183.
Corresponding author: Annette E. Fineberg, MD, Department of
Sutter West Medical Group, 2020 Sutter Place # 203, Davis, CA
Financial Disclosure The author did not report any potential
A few weeks ago, during a prenatal visit, a woman pregnant with
me she would love to have a home birth, but did not have the
required upfront to do so. She was afraid of potential
interventions in the
hospital. After a discussion of her fears as well as potential
that can abruptly occur in a twin birth, she admitted she would
hospital birth if she could maintain some control over the
is not a woman who cares more about the birth experience than the
she was tempted, and in some ways I can understand her concerns.
wife had her twin induction halted at 4 cm because the new
call did not do breech extractions for second twins. Her only
I recently received a phone call from a woman 2 hours away who had
home birth for her second baby after having an easy first birth.
fetus, which was anticipated to be a little smaller, was found to
breech, the midwife sent the woman to the local obstetricians.
only deliver the fetus by cesarean delivery. The midwife offered
the woman a
home breech birth, but admitted she had only delivered one breech
(stillbirth) in her career. The woman appropriately questioned the
this, and was referred to us. She met the criteria for our vaginal
protocol, and had an easy vaginal breech birth in our hospital.
Unfortunately, this is becoming a rarity. A colleague of mine in
state watched the residents she was supervising emotionally bully
woman and her mother into a cesarean delivery. The young woman had
progressing active labor with a normal-sized frank breech fetus.
residents been open to the idea, my colleague easily could have
how to deliver a vaginal breech.
The running joke in our community is that the only way to get a
birth after cesarean delivery (VBAC) is to have the birth at home.
Unfortunately, this is a reality rather than a joke. Our small
hospital, owing to regional liability insurance constraints,
allowing VBACs in 2002 after many years of successfully offering
has led many women to risk home birth rather than travel to a
center to attempt VBAC. I recently counseled a woman against
cesarean delivery who had a BMI of 52 and who arrived in active
over 35 weeks of gestation with two previous successful VBACs. I
following months defending that recommendation, despite her
operative risks and high likelihood of success.
Recent news and media excitement about the benefits and increased
home birth over hospital birth have made the former seem like a
attractive alternative. A growing notion among women in our
perhaps across the country, is that hospitals and obstetricians
are a more
risky option than lay-home midwives for birth. Although my initial
is disbelief, perhaps we should look at how we, the obstetricians,
contribute to this trend.
Each of these women deserves an honest discussion about the fetal
maternal risks of each birthing option. However, our lack of
obstetricians colored by our fear of liability is narrowing
and sometimes motivating them to ignore fetal and maternal safety
effort not to be coerced into unnecessary interventions. I sense a
tension, because many obstetricians do not have the willingness,
skills to provide maternal choices.
I believe we are at a crossroad in maternity care in this country,
and I am
saddened that obstetricians are considered the culprits. Our
skill set as obstetric providers, as well as the prevailing
culture among physicians and hospitals, have given support to home
can all agree that VBAC, twins, and breech should not be managed
yet we frequently demand complete control of the situation and
some appropriate choices in the hospital. I understand that it can
unnerving to be ultimately responsible for the outcome, as we are,
pushed into situations outside of our comfort zones. However, our
unwillingness to budge in these situations is causing us to lose
regarding what is really important to most obstetricians: safety
Certainly, we can be proud of the dramatic decrease in maternal
the last century. But, despite the highest per capita expenditure
care in the world, infant and maternal mortality rates in the
are higher than in all of western Europe. We have the
delivery rate in the world.1
Lament.25.aspx#P24> According to a recent study, nearly half of
primigravidas attempting vaginal delivery are induced, and half of
deliveries for dystocia are done before 6 cm of dilation,
Lament.25.aspx#P25> It is amazing how many women begging for
induction change their minds when told it doubles3
Lament.25.aspx#P26> their cesarean delivery risk.
