Monday, August 31, 2009

Sling website, take 1 and 2

Okay, I need your input again. I've made the vine image smaller and purely decorative (no links on the dots anymore). I've shifted the logo and menu farther to the left and taken out the "welcome" text. I'll probably use a different photo, but I haven't had time to do a new photo shoot yet. I took out the extra text under the FAQ link.

So here are two alternative views. View 1 has the photo on top and the bit of text underneath. View 2 has the text on top and the photo on the bottom. Any preferences for one or the other? Do you think I need this text? I wanted somewhere on the home page that briefly explains my main products, so this text serves that function.

Any other final comments or suggestions? Many thanks...

View 1: photo on topView 2: text on top
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Interview with Dr. Stuart J. Fischbein

A few days I spoke on the telephone with Dr. Stuart Fischbein, an obstetrician who is currently fighting his hospital's ban on VBAC and vaginal breech birth. Below is the transcript of our interview.

Some blog posts worth revisiting in the context of this interview:
Stand & Deliver: Tell me more about your residency and how you came to where you are now.

Fischbein: I went to medical school at the University of Minnesota and did my residency at Cedars Sinai Medical Center in Los Angeles. As part of my residency program--there were no midwives at Cedars--I spent four months at LA County’s USC Hospital. Those were the days when they were doing 23,000 deliveries a year, about 65 deliveries a day. So we saw everything. There were midwives upstairs who took care of a lot of the low-risk stuff, and occasionally I encountered them. I had a really good experience talking with them and learning from them. But it didn’t really influence me much during my residency program.

When I finished my residency and started my private practice, I was approached by a couple of local midwives who were running a birth center and they asked if I would be their backup physician. At that time, of course, I was looking for business anywhere I could get it. You’re starting to build a practice, you’re hustling, you’re covering ERs, you’re delivering at four different hospitals. It was a different era in those days. So I said “sure.” That was the beginning of my real exposure to midwifery.

About 5-7 years into my practice, in 1995 or 1996, 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. UCLA might have been a place, but it wasn’t on our radar screen. The only option we could find was in Ventura County. 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.

Stand & Deliver: I’m surprised that there is so much resistance to nurse-midwives from the obstetrical community.

Fischbein: I find out there that is a lot of ignorance about what a midwife means. A lot of people think of midwives as somebody who wears Birkenstocks and a long skirt, doesn’t shave her legs, and delivers babies in barns! They don’t have an understanding of the exquisite training that a certified nurse-midwife gets. They don’t differentiate between a CNM, a LM, a CPM—all of which are licensed by the state boards where they practice—and something called a lay midwife who, in California, can’t legally practice unless they have a religious exemption. But they’re all lumped in together and they’re constantly called lay midwives or just midwives by their detractors. There’s no distinction. It’s not malice so much as it is ignorance, I think.

Stand & Deliver: Are there more hospitals now in the LA area that allow CNMs to attend births?

Fischbein: No, I don’t think there are. CNMs’ ability to deliver in hospitals is still very restricted. I think UCLA has them. Kaiser, much to their credit, has always used the midwifery model, where the midwives take care of the low-risk laboring patients and the obstetricians come in when there’s a problem. That, to me, makes much more sense. It doesn’t make sense to have a board-certified OB/GYN tied up doing a normal vaginal birth.

Stand & Deliver: What are some of the things that your practice—two nurse-midwives and yourself—do that are different from your physician colleagues that account for your low cesarean rate? It’s so much lower compared to everyone else in your hospital and also compared to our national statistics.

Fischbein: 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. In our practice, we don’t automatically induce somebody because they’re a few days overdue. If someone ruptures their membranes and they’re not in labor, we let them stay home. If they answer a few questions correctly and the baby’s doing okay, we let them stay home. There’s no reason they need to be in the hospital starting Pitocin right away. Other practices will bring them in immediately and start Pitocin. This often leads to a cascade of interventions that end up in c/section. They have some sort of panic about the 24 hour mark; if they’re not delivered in 24 hours, the misconception is that the baby will die of sepsis. The midwifery model also teaches women to be calmer, more educated, more secure, less anxious patients. We have fewer problems with labor itself. Our epidural rate is not quite as high, but I support the use of epidurals when needed. So it’s not about the old-fashioned idea of completely natural childbirth; there are differences. We’ve always allowed VBACs in our practice. However, nowadays the midwives don’t do VBACs or breeches. I’ve always done them, except now I’m under threat of losing my privileges and suspension if I do another VBAC or vaginal breech delivery at the hospital.

Stand & Deliver: Does your hospital have a formal VBAC ban?

Fischbein: Yes.

Stand & Deliver: How long has that been in place?

Fischbein: A couple of years, I believe. 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—the hospital does, not necessarily the physician, but the hospital does—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.

Stand & Deliver: Since the right to refuse treatment is part of most hospitals’ patient’s bills of rights, how can the hospital justify sanctioning you for upholding a woman’s legal right to refuse treatment? What are their grounds for that?

Fischbein: It’s Goliath versus David. Essentially the hospital has unlimited funds. There aren’t a whole lot of doctors like me in this community or across the country. Doctors who support midwives are few and far between. They are sometimes or harassed, ridiculed, or isolated. They face the potential of a disciplinary hearing, requiring a report to the medical board, which every doctor fears. Not because they’re necessarily doing anything wrong. But the cost of defending yourself against such a thing is enormous. Literally all you can win is the right to go to another hospital, because the hospital is still not going to change its policies. It becomes a lesson in futility to fight for what’s right, unless you’ve been pushed to the limit and are much more concerned about maintaining your values and your ethics. The choice they give you is what I call a Sophie’s Choice: keep your practice and compromise your values, or compromise your practice to keep your values. Either way, you’re screwed. I think that you should be able to keep your practice and keep your values. But it’s a real battle, and I’m facing it right now.

Stand & Deliver: Did your hospital ban VBACs because they couldn’t meet the ACOG’s new recommendation of 24-hour in-house OB and anesthesia?

Fischbein: Yes.

