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.
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)