BY Harvey Jacobson
HP: We’re so excited to be spending the afternoon with you Dr Fischbein! Tell us how you came to practice as you currently do, supporting women in their “unconventional” birthing choices.
HJ: It’s great to be here! I was trained back in the late seventies and early eighties. I chose obstetrics and gynecology for many reasons, most of which were that I like the idea of doing all kinds of specialties including surgery, internal medicine, endocrinology, some psychiatry, and of course, obstetrics. So that’s how I came to that specialty. I was trained in the medical model of birth, which is a fear based model: birth is considered dangerous unless modern medicine keeps it in check. I was the chief resident of my program at the time it was the busiest hospital in the country (they had about 65 births a day there, 22,000 per annum). The model was “see one, do one, teach one,” which may be the best model for teaching skills, but it’s not the best at learning bedside manner, patient care, etc. Nevertheless it was a great way to train, I learned breech delivery, twin delivery, how to turn babies, how to use forceps, I saw women having seizures with eclamsia, women suffering from heart disease. I was well trained in all this, but of course everything I saw was abnormal. The normal cases weren’t dealt with by residents, they were funnelled to the private doctors or to the midwives in LA county.
When I came out of residency, I was well trained and thought I was the smartest tack in the box, and knew everything there was to know! I was very confident in my knowledge. I was then approached by some midwives to be their backup physician. I worked as their backup physician for about 10 years and over that time I began to see a different way of doing things: the midwives’ clients were better taken care of in terms of nutrition and preventative healthcare. The midwives had better communication with their patients and were spending more time with them. In fact, midwives called their patients “clients” cause patients are sick people! In their model of care, pregnant women certainly weren’t treated as sick. In 1996, I opened a collaborative practice with two certified nurse midwives in the Ventura County area, and we practiced a collaborative form of healthcare. Although we were only doing hospital births at the time, the midwives took care of all the low risk women, and I took care of the cases I found more interesting, ultrasounds, high risk cases, abnormal pap smears, menopausal hormone replacement, etc.
This model had a strong influence on me, because I began to practice as midwives practice: I began to do my prenatal visits in 35 or 40 minutes, rather than 5 or 6 minutes. This model is difficult to sustain in the insurance world, but we were able to do this for about 15 years. However we were never really accepted in the community, which consisted of old school guys, who never liked the fact that we had better statistics, and were taking better care of people. Our practice was never treated the same as other practices, we were under more scrutiny, and more peer review; There were definitely discriminatory practices going on. We were successfully doing VBACs and breeches and twins when they started to change the rules: they started to ban VBACs, vaginal breech deliveries, and ban midwives from doing deliveries themselves in the hospital, for no legitimate reason. It gradually became very uncomfortable and we realized that this is a loosing battle for us: if the hospital doesn’t want you there, you’re just not going to win.
So, after talking with friends and supporters, I decided to strike out on my own. The current clients I had were all happy to have a homebirth with me attending. The more homebirths I attended, the more I enjoyed it! I resigned from my hospital privileges and went on to becoming a homebirth obstetrician and I was never happier. Now I was able to do the things I was trained to do, in an environment where there is no one-size-fits-all policy for all women, and the decisions that are made are in conjunction with respect of the autonomy of the individual client and their individual needs, and what is really best for the woman and her family. So this is what I’ve been doing since 2010, I’ve never looked back, and I’m unbelievably happier with what I’m doing: I’m able to provide women with a decent opportunity to have an alternative to the medicalized model of birth, which has lead to so much patient dissatisfaction and a cesarian section rate close to one third pregnant women in this country.
HP: In your opinion and experience, are women who are classified high risk because of wanting a vaginal breech birth, or a VBAC, or a natural twins delivery, more likely to achieve this at home rather than in the hospital?
HJ: The short answer to that question is, yes, if the woman is otherwise healthy, home is a much better place to give birth. I’d like to explain why: we have to go back to the basic tenant of mammalian birth, and how mammals are designed to give birth. All other mammals, when they are ready to give birth, they go off alone to a quiet, safe place. If they’re hungry, they eat, if they’re thirsty they drink. If they’re uncomfortable, they move around. The other animals don’t come and check on them, or bother them. They’re not interrupted, and when the babies come out they fall into the dirt, and nobody’s worried about sterility, no one rushes to clamp the umbilical cord, the baby is never separated from it’s mother, mother and baby are treated as a unit. This is how nature has designed mammals to give birth, and for the most part, it works really well. What happens to a mammal when it’s disturbed is you trigger the fight or flight response. For example, you have a cat laboring in the closet, and the little kids are running in and out of the closet, the cat will get scared and run away. What happens to contractions when the woman is startled like that? Her body produces adrenalin, just like an animal in the wild would if a predator is approaching, and the contractions will stop. The animal gets up and runs away, and only when it feels safe again does the labor start again.