Stand & Deliver: Some hospitals that can meet those requirements still ban VBACs.

Fischbein: They do that for two reasons. 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? I don’t think it would serve American women very much to have all hospitals that can’t have 24-hour anesthesia close down.

It’s always baffled me that they use the 24-hour rule as their reasoning--that it’s for patient safety. But if it’s not safe to do VBACs, how is it safe to do any laboring patient? Far more often, it’s something unrelated to the VBAC that causes an emergency.

Stand & Deliver: The ACOG’s evidence for their VBAC policy was not based on scientific evidence, but on consensus opinion. The AAFP found that there is no evidence to restrict VBAC only to tertiary care hospitals that have 24-hour OB and anesthesia coverage.

Fischbein: Ultimately it won’t matter to the hospital. It’s not about evidence-based medicine. It’s very clear to me in discussing this with the committees that they don’t care. They’re being told by the risk managers, the lawyers, and the insurance companies that they cannot do VBACs. And that’s the final word. The anesthesia departments are also often behind VBAC bans. They talk about patient safety, but really it is that reimbursement is so bad and they don’t want to have to sit around in the hospital all day long and they are fearful of being sued. Sadly, a legitimate concern in today’s litigation happy society. Even in the absence of any negligence, one frivolous lawsuit can destroy a career.

This is separate from the patient’s rights issue. These are two separate issues. I think that patient’s rights trumps the other issue, but other people don’t. That’s where the disagreement lies.

Stand & Deliver: So what do they say when you talk about patient’s rights to refuse surgery? Basically, they’re telling you that you have to force your patients to have surgery, or you have to lie to them and say that they can’t even consider it as an option.

Fischbein: They’ve even put in writing to me that, when I am counseling patients, to be sure that they comply with the hospital’s VBAC policy. I’m supposed to tell patients that they have to go elsewhere if they want a VBAC, that they can’t stay in their own community, that they have to drive 50 miles. Even if their families are benefactors of the hospital or their father is on the board of directions, they have to go elsewhere. I’m not supposed to tell them that they have the option of showing up in labor and refusing surgery. The hospital actually put in writing that I should avoid telling them that. They’re telling me to skew my counseling, and they have no shame in doing so.

Stand & Deliver: That is astounding to me.

Fischbein: Here’s the argument that they put forward: Dr. Fischbein, how do you feel about the fact that the anesthesiologist, the nurses, and the pediatricians feel that your patients’ decision is putting them at risks that they don’t want to take? My answer to them is: “listen, I understand that. But you really only have two options here. You can close the unit, or you’re asking that patient’s rights should be subservient to what healthcare workers want.” That’s an easy one for me. But their whole concern is that it’s putting other healthcare workers at risk by allowing patients this choice. If they still have an opinion like that, they’re not going to change it easily. Logic is out the window here. It’s not about logic. It’s not about evidence-based medicine. It’s not about outcome data. This seems to be how we’re supposed to practice medicine. Even though ACOG comes up with stupid stuff sometimes, if you go on their 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.

Stand & Deliver: So why does this not translate into obstetric and hospital practice more often?

Fischbein: Well, I think I’ve already gone over that. One reason is litigation mitigation. Other reasons are for economics and expediency. For physicians who are not really committed to doing VBACs or breeches, it’s a lot easier to do a section. You get paid about the same. With a section, you can do the surgery at 7:30 am and you’re in the office by 9 am. If you have a breech or a VBAC, you have to cancel your day or spend the night at the hospital. It’s a lot more work, and you don’t get paid any more for it. So you really have to be either dedicated or crazy or somewhere in between. You have to keep your ethical feet well-grounded.

It’s really hard when doctors are squeezed financially, by fear of liability, by this axe hanging over their head. Nobody who I went to medical school or residency with ever believed that they’d spend the rest of their lives with an axe hanging over their head. Every day that they go to work. It’s untenable. It’s a situation that wears doctors down, and they don’t have the fight in them any more.

For hospitals, it’s easy. Does a hospital make more money off a practice that has a 5% c-section rate or a 25% c-section rate? That’s an easy question. Although they will never admit that; it will always be patient safety. Clearly, there’s no incentive for them to offer a VBAC to anybody.

Stand & Deliver: What could possibly get us out of this crazy state of maternity care—the fear of litigation and the administrative bureaucracy that dictate much of obstetric practice nowadays?

Fischbein: There’s one big answer. This trend will be hard to reverse in any situation, but will be impossible without tort reform. If I had five minutes to spend with Obama, that is would I would recommend. President Obama spoke to the AMA in San Diego a few months ago, and he said exactly the opposite. He said that tort reform is not on the table.

The one thing that needs to be changed in this country is malpractice tort reform. It has to happen. If you want a single-payer system, if you want rationing, if you want patient’s autonomy restored, you have to get the trial lawyers and the money and the greed out of medicine. You have to stop defensive medicine. You have to let doctors make the decisions. You have to keep insurance companies from dictating policies because their actuaries have determined that it’s cheaper to do X or Y.

A few decades ago, Ford made a car called the Pinto. During tests, they found that if you rear-ended it, it blew up. But they marketed it anyway, because their actuarial data found that the number of lawsuits they would have did not justify pulling the car off the market. The number of dead people was not worth pulling the car off the market. They got busted for it, but none the less, that’s the way the decision was made.

Until you have tort reform, you’re never going to have any change in this kind of policy. You have to have malpractice reform. There has to be immunity for physicians, unless there was real malice. Then the civil courts can take care of that. Most doctors don’t intentionally hurt people. There are bad outcomes despite the best doctors’ efforts. When 70 to 80% of obstetricians in this country have been sued, that doesn’t mean that we’re all bad. It just means that we all pay a fortune in malpractice insurance, and that cost has to be transferred somewhere. If doctors can’t pass the costs on to the patients, like other businesses can, they basically say, “I’m not going to go out on a limb for somebody, because they’ll sue me at the drop of a hat anyway.” So the one thing that needs to be done, more than anything else—whether or not you agree with VBAC or breeches or midwifery—is tort reform. All obstetricians should unite with midwives and other doctors over the issue of tort reform. It is the one key issue. It all has to start with tort reform.

