Thank you for giving me the opportunity to speak today via written testimony in support of House Bill 9. My name is Stuart James Fischbein, MD. I currently am and have been a practicing obstetrician in the Los Angeles area since 1986. I attended the University of Minnesota Medical School from 1978-1982. I was an obstetrical resident at Cedars-Sinai Medical Center from 1982-1986. I was Board Certified in obstetrics and gynecology in 1989. I am a Fellow of the American College of Obstetrics and Gynecology (ACOG). I have collaborated with direct-entry midwives my entire career. I co-authored the book, Fearless Pregnancy: Wisdom and Reassurance from a Doctor, a Midwife and a Mom in 2004.
I am not an academician. I actively assist women with pregnancy and childbirth, often in collaboration with a team consisting of a midwife and midwifery students. I am credential as a proctor/supervisor of students with The National Midwifery Institute (NMI) and The Nizhoni Institute of Midwifery. From 1986 until 2010 I had a hospital based practice and collaborated with Certified Nurse Midwives while at the same time serving as a consultant and “back-up” physician to several local direct-entry midwives. In 2010 I chose to leave hospital-based practice and now assist families with home birthing including VBAC. My nearly 30 years of work experience has given me a very unique perspective on both the obstetric and midwifery models of care of pregnant women with which to testify to today.
While home birthing with a midwife may not be for everybody, informed choice and respect for the autonomy of patient decision making is. Beneficence based medical ethics dictates that practitioners are obligated to support reasonable medical choices. There is enough data in the world literature to support the reasonableness of the choice of home birthing. The women of Maryland deserve this option. Especially in light of the high rates of inductions, interventions and surgical births for otherwise healthy pregnant women who labor in the hospital.
I have attended over 125 home deliveries, always in collaboration with a CPM. I offer women with VBAC pregnancies who meet respected selection criteria this option, often because no similar option exists in many local hospitals. We have a success rate of 93% using this collaborative model with home VBAC. I have found that VBAC is more likely to succeed in a home birth environment than in the hospital. The simple explanation for this is the understanding that normal mammalian birth progresses better when undisturbed and without anxiety and fear. VBAC is not a procedure requiring special skills therefore success should be the desired endpoint. The medical model looks at women attempting a trial of labor after cesarean section as a disaster in waiting. Midwives understand this is not conducive to success. The published Maryland statistics on successful hospital VBAC rates is pretty dismal.
The NIH VBAC consensus statement of 2010 supports VBAC with level A evidence as does the American College of Obstetrics and Gynecology. VBAC bans and restrictions attributed to an ACOG recommendation based on the word “immediate” have no basis in science. This past December I attended the interested parties meeting for California AB1308 in Sacramento. VBAC was a major topic of discussion. The regional representative from ACOG District 9 admitted that serious complications from VBAC are rare (about 1/2000) and unpredictable. I commented that if that is so then having physician consultation during the prenatal period was useless. The point was taken. I was assured by the Medical Board Representative that California direct-entry midwives will continue to assist with out-of-hospital VBAC. We need to do everything we can to lower the cesarean section rate and the subsequent short and long term morbidity to mother and baby. Licensing and supporting direct-entry midwifery is the logical next step.
It is important to note that midwifery is not a subset of obstetrics. Midwives are well trained and experienced in the care of normal pregnancy and delivery, including VBAC. They excel at preventative medicine. They have an excellent knowledge base and therefore can quickly recognize abnormal and consult or refer as needed. Obstetricians are trained to deal with problems that arise so that is how we see our patients. Residency training of future obstetricians is not designed to care for normal. Over the years I have practiced I have evolved from the true believer in the medical model of obstetrics as illness to an understanding that normal pregnancy is wellness and the female body is designed for it. My personal evolution and successful professional outcomes would not be possible were it not for my good fortune to have collaborated with midwives. The women of Maryland deserve honest dialogue and information from which to make a choice. For ultimately in a free society, the decision of where and with who to give birth belongs to them.