We need to draw lines around patient safety, but must they be so
midwives know from experience that Friedman's curve is too strict.
study validates that knowledge.4
Lament.25.aspx#P27> I sincerely hope it is taken seriously.
management of ruptured membranes at term has been declared unsafe
and of no
Lament.25.aspx#P28> The study that settled the question did not
the number of vaginal examinations women received, and group B
strep was not
treated, both important variables.6,7
Lament.25.aspx#P29> Most women do go into labor in 24 to 72
Lament.25.aspx#P31> The Cochrane systematic review concludes
the differences in outcome are not substantial, women need to be
appropriate information to make a decision.9
Lament.25.aspx#P32> This very rarely occurs in the hospital
Term Breech Study10
Lament.25.aspx#P33> closed the door on vaginal breech delivery
even for the
lowest-risk women in most obstetricians' minds (including the
mentioned above). This, despite the opinion of the College that it
appropriate in carefully selected situations.11
Lament.25.aspx#P34> In any case, vaginal breech delivery is not
avoidable, and should not be relegated to the history books with
delivery for previa and high forceps.
Our mission has become more difficult in the last 20 years as
become older, heavier, and of lower parity.12
Lament.25.aspx#P35> Many women, admittedly, do have unrealistic
expectations. Although I am eternally grateful for the obstetric
learned in residency, I have been amazed in my 14 years of
practice to see
much of the dogma I also absorbed disproven with experience and
(both my own, my colleagues', and the midwives I have worked with
Collaborative practice with midwives is a good start, but in order
obstetricians to be more than providers of cesarean deliveries (a
and, in most cases, technically simple procedure) we need to have
conversations with our patients that are not one sided and allow
informed consent. Many of the obstetric disasters we have all seen
color our perspective (which David Grimes has called "numerators
Lament.25.aspx#P36> are at least in some part iatrogenic if
enough. That failed induction for convenience with early
of membranes and chorioamnionitis. The first cesarean delivery
done at age
15 after 2 hours of pushing with an epidural that then leads to
cesarean years later, and then accreta and life-threatening
both typical examples. We need to recognize and own those aspects
obstetric management that are driving our skyrocketing cesarean
rate but having no positive effect on maternal or infant morbidity
Admitting what is truly evidence based versus what is tradition
is a good start. It is essential that we offer real choices to our
We need to recover and disseminate the skills that make obstetrics
and a privilege. Seek out mentors skilled in forceps, vaginal
breech extractions before it is too late. Then learn to be
patient, so that
you very rarely need to use them.
Even better was this reply to the article posted.
For more of the thread, visit www.theunnecesarean.com/blog
An Obstetrician's Hope
> [Date] Friday, May
13, 2011 at 6:26AM By David Hayes, MD
I am encouraged by Dr. Fineberg's recognition and admission that
the current standard of practice of obstetrics in the United States
in fact lamentable. I am encouraged that she has felt the need to
a public declaration of her concern over the disconnect between the
information available in the obstetrical literature (not to mention
midwifery literature – which obstetricians rarely even concede
exists) and the routine practices in virtually every hospital in the
I appreciate that she understands and delineates at least portions
the various chains of events that lead to an increase in the number
unnecessary cesarean deliveries. I appreciate that she describes the
role that dogmatic adherence to the long discredited Friedman curve,
overly aggressive management of rupture of membranes at term, and
irrational discontinuance of performing and even training future
obstetricians to perform vaginal breech deliveries plays in driving
the numbers of these unnecessary cesarean deliveries.
I am positively thrilled that she recognizes and calls out the
to which obstetricians routinely ignore the doctrine of informed
consent, except to pay lip service to the satisfy the legal
for their own protection.
But then, just when I think she might scale those rarified heights
suggest that we actually consider those options that make prenatal
and delivery safer for mothers and their babies in virtually every
developed country on the planet, she retreats squarely inside the
"A growing notion among women in our region, and perhaps across the
country, is that hospitals and obstetricians are a more risky option
than lay-home midwives for birth. Although my initial reaction is
disbelief, perhaps we should look at how we, the obstetricians,
contribute to this trend."
Perhaps? Really? Yes, perhaps we should!