Stand & Deliver: Do you think that we’re so entrenched in our current maternity practices that we’d actually be able to break away from that?

Fischbein: If you eliminate tort reform, you might be able to make changes by improving competition. If you get rid of some of the restrictions on businesses, you might see more competition start up. You might see more birth centers open, or birth centers that actually have operating rooms, little maternity hospitals. Just like we’ve seen specialty surgery centers open up recently. For years hospitals tried to squelch these things because they know they can’t compete with them. Some day, maybe the major hospital model will go out of business. And would that be so terrible? We have specialty hospitals that do heart surgeries, gastric bypass, or plastic surgery. Why not specialty hospitals that just do maternity? Run by doctors and midwives.

Stand & Deliver: Not administrators and bureaucrats.

Fischbein: It’s very hard to get financing or insurance to open something like that nowadays. It’s very hard to get an insurance policy for this kind of thing, because all it takes is one angry patient to destroy a life’s work.

Stand & Deliver: What explains our country’s high litigation rate? Is it in part because patients have the perception that they can almost be guaranteed perfection—that if they do all the right things, they can have a perfect baby? I wonder if the rate of litigation is more patient-led or more trial lawyer-led, or is it led by the way obstetricians advertise their services. Where is it coming from?

Fischbein: I don’t think obstetricians, or anyone in medicine nowadays, promises perfection any more. Increasing the cesarean rate from 15% in the 1970s to 32% in 2009 has not decreased infant mortality or improved outcomes one bit. All it’s done is increase the section rate and the potential complications that come from that. So I don’t think that anyone’s preaching perfection. I think we do live in a society where if something goes wrong and people think they can get money for it, we don’t have a society where shame or public condemnation means anything anymore. We’re so big and diffuse. If you’re in a small town and you sue the only doctor in town for something that was not his fault, other people in town might give you a hard time, and you may think twice about doing it. But in big cities, there’s no reason not to. It costs something like $180 to file a claim. And we’re pumping out attorneys like Washington’s printing money, and they need work. They make the laws. That’s one reason that tort reform is not on the table with Obama. His leading supporter is the Trial Lawyers of America. They gave more money to Obama than any other lobbying group, I believe. You’re not going to see them cutting their own throats. The more that lawyers can push papers around, the more they make money. There’s no reason to resolve any issue if you’re a lawyer charging an hourly fee.

There should be a catastrophic fund for babies who are born severely brain damaged or handicapped, even if it’s Down’s. A lot of cases with bad outcomes never get sued with the midwifery model, because midwives have such good relationships with their patients. Clearly it’s known that lawsuits are much more common in large OB groups or Medicaid patients or patients who go to clinics, because there’s no face behind the care. The thinking is: the doctor has malpractice insurance; that’s what it’s for. You’re not hurting the doctor. Little do they know what it does to the doctor’s life, career, sleep, family life, and malpractice premiums.

Stand & Deliver: I’m sure it’s devastating.

Fischbein: One bad case for a physician, despite the best intentions all their life, can destroy them. There’s no other profession where that happens. I think that tort reform is the key. Without tort reform, it’s only going to get worse. Without it, all the arguments in the world are not going to get a hospital to change its VBAC policy or its breech policy or its persecution of midwives or the midwifery model. But if you get tort reform of some sort, where doctors are protected as long as they did not have malicious intentions, we can start to see some changes. And, like I said earlier, we need to improve competition. I would love to open a birth center, but trying to find funding, trying to get anything open in California, is a nightmare. Getting the permits, malpractice insurance, and approval from the right federal and state organizations is a monumental task that has defeated a lot of people I know who wanted to open birth centers.

Stand & Deliver: Let’s talk about breech birth now. Talk to me about how you were trained in breech and what a typical breech birth with you looks like.

Fischbein: I trained in breeches during residency in 1982-86, and vaginal breech birth was commonly done at Cedars and USC. I feel very comfortable doing them. I follow the literature on breeches. I know that there are certain risks to breech deliveries. I do what’s known as selective breech deliveries; they have to meet certain criteria. Patients who qualify under those criteria are given options, including c-section. Certainly we try all the tricks first. We offer chiropractic, acupuncture, certain positions and exercises. And then we offer everybody the option of external version, and around 50-70% of the time that’s successful. Then you still end up with a few patients who have breech babies.

The criteria are very simple. They have to have an adequate pelvis. In the old days, we used X-rays or CT scan pelvimetry. Nowadays I just use my clinical judgment with an exam. The baby has to be between 2500-4000 grams estimated fetal weight. The baby’s had has to be flexed. The baby has to be either complete or frank breech. The fetal heart rate tracing has to be good. Patients have to go into spontaneous labor. It’s pretty rare I’ll ever induce a breech. But I will augment a breech in labor; if a patient gets an epidural and labor spaces out, I would augment them.

Those are the criteria. If they meet those criteria, then all the evidence, including ACOG's guidelines, say that 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. No one will know how to put on forceps to get the head out. 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.

My hospital says if I do another VBAC or elective breech delivery, they’re going to “summarily suspend my privileges.” Until I can solve this problem one way or the other, if I do another breech delivery or VBAC, I’m going to jeopardize all my patients’ care. I’m going to have to tell my patients that if they want a vaginal breech delivery, they’re going to have to go some place else.

Stand & Deliver: Is there anywhere else in the LA area that offers vaginal breech birth?

Fischbein: I have some colleagues who work at Cedars who still might rarely allow vaginal breech deliveries. But I can certainly see other doctors not wanting of offer patients that choice, saying that the safest way is to have a c-section. If all I told you was that if you have a VBAC, you could rupture your uterus and your baby could die, if that’s all you heard, you would never choose to have a VBAC. 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.

Stand & Deliver: Let’s turn to home birth now. How might home birth midwives improve the way they practice? What could obstetricians learn from home birth midwives? In other words, what could each group learn from each other to improve maternity care?