When everything else is normal, homebirth is more successful, because everything I’ve just described as normal for our species can happen at home. Sadly, the exact opposite occurs in the hospital: you have to leave your safe nest to drive there; you’re brought to the emergency room and put in a wheelchair as if you’re sick; you have to change into a hospital gown and pee in a cup, and between contractions every three or four minutes you’re supposed to sign consent forms, talk about surgery and death. You’re constantly interrupted, you’re probably only allowed ice chips to suck on, but nothing else to eat or drink, you have to lay in bed wearing fetal monitors which restrict movement. If you want to go to the bathroom you have to ask permission, you have your mother and grandmother sitting in chairs staring at you, nurses are constantly coming in to take your vital signs, and you can hear other women in labor down the hall, other people talking about trivia, the tv is probably on in the room… With all this happening to you, of course you’ll request an epidural, and then the whole cascade of intervention will begin. The obstetric model is depersonalized, and this increases fear and anxiety, thus increasing the chance of a dysfunctional labor.
HP: Let’s talk about birthing instincts. Do you trust them?
HJ: Well I talk a lot about how birth is instinctual. In fact, the whole process is instinctual: you don’t have to think about growing a baby, or going into labor, or breathing during labor. All these things will happened on their own. We can certainly mess up the process, the same way you can mess up digestion by eating too much fast food, but you won’t take every meal that you eat in an emergency room because there’s a small chance you might choke. The body won’t normally grow a fetus that is too big to come through the pelvis, except in very rare cases (certainly not as often as we hear it happening these days). In my first 100 births I had 21 breeches, 27 VBACs, 7 twins, and my total number of cesarians was 5. If you compare this with many practices in LA, all 50 of those “high risk” cases would have been cesarians.
The reasons for my low rate, is that I’m good at what I do, I carefully select clients who have good sense and intuition, I trust the natural process, and I place emphasis on nutrition and health, (the midwifery model emphasizes preventative health care). Doctors are experts at problems, and midwives are experts at normal, so when something isn’t normal, midwives can spot it probably even more quickly than a physician would. I am eternally grateful to have been exposed to and changed by the midwifery model. I am one of the very few people who is a happy obstetrician. I don’t think there are many people who can say that any more. The whole economic model of obstetric care is backwards; it inevitably leads to a cesarian rate of 30%. It has to, because of the economic rewards, because of the expediency of a cesarian over vaginal birth, because of hospital policy, and fear of litigation, and liability, and because a lot of the policies and protocols are not made by the obstetric department, or the anesthesia department, by the risk managers, by the hospital administrators, etc.
HP: What are your views on medical ethics and informed consent? What role do these play in a woman’s decision making?
HJ: The beneficence model of ethics dictates that you’re supposed to give your patients true informed consent and you’re supposed to support her decision if she has a reasonable choice. Everybody has biases, it’s human nature, but you cannot forget to tell people about reasonable options. If you trust your physician and he tells you it’s dangerous to have a breech birth because your baby will get stuck and have brain damage, what is the average lay person supposed to do with information like that? Of if you’re hoping for a VBAC, and you’re told you could rupture your uterus and your baby could die. Of course this is devastating for a woman to hear and completely unethical from the physician’s part. Everything we do in the homebirth setting has significant substantial scientific evidence to support it. Whether it’s a breech delivery or a vbac, someone going beyond 42 weeks, letting clients eat in labor, getting up and walking around, not having them continuously monitored, these are all evidence based choices that are not given as options in the hospital based model. The biggest problem I have with many of my colleagues is that they have lost their ethical path when it comes to the American Medical Association Code of Ethics, respect for patient autonomy and decision making. They are giving them false information in order to get them to follow the path they want them to take.
There are two realities to birth: There is the fear-based reality, that doesn’t trust birth, believes the medical model is the only solution, and that birth is a disaster waiting to happen. For the people who believe in that model, this is their reality. There’s another reality that says, birth is normal, we trust birth, we realize that occasionally things go wrong, but we accept that, because that’s part of life. In this reality, we go on to view birth as a positive thing, treating problems preventatively. For the readers of Holistic Parenting magazine, I’m asking, which reality do you want to live in?
HP: Thank you so much for sharing your insights and experiences with us Dr Stu! This is all certainly food for thought.