Consider first the state of obstetrics in our self-proclaimed best
medical system in the world:
"The United States' rate for maternal mortality is 1 in 2,100
– the highest of any industrialized nation. In fact, only three
Tier I developed countries – Albania, the Russian Federation and
Moldova – performed worse than the United States on this indicator.
A woman in the U.S. is more than 7 times as likely as a woman in
or Ireland to die from pregnancy-related causes and her risk of
maternal death is 15-fold that of a woman in Greece."(1)
"Similarly, the United States does not do as well as most other
developed countries with regard to under-5 mortality. The U.S.
mortality rate is 8 per 1,000 births. This is on par with rates in
Latvia. Forty countries performed better than the U.S. on this
indicator. At this rate, a child in the U.S. is more than twice as
likely as a child in Finland, Greece, Iceland, Japan, Luxembourg,
Norway, Slovenia, Singapore or Sweden to die before reaching age
The women who are increasingly asking for out of hospital care are
doing so because they are informed, intelligent, and empowered women
are concerned about their health and the health of their baby.
the international human rights organization Amnesty International
the extraordinary step just last fall of issuing a report in which
referred to the "maternity health care crisis in the USA" in
calling world wide attention to the state of obstetrical care in the
U.S.(3) The only people who seem not to see it are the obstetricians
who are at the root cause of it.
Any thinking woman who bothers to look should be disturbed by what
sees. There is something very wrong here. Part of the problem
certainly arises from the for-profit health care system that even
makes access to health care impossible for millions of Americans.
the problem is much deeper than even that. The statistics cut
across racial and socio-economic lines and there is no indication
it can all be accounted for by access.
Yes, women are increasingly avoiding the medical model of childbirth
and the hospital setting for deliveries. They are fully capable of
reading and of obtaining good, accurate information. They are well
that the decisions their obstetricians are making on their behalf
are not supported by the literature and do result in worse outcomes.
They do understand the problems endemic in the US obstetrical
And as a result they are well aware, if Dr. Fineberg is not, that
risk of morbidity and mortality is significantly lower when
their baby with a skilled birth attendant in their own home than it
in any hospital in the United States.(4, 5, 6, 7) The fact is, 90%
births in the US could be accomplished at home, at lower cost, with
better outcomes, and with more satisfied moms and babies.
We debate the causes, bemoan the rise in cesarean delivery rates,
through it all we are missing a hugely important fact – a fact that
is not lost on a generation of intelligent, educated women. Outcomes
are better in a home birth attended by a skilled birth attendant
hospital birth attended by ANY attendant, midwife or
Until we admit that basic premise, we will make no progress.
Physicians are admonished to "first do no harm." In practice
that implies we should do nothing unless we have evidence it may
improve an outcome. Yet for the vast majority of things we do in
obstetrics, we do not have that evidence. In fact we often have
evidence to the contrary. We routinely order continuous monitoring
has shown no benefit at all to fetal morbidity and mortality but
dramatically increases the rate of unnecessary interventions thereby
dramatically increasing maternal morbidity and mortality. We,
thinking, perform or order invasive cervical exams that have very
prognostic value, have never been shown to improve any index of
maternal or fetal morbidity, yet have been shown to increase the
of fetal and maternal infection. Indeed, we routinely order or
dozens of procedures in every labor and delivery unit in the country
that have no proven benefit and in many cases fly in the face of
evidence in our own literature that they worsen maternal and fetal
I cannot agree more with Dr. Fineberg's observation that "each
of these women deserves an honest discussion about the fetal and
maternal risks of each option." But she should not stop with that
discussion. After that discussion is held, each of these women
deserves a birth attendant that respects and supports her regardless
the option she chooses. That is where the U.S. obstetrical culture
utterly failed its clientele. We, as obstetricians, have entirely
sight of the fact that our first obligation in ethical medical
decision-making is to respect patient autonomy. We routinely order
perform procedures against our patients' wishes, often exploiting
the vulnerability of our patients, enforcing our authority through
intimidation, fear mongering, and occasionally even obtaining court
orders that are virtually always invalid and overturned when it is
I found Dr. Fineberg's statement "This is not a woman who cares
more about the birth experience than her baby" very telling and
typical of the condescending attitude that has gotten us where we
today. They do care about their delivery experience, not entirely in
the sense that they are looking to make a spiritual or emotional
connection to one of the defining experiences of womanhood (although
that is certainly much more important than the dismissive derision
implied by the statement). They care about it also because they want
control over, or at the very least input into, the decision making
process involving their life, their health, and their baby. They
about it because they do not trust their obstetrician to make the
decision that's in their patient's best interest, rather than
their own. They care about it because they know the hospital
being blindly followed with little reason are not necessarily
applicable to their particular situation.