Fischbein: I think home birth providers right now are under an extreme microscope. There’s a witch hunt right now. Home birth providers have to follow every single protocol they have to the letter. They can’t go out on a limb or individualize. It’s really hard for them to practice that way. But it’s a sign of the times that any bad outcome in a home birth is magnified a hundred times. You could have a thousand bad outcomes in a hospital and nobody cares. But you have one bad outcome in a home birth, and ACOG is looking for you to call in on them, almost like a spy. Did you see the recent post on my blog? Can you believe that? They don’t care how many successes there are; they’re just looking for failures. Last year ACOG said that hospital births are safer than home births. This year they’re only now collecting data to try and prove their point? Don’t you think they should have done it the other way around?

I don’t know that modern obstetricians are ever going to support home birth because the model that they’re trained with—the obstetric model—treats pregnancy as if it’s a disease. In their minds, a disease is best treated in a hospital. They’ll never look at pregnancy as something that is beautiful and safe most of the time and that is rarely an emergency, especially when you cherry pick your patients and only have low-risk patients to start with. They’ll never see it that way. Again, it gets down to a choice issue. Some physicians just do not believe in the informed consent and refusal modality that I believe in. They believe strongly that home birth is dangerous and therefore they won’t even offer it to their patients. Any patients who mentions it gets the “Oh my g-d, are you out of your mind?” comment. Once that happens, it’s out of the question. I don’t think that there’s going to be a whole lot of change here. It needs to be consumer-driven, and patients have to demand it. I don’t know how that’s going to happen without a coordinated effort. Like what you’re doing, and what I’m doing, and the Birth Survey is a start. There are so many groups out there, but we’re all disjointed. There’s no one clearing house for all these groups. It’s starting to change a little bit, I’ve noticed, as I’ve been more active on the internet. It seems like everybody knows everybody. But trying to get the word out to people who aren’t already fellow travelers is really difficult.

Stand & Deliver: Yes, it is. The biggest thing that has happened so far is Ricki Lake’s documentary and book. As far as mass influence and really getting the word out there, her book and her documentary have been extraordinarily successful. She’s reaching very mainstream women.

Fischbein: She has power to get us exposure. We need to get people on Oprah or 60 Minutes or 20/20. We need to do a 20-minute segment on walking up to the CEOs of hospitals and saying to them, “Here’s your mission statement from your hospital, yet you’re telling patients that they have to have surgery.” Confront them and embarrass them a little bit. 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.

Stand & Deliver: It affects so many people. I wonder why there isn’t more uproar.

Fischbein: Maybe it’s because pregnant women feel very vulnerable, and once they have the baby they’re too busy dealing with life. The power of having 10,000 pregnant women march on Sacramento or march on Washington would be fantastic. Maybe we need a Million Pregnant Women March! It would be a marvelous thing to raise awareness. I’m at the mall right now, and everywhere I go there are pregnant women or women pushing their kids in strollers. 33% of these women have been delivered by cesarean section. And it’s only going to go up.
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Friday, August 28, 2009

Sneak preview

Here's a snapshot of my new Second Womb Slings website (click on the full magnification for a full-screen view). I'm pretty much finished designing it on Photoshop. The next step is to slice the image, then turn it into a working web template on Dreamweaver. Then I need to figure out how to get everything uploaded and online.
I'd love your input on the design, layout, etc. Is there anything that still needs tweaking? Does it look sufficiently professional? In other words, if you stumbled across this site and didn't already know about my business, would you actually buy a sling?

I still haven't selected a web host. I was thinking of using GoDaddy's Deluxe Plan. I want to be able to host more than one domain, since my next big project is moving this blog to a real website. Are there other comparable hosting services that are inexpensive, reliable, and have sufficient storage space/etc that you would recommend?
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Thursday, August 27, 2009

Four month pictures

Devouring Eric's hands
Most likely Dio is thinking:
get me away from this large fiendish girl! heeelp! Eating borscht with gusto
He loves the Johnny Jump-Up. Zari loves to treat it like a swing/punching bag/trampoline. Yeah, we did that too to our siblings when we were little. He'll survive.
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Wednesday, August 26, 2009

Four months old!

Pictures coming tomorrow, since I've been sick the past two days and need to get to bed soon. I was thinking this afternoon how deeply and intensely I love my children. I probably said something to the same effect when Zari was younger, so forgive me for repeating myself. But it's really crazy-intense. I wonder why romantic love is always portrayed as the pinnacle of human emotion in film, when in reality it pales in comparison to how parents feel for their children. But I guess sex sells better than, say, changing diapers or wiping curdled breastmilk off your shirt.

Dio's had a few scattered episodes of long sleeps at night (7 hours), but usually he's out for about 5 hours at first, then every 2-3 the rest of the night. But since I don't go to bed right when he does, I miss out on that nice long stretch! That's okay, though; I feel rested enough most days. He always nurses back to sleep at night, but during the day he often will just fall asleep on his own, or with just a little shushing and swaddling. It's nice because Eric can put him down for naps, rather than me having to always be the one doing it. Very different from Zari, who I always nursed to sleep for both naps and nighttime.

Zari is learning how to be a big sister. She's kicking and hitting Dio less often. Whenever he cries, she tells me earnestly, "Dio is crying. You need to go get Dio." She loves to play with him and blow on his belly and thinks it's hilarious when he grabs her hair. Last week when I was gone exercising, Eric was showering and Dio was on the bed, starting to fuss. Zari climbed up and played with him until Eric got out of the shower.

I've been super busy with sling orders (7 or 8 recently finished, 11 more in the works!). I'll soon be offering a huge selection of 30-40 batik fabrics, thanks to a partnership with my local fabric store. I've also been working on my fabulous new website, with help from my cousin who is a graphic designer. So, anyone want a sneak preview? I'm trying to decide if I should share a screen shot now, or wait until it's up and ready to go...
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Tuesday, August 25, 2009

Real bodies in fancy magazines

While I'm not terribly enthusiastic about nude photos in glossy magazines--sexual or not--I have to admit that I loved this picture of a "real" woman, complete with sagging belly, stretch marks, and larger thighs, in Glamour. She's a plus-size model and her body is the real deal.

It's sad, though, that a size 12-14 is considered plus-size. I'm in the neighborhood of size 10-12 right now and last time I checked, I was a size medium. If medium is plus-size, I hate to think what a large or extra-large would be...
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Sunday, August 23, 2009

Another Dr. Wonderful needs your help!

Just a few weeks after I posted about litigation and the obstetric mindset, I heard that a wonderful obstetrician, Dr. Stuart Fischbein, is being threatened with disciplinary action by his hospital "for violating hospital policies." The hospital has already suspended the privileges of the two CNMs he works with, and now he faces a possible loss of his livelihood.

His crime? Supporting women's right to informed consent and to having a say about happens to their bodies. In the past few months, he attended 3 VBACs and 3 vaginal breech births, all successful and with healthy outcomes.

Dr. Fischbein is a vocal supporter of midwifery and home birth. His collaborative midwife practice had a primary c-section rate last year of only 5% (compared to his colleagues' primary CS rate of 20%) and an overall rate of 12% (including repeat CS), compared to his colleagues' 29%.

To learn more about Dr. Fischbein's case and how to lend your support, please visit his blog and his website. He has been forced to start a legal defense fund in order to defend his right to continue practicing obstetrics.

So what can you do to help?

1. Contribute to Dr. Fischbein's Legal Aid Fund. Make Paypal Payment to or mail a check payable to Alan J. Sedley, Attorney at Law to: 1234C Westlake Blvd., Westlake Village, CA 91361
2. Write a Letter to: Mr. Michael T. Murray, President, St. John's Regional Medical Center, 1600 Rose Avenue, Oxnard, CA, 93030 and copy to: angelfischs at
3. File a complaint with the Joint Commission.
4. Spread the word. Blog, tweet, link, email. Share the button on my sidebar. Flood his hospital with letters.
5. Buy a Second Womb Sling. I will contribute $5 to his Legal Aid Fund for every sling purchased from now until the end of this year.

Below is a summary of Dr. Fischbein's situation. Visit his blog regularly for updates about his ongoing battle to keep his hospital privileges and to offer women vital choices such as VBAC and vaginal breech birth.
I am an obstetrician who collaborates with midwives and believes strongly in the midwifery model of obstetrics and the right of a woman to true informed consent and refusal in the birth process. The hospitals I work at have a malicious attitude towards me and those things I believe in. They have created policies that seem to violate basic human rights, patient autonomy, possibly EMTALA and may very well be illegal. They do not seem to care that these policies violate their own mission statement, as well. Policies such as "banning" VBAC are becoming pervasive. They also have a policy denying a laboring woman an epidural who chooses to violate that policy as well as one that says a woman transferred from a home birth no matter what the reason for transfer must not go to one of the two sister hospitals. This is just the tip of the iceberg of the extent to which the hospital committees, administrators and their lawyer have gone. Their malice and pettiness now threatens my privileges for allowing 3 women this year the informed choice of refusing a repeat c/section, 3 more for having a breech delivery and for allowing a woman to choose what hospital she feels most comfortable at. They have suspended the privileges of my 2 CNMs for the pettiness of reasons and when I was able to refute that one they came up with something else. Clearly we believe this is a combination of a witch-hunt against midwifery, personal animosity towards me and what I believe and, most significantly, an assault on a woman's right to self determination, likely for economics, expediency and litigation mitigation and not for their standard line "patient safety." Feel free to ask me about that one.

This country now performs c/sections on nearly 1/3 of all pregnant women. Major surgery that carries significant short and long term risks to them and their babies of which they are rarely informed. VBAC is successful over 73% of the time and carries less morbidity that repeat c/section but all these women are told is that if they try a VBAC they could rupture their uterus and their baby could die. Thus skewing them into a choice the doctor or hospital wants them to make. Easier on the doctor, more money for the hospital. Using the midwifery model last year my collaborative midwife practice had a primary c/section rate of 5% compared with 20% for the rest of the doctors at this hospital that only does low risk OB. (Overall rate 12% vs. 29% includes repeat c/sections). All 6 of my VBAC and Breech deliveries this year went well with great outcomes, bonding and patient satisfaction. These six women would all have had c/sections against their desire if I was not in the community. Now the doctors on the OB committee, the anesthesiologists and the hospital administration are going full bore to eliminate us from that community. I would not doubt that this sort of bullying goes on under the radar in numerous communities around the country and pregnant women are the real victims.

In order to defend myself and my support of women's informed birth choices against the actions of the Hospital, I have had to retain legal counsel. I find myself in a situation I had never imagined I would be in, where I must ask for financial help for my legal defense. Please consider contributing to my legal defense fund via PayPal.
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Saturday, August 22, 2009

Top birth and breastfeeding books

I recently received a request from a blog reader for books on birth and breastfeeding. She's trying to narrow her list down to just a few and wanted to know which ones I'd recommend. She is 24 weeks pregnant with her first baby and is planning to give birth in a freestanding birth center. Her husband is a 3rd year medical student and is on board with her birth plans.

I am trying to think what my super short list of must-reads would be for a woman in her situation. Let's see...

  • Ina May's Guide to Childbirth: I like it for its inspirational stories that make me go, "yes, I can do this!" and for its information on the birth process.
  • Sarah J. Buckley's Gentle Birth, Gentle Mothering (recently released in an updated, North American edition). I love the chapters that review the science & the hormones of labor, birth, and breastfeeding.
  • Peggy Vincent's memoir Baby Catcher. This gave me an understanding of what birth really looks, sounds, and feels like. Hilarious, gripping, great read. And because reading only advice books gets a bit dull when you're getting ready to have a baby.
I might recommend different books for a woman planning a hospital birth, but I think this is a good start for someone going to a birth center.