In my experience, no mother cares more about the "birth
experience" than they do their baby. It is precisely because they
care about their baby and their life that they are making the
completely rational decision to avoid a hospital birth at all costs.
Many of them are avoiding hospital births because they have had
hospital births, because they have been bullied into unnecessary
inductions, which failed, because they've had "emergency"
c-sections and suffered through difficulties in bonding, breast
feeding, post partum depression, because they have been treated with
condescension and had their own wishes about their own bodies
with coercion and fear tactics that were completely inappropriate.
There are many reasons we should encourage home deliveries attended
qualified birth attendants: it's more comfortable and convenient;
it's less expensive; we should respect patient autonomy. But there
is one reason why we cannot ethically avoid it — it is safer. The
outcomes, for mothers and babies, are simply better.
I am an obstetrician. I too lamented when, at the behest of risk
averse pediatricians, my local hospital stopped allowing trials of
in women with prior cesarean deliveries. But I did more than just
lament. I studied the data carefully. I looked closely at the real
and who might be appropriate candidates, and I began doing VBACs at
home. I have done this for several years and had many successful
and no complications. I know the obstetricians reading this are
in their boots, but there is no rational reason to. In one classic
study, 3 of the 17,898 women undergoing a trial of labor after
died, while 7 of the 15,801 women undergoing a repeat C/S died(9) It
likely that the trial of labor morbidity and mortality would have
even lower had the study participants refrained from inducing or
augmenting labor. But even those numbers are roughly half of the 2
10,000 risk that a woman will be killed in an automobile accident
the period of time she is pregnant.(10)
Furthermore, other studies suggest that while around 5/10000 serious
uterine ruptures may occur during a trial of labor, around 2/10000
uterine ruptures occur prior to the onset on labor. In other words,
pregnant woman who has had a prior C/S is at increased risk of
rupture even if she elects a repeat C/S. And as we well know, there
many other consequences of cesarean delivery that may be life
threatening. Why then are we not approaching performing a C/S with
a fraction of the trepidation that we approach normal vaginal
A woman choosing to have a home VBAC rather than be forced to have a
repeat C/S in her local hospital is making a rational decision given
data we have available, a decision which we should be prepared to
support if we cannot offer her a better alternative. I have
several hundred VBACs in the past several years without incident. In
same time frame, my local hospital has lost at least 3 mothers
or shortly following cesarean deliveries.
U.S. obstetricians have already come to the crossroads and have
the wrong path. It can be fixed, but they need to start having
and open discussions among themselves about the real maternal and
risks, about the rampant rate of unnecessary induction which leads
unneeded cesarean delivery, about the continued use of continuous
monitoring, restricted movement, withholding of nutrition, unneeded
augmentation of labor, artificial rupture of membranes, epidural
anesthesia and even multiple cervical exams, none of which have any
proven benefit and all of which contribute to increased morbidity
Less than two per cent of what is routinely done on labor and
units in the US has been shown to have any positive benefit. Over
has been shown to have demonstrably adverse impact. ACOG continues
spout, with no evidence, the tired old line that delivery is safer
hospitals or birth centers joined at the hip to hospitals.(11) At
same time, every EU member country is actively seeking to increase
numbers of home deliveries, increase the numbers of midwife managed
pregnancies, and work to ensure there is a seamless interface
home delivery practices and the hospital system. In the US,
all medical boards and obstetrical societies, and most obstetricians
and hospitals, are actively hostile to the idea of home delivery and
the practitioners and pregnant women who choose it.