I'd like to hear your suggestions if you had to list your favorite birth and breastfeeding books. Which would be better for women planning hospital births? For women using birth centers or having home births?
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Friday, August 21, 2009

Before & after, or how not to sew

A midwife recently asked me to make her a baby scale sling--the kind you use when to weigh a newborn after the birth. She purchased one online and it was, to put it nicely, a piece of work. The fabric was hideous. The thread didn't match. The stitching was uneven. The hems were unfinished in places. The rings were thin and flimsy. The raw edges weren't matched up at all. She asked if I could make her a new one. Here are the before & after pictures:

(chartreuse batik with blue rings)
I've been busy making slings. Besides the chocolate/blue and silk/batik reversible slings from last week, I've made the following this week and have more on order.

Turquoise linen with silver rings & decorative stitching.Brown linen with embroidered dots, bronze rings, and bronze embroidery
Peacock silk dupioni with silver rings & decorative stitchingBlack linen embroidered with gold flowers, black ringsBlack linen embroidered with fruit, pink rings
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Wednesday, August 19, 2009

Russia supports breastfeeding

My brother, who's living in Vladivostok, Russia, just sent me this picture. It says "Russia supports breastfeeding." His email said:

so this is just saying how good breast feeding is. This is on a main road that is in the richest part of town, where lots of the really rich people live, and where the mafia lives. i thought of you when i saw this. sorry it's not the best quality, it was taken at night.

love, your brother
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Tuesday, August 18, 2009

What did you say?

Reality Rounds has a great collection of things not to say to a pregnant woman: Take a Pregnant Pause, Before You Speak. The worst I ever encountered was when a woman warned me I could die if I gave birth at home. Not something you want to hear when you're seven months pregnant, especially from someone who hardly knows you.

If someone has ever said anything outrageous, silly, or rude to you when you were pregnant, in labor, or a new mom, hop on over to Reality Rounds and add your two cents!
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Monday, August 17, 2009

My newest creation

A recent order: reversible ring sling in pomegranate cotton batik and peacock silk dupioni. Create a custom silk/silk or silk/batik reversible sling for $70.

Or, if you're a DIYer like me and know your way around a sewing machine, make your own. Directions are for a single layer of fabric. To make a reversible sling, stitch the two layers together with the rights sides facing each other, leaving one short end open. Press & turn, then topstitch 1/4" from the edge. Then proceed with the tutorial.
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Sunday, August 16, 2009

16 weeks old

I had to double-check the number of weeks old Dio is...I'm starting to count in months now. So what's new? He's discovered his hands and is always chomping on his fingers or thumb. And when he's not slobbering over his fingers or twisting his hands together, he's (trying to) play with toys. He can roll over now, too.

He's been sleeping more fitfully at night again. I get a 3-4 hour stretch when I first put him down, then it's every 1 1/2 to 2 hours the rest of the night. It's been too hot to swaddle him well, and I don't know if that's one of the reasons. Dio is so sensitive to sounds and movement. I should try putting him back in his crib (which is right next to our bed) at night but I'm too tired to do anything but nurse him and go back to sleep.

Zari is having lots of fun with him, but Dio isn't so sure about her at times. She sometimes likes to play a bit rough. As in deliberately kicking and hitting him to see what I'll do. But she can also get him to laugh and smile. I figure soon enough he'll be able to dish it back to her.
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Saturday, August 15, 2009

My garden

We're starting to harvest the fruits (well, vegetables) of our labors. We have a lovely sunny patch of yard--the only good place to have a vegetable garden--that one of the previous owners graveled over for a parking area. So this spring we built six 4x4 foot raised bed gardens out of 2x12 lumber. We dug up soil at our friend's property, hauled it to the raised beds, then amended it with peat moss, vermiculite, perlite, and composted manure. This turned the heavy, clay soil into light, fluffy dirt. It's amazing to work with. There are three other garden beds along the kitchen and garage. They are approximately 20x3' (morning sun), 8x4' (full sun), and 15x4' (afternoon sun).

In these 9 beds total I planted:
  • 11 tomato plants (mixture of heirlooms, one cherry tomato, and lots of mystery tomatoes). 8 of my tomato plants look like they have some sort of blight: the leaves are getting black spots and then dying off. Fortunately the tomatoes are still ripening.
  • 17 peppers (bell, Thai chili, jalapeno, and many more varieties)
  • 4 tomatillos
  • 4 eggplants (I've only seen 2 eggplant fruits total from the 4 plants, not sure what happened)
  • beets, lots and lots and lots
  • carrots: rainbow mix and Danvers variety
  • shallots
  • leeks (not sure if they made it)
  • parsnips
  • watermelon
  • muskmelon
  • cantaloupe
  • 10 asparagus
  • 5 blackberries
  • 3 raspberries
  • potatoes (from mushy sprouted ones I found in my pantry this spring)
  • red, white, and yellow onions (from sets)
  • spinach
  • mesclun mix (mixture of lettuces and mustard greens)
  • mache (I eat this every day when I am in France...mmmmmm...)
  • kale: lots and lots of Winterbor (ruffly leaves) and Nero di Toscana (flat leaves), definitely like the ruffly one better.
  • strawberries
  • bush beans
  • zucchini (didn't make it)
  • summer squash (just starting to see the first ones coming on)
  • 3 broccoli
  • 4 cabbage
  • 1 rhubarb
  • acorn squash (didn't make it)
  • cucumbers (off to a slow start...not sure if we'll get anything)
  • butternut squash (didn't make it)
  • 8 basil plants (1 lemon, 1 lime, the rest sweet basil)
  • chocolate mint (in a pot so it doesn't take over everything)
  • 1 each of: oregano, thyme, sage, chives, sweet marjoram, flat-leaf parsley, dill (didn't make it), rosemary
We left town for 6 weeks and, amazingly, almost everything had survived when we came back! I attribute that in large part to using square foot gardening. The plants grow so close together that there isn't much room for weeds.

I am amazed at the variety of plants I was able to fit into a relatively small footprint. Next year I want to add a few more raised beds. I like the aesthetics of the square 4x4' beds, but I'm going to put in rectangular beds, still 4' deep but longer to use up more of the available ground. I also want to add fruit trees (apple, pear, peach, cherry) and bushes (red currant, chokecherry, blueberry, elderberry) and lots more raspberries.

Now the challenge this year is to not let anything go to waste!
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Thursday, August 13, 2009

Lamaze International's Annual Media Award Winner

I am thrilled to announce that I was chosen to receive Lamaze International's Annual Media Award! Amy Romano did an interview with me recently--please visit the announcement at Science & Sensibility if you want to know more about me, my blog, and my thoughts on our maternity care system. From the award announcement:

Earlier this year, I announced on this blog that, for the first time, bloggers would be eligible for Lamaze International’s Annual Media Award. The Media Award is intended for individuals or organizations shaping the public discourse about natural, safe and healthy choices for childbirth. With blogs and other social media now firmly on the scene, it was clear that restricting our award to “traditional media” would have been looking too narrowly.

The response was tremendous, and we faced a difficult task of choosing from among many wonderful and informative blogs written by mothers, fathers, nurses, childbirth educators, doulas, midwives, and consumer advocates. But one blogger rose to the top. Rixa Freeze, MA, PhD, blogs at Stand and Deliver, and reaches over 30,000 readers a month. Known for her warm, thoughtful tone and expert critical analysis of all things birth- and mothering-related, Rixa has built a strong community of engaged readers who comment often, challenge Rixa and one another, and shape and shift a conversation about birth that very often trickles onto other blogs and online forums and, occasionally, even the mass media. Rixa will receive her award, along with the recipients of Lamaze International’s other prestigious awards (to be announced this Fall), on October 3 at the 2009 Lamaze International Annual Conference in Orlando.

To read the rest, click here.

And finally, I want to give my readers a big thank-you. Your comments and discussion have made this blog so much richer. I wouldn't be making this announcement today without you.
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Tuesday, August 11, 2009


I've been busy working on something that is top for now, I will share a review of Laura Keegan's book Breastfeeding with Comfort and Joy at Feminist Childbirth Studies. I love this part, describing the changes in her breasts during pregnancy:
My breasts felt full and odd, and I was convinced that the only thing that would make them feel right was to grow that fetus into a baby, get him or her out, and get him or her latched on. So my body convinced me that it would be okay ... indeed, that it would feel really good.
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Sunday, August 09, 2009

Musings on food

Earlier this week I was listening to an NPR program interviewing Michael Pollan (author of several books on food, including The Omnivore's Dilemma and In Defense of Food: An Eater's Manifesto). During the half-hour broadcast, Pollan discussed the phenomenon of Cooking as a Spectator Sport. As he noted in his recent cover story in The New York Times Magazine, Out of the Kitchen, Onto the Couch, cooking shows are wildly popular, yet at the same Americans are spending less and less time cooking.

This reminded me of the discussion in my recent post about home birth including EnjoyBirth's Restaurant Wars analogy. Is it so preposterous that in the future, home cooking will be as quaint and antiquated and rare as home birth? Probably not to the same extent, yet American culture is moving further away from food as it exists in its original state. Meat comes shrink-wrapped in styrofoam trays. Milk comes from plastic bottles or stainless steel dispensing machines. You can buy aerosol cheese products that last indefinitely, macaroni & cheese mixes featuring a mysterious neon orange powder that claims to be 100& natural because it was, in the distant past, derived from a cow. Vegetables are disguised as much as possible in various processed food products, and marketed to both kids and parents for their invisibility. Look! Your kids won't even know there are vegetables in the sauce!

At the same time that many Americans subsist on a diet of foods far removed from the original plants, grains, nuts, or meats they began as, there are countercurrents that challenge this trend: community-supported agriculture, the Slow Food movement, organic agriculture, backyard gardens, raw foodism...Many of these foodways have their own demons to face. Organic agriculture can mean a small, sustainable farm growing vegetables for its CSA members--but it can also mean industrialized monoculture farms that ship their produce thousands of miles away to high-priced natural food stores that most normal people can't afford to shop at. Raw foodists advocate eating foods that have not been altered by heat, with the belief (gross oversimplification here) that heat destroys many of the important properties of food, rendering it less nutritious and therefore "dead." I've read quite a bit about the raw food movement and follow several blogs about it. I find myself fascinated and repelled at the same time. I am sure that eating more raw food would greatly benefit people's health. However, I'm not as convinced that it's the rawness per se that does it, rather than the fact that eating raw forces you to eat fresh, unprocessed, whole foods. And the whole side of raw food that preaches a strict binary of raw=good and cooked=bad really turns me off. Not to mention that going 100% raw is not a very ecologically friendly or sustainable way of eating--for much of the year, you have to consume large quantities of out-of-season produce shipped in from thousands of miles away. I've been musing about this a lot recently, since I've been trying to add more raw/fresh fruits and vegetables into my diet and thus have been browsing around raw food websites for recipes and ideas.

Which leads me to another point in my meandering train of thought: Americans are simultaneously obsessed with and terrified of their food. Fat is bad. Carbs are bad. Too much protein is bad. Cooked food is bad. Raw food is bad. Dairy is bad. Cholesterol is bad. Eating the wrong combination of food is bad. Calories are bad. It's always about the "bad" elements lurking in your food that must be avoided.

Except for this year, I have spent every summer for the past nine years in France, where the food and food culture can only be described as divine. I've had lengthy conversations with bus drivers and chauffeurs about the virtues of home-grown tomatoes. I've eaten everyday food at friends' houses that makes you think you've died and gone to heaven. Farmer's markets are everywhere, from the largest city to the smallest village, year-round. American supermarkets have entire aisles dedicated to carbonated beverages and potato chips. French supermarkets have an aisle full of yogurt. Another entire aisle of just cheese, half of it raw, much of it from animals other than cows. Another of smoked/raw/cured meats and sausages. Yes, industrialized farming and fast food and processed foods (and the concurrent rise in obesity, especially among children) are becoming a problem in France. But still, food in France is something to look forward to, not something to be feared. It's a powerful social bond. For many families, the family dinner remains sacred. French people eat all sorts of "bad" foods that Americans would gasp at: heavy cream, chocolate, butter, cheese, raw meats and seafood, organ meats. And they enjoy them. What's the difference? They don't eat twelve eclairs in one sitting or sit on a couch munching mindlessly on foie gras. They eat a wide variety of foods: some cooked, some raw, some animal, some plant, some fatty, some lean. And they derive great pleasure from them.