Our maternal and infant mortality rates continue to climb. We
to do the same things and expect different outcomes. Is it because
the "risk averse culture of doctors and hospitals"? Partly,
yes. But it is also pressure from their peers that prevents
obstetricians from actually practicing the evidence based medicine
have and from even considering the vast realms of international EBM
midwifery EBM. Obstetricians who attempt to practice based on the
literature rather than the "local standard of practice" run a
very real risk of losing their hospital privileges and possibly even
their medical licenses. If they practice according to the "local
standard of care" they almost invariably must violate all four of
the accepted principals of medical ethics: patient autonomy,
beneficence, non-maleficence, and justice.
We have the information to fix this problem. When we address the
culture of peer pressure, the local "standards of care" that
bear no resemblance to what the literature supports, when we
that many (including some among the top leadership and most
names in obstetrics) are more interested in procuring their
promoting their ideology, protecting their power, and preserving
market share than they are in really addressing the problems,
maternity care, and truly supporting their patients, then and only
can we start to make headway towards creating a model of maternity
that is both world class and genuinely supportive of its clientele.
David Hayes, MD has been offering home births since 2005 and has
attended exclusively home births for the last three years. He is
closing his practice this month to devote his energies to the
international humanitarian aid organization, Doctors Without Borders
This post is featured as one of a series of posts
> by OB-GYNs in response to the May 2011 article, An
Lament, by Dr. Annette Fineberg.
1. WHO. Trends in Maternal Mortality: 1990 to 2008. (Geneva: 2010).
2. UNICEF. The State of the World's Children 2011.
(New York: 2010) Table 1, pp.88-91. www.unicef.org/sowc2011/
3. Deadly Delivery; The Maternal Health Care Crisis In The USA,
Amnesty International Publications, Nov 2010 Index: AMR 51/007/2010
4. Patricia A. Janssen PhD, Lee Saxell MA, Lesley A. Page PhD,
C. Klein MD, Robert M. Liston MD, Shoo K. Lee MBBS PhD. Outcomes of
planned home birth with registered midwife versus planned hospital
birth with midwife or physician., CMAJ 2009. DOI:10.1503/cmaj.081869
5. de Jonge A, van der Goes B, Ravelli A, Amelink-Verburg M, Mol B,
Nijhuis J, Bennebroek Gravenhorst J, Buitendijk S. Perinatal
and morbidity in a nationwide cohort of 529 688 low-risk planned
and hospital births. BJOG 2009; DOI: 10.1111/j.1471-0528.2009.
6. Hatem M, Sandall J, Devane D, Soltani H, Gates S. Midwife-led
other models of care for childbearing women. Cochrane Database of
Systematic Reviews 2008, Issue 4. Art. No.: CD004667. DOI:
7. Kenneth C Johnson, Betty-Anne Daviss: Outcomes of planned home
births with certified professional midwives: large prospective
BMJ 330 : 1416 doi: 10.1136/bmj.330.7505.1416 (Published 16 June
8. Vincenzo Berghella, MD; Jason K. Baxter, MD, MSCP; Suneet P.
Chauhan, MD. Evidence-based labor and delivery management,
Journal of Obstetrics & Gynecology, NOV 2008, pp 445 – 454.
9. Landon, MB, et.al
Maternal and perinatal outcomes associated with
a trial of labor after prior cesarean delivery. NEMJ Volume
351:2581-2589 December 16, 2004 Number 25
10. National Highway Traffic Safety Administration, Fatality
Reporting System. www-fars.nhtsa.dot.gov/Main.index.aspx
11. AMERICAN MEDICAL ASSOCIATION HOUSE OF DELEGATES, Resolution:
annual meeting 2008.
-- Ingrid Andersson, MSN, CNM
Community Midwives LLC
3530 Lucia Crest
Madison, WI 53705
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