Back to Michael Pollan: of all the philosophies about food, I find his eater's manifesto the most brilliant of all. Eat food, not too much, mostly plants. It is simple and incredibly flexible, wide enough to encompass diverse foodways. It doesn't advocate any one way of eating as the only right/ethical/healthy approach to food.

For dinner tonight, we ate a simple meal. It was hot, 90+ degrees and extremely humid. We'd been outside in the back yard for several hours, and I wasn't in the mood for anything too heavy or elaborate. We prepared a simple salad of beet greens, mache, tomatoes, cucumbers, and hard boiled eggs (mostly from our garden or the farmer's market). I made a quick risotto with sauteed onions, saffron, jasmine rice, and parmesan cheese. Zari wolfed down her egg before we even had time to say the blessing on the food. She asked for "black sauce" (balsamic vinegar) for dipping her vegetables. She ate all of her rice and snitched some of mine. I hope to teach Zari to love her food--real food, not processed imitation junk--not to fear it. So far, I think we're on the right track.
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Saturday, August 08, 2009

Hold on tight

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Friday, August 07, 2009

CSx2 (Carrots, Sticks & C-Sections)

There are a lot of ideas about how to reduce the cesarean rate (current figures are 31.8% in the US and over 26% in Canada):
  • increase the rate of out-of-hospital births (freestanding birth centers and home births, both of which have cesarean rates under or around 4%)
  • encourage hospitals and birth attendants to follow evidence-based medicine, such as the Mother-Friendly Childbirth Initiative
  • increase access to VBAC
  • decrease the primary cesarean rate
  • encourage healthy pregnant women planning hospital births to seek care from CNMs rather than obstetricians
  • educate pregnant women and couples about practices that facilitate normal birth, such as Lamaze's 6 Care Practices that Support Normal Birth
  • decrease physician liability--or fear about liability that drives up the cesarean rate
Washington State has implemented a new policy that creates strong financial incentives to bring down the cesarean rate. Starting next month, Medicaid will reimburse hospitals the same amount for cesareans as for vaginal births. Before this change, hospitals were reimbursed much more for cesareans than for vaginal births. From an article about taking away the incentives for too many c-sections:
On average, Medicaid pays $5,000 more for a C-section than for a vaginal birth, and private insurance pays a far greater premium. You don’t have to be a cynic to wonder if that could have something to do with the rise in unnecessary C-sections.

[Dr. Jeff Thompson, the state’s chief medical officer for Medicaid] explains that there’s no good way for the state to pick out which C-sections are unnecessary. “Medicaid won’t pay for an unnecessary C-section, so hospitals have to code every section as necessary,” he says. But equalizing the amount hospitals get paid for vaginal and C-section births eliminates a financial incentive to perform C-sections. That should mean that the only reason for a doctor to perform a C-section will be that it is medically necessary, and in fact doctors and hospitals will have every financial reason to avoid C-sections — letting money sort out the necessary from the unnecessary. Policy wonks call this “realigning incentives."

“We are choosing to improve quality mostly by using carrots rather than sticks,” says Dr. Dimer.
So will this work? And how?
The size of the financial incentive is crucial, he says. That’s because there are such powerful incentives pushing for C-sections. Dr. Dimer [a Group Health obstetrician who chairs the regional ACOG chapter and co-chairs Washington's perinatal advisory committee] explains that the incentives for C-section go beyond money. “In nature, labor can go on for hours and is highly unpredictable,” whereas a C-section delivery is highly predictable and far shorter. “In American culture, where time is money, having something that is finite and predictable is highly desirable,” she says.

[Dr. Elliott Main, chair of obstetrics at California Pacific Medical Center and principal investigator for the California Maternal Quality Care Collaborative] says that financial incentives for vaginal birth have to be enough to counteract those factors, enough to command attention. He thinks Washington’s cuts in C-section reimbursement may just be that big. The state has slashed Medicaid reimbursement for uncomplicated C-sections from about $3,600 to around $1,000. Hospitals with high C-section rates are in for a rude awakening. Thompson says that since the change in reimbursements took effect he has already received calls from hospitals asking for help revising the protocols they use to decide when a C-section is called for.
Washington State has already implemented another cost-saving and cesarean-lowering initiative: providing Medicaid reimbursement for licensed midwives who attend out-of-hospital births. From the article:
Washington has a history of bucking the national tide when it comes to childbirth. It has a rate of out-of-hospital birth double the national average, and the state is one of only nine states in the country where Medicaid will cover out-of-hospital birth attended by a licensed midwife. In 2008 the Department of Health funded a cost-benefit analysis of the practice. It found that paying for home birth resulted in good outcomes for mothers and babies and yielded a net savings to the government of about $250,000 per year from the reduced numbers of C-sections. (Licensed midwives have every incentive for their patients not to have C-sections, including the obvious: Licensed midwives don’t do C-sections. They get paid next to nothing when their clients transfer to a hospital and have C-sections.)

Currently, midwives from Washington state are lobbying in the other Washington for legislation to push all states to cover out-of-hospital births with licensed midwives through Medicaid. Amber Ulvenes, a lobbyist for the Midwives Association of Washington State, recently used the state’s cost-benefit analysis to come up with an estimate of how much money this would save nationwide. She says if 1 percent of Medicaid-covered births were attended by certified midwives, at least $71 million would be saved annually.
If this new financial incentive works, all the better. It seems like nothing so far has been able to turn the tide of rising cesarean rates, except for a brief period in the 1990s when VBACs were actively encouraged. Perhaps money speaks the loudest language of all.
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