Text-wrangler 2013 doc really screwed up! – deep hx of my writing & personal family stuff

‘Why another web site about childbirth?

I began my first website — www.collegeofmidwives.org — in 1994, when one still had to write HTML code. Since then, I”ve moved to a more reliable web design program (FrontPage). I often get emails and phone calls from people who find our College of Midwives site to be a reliably helpful source for information on a wide variety of legal, legislative, and political issue, as well as the story of how we got our currently dysfunctional and unproductively expensive maternity care system.

But over the years, the website has become very hard to navigate and Since 1910,  normal childbirth in healthy women has become the property of obstetrics as a surgical speciality.So I created <faithgibson.org> to provide a stand-along website for historical and contemporary political material and policy issues relative to childbirth practices in the US. Currently, this information is amply sprinkled throughout my huge, but hard-to-navigate website — the \”CollegeofMidwives.org\”.

Due to technical issues, I have to eventually migrate all content from the web program \’FrontPage\’ because Microsoft stopped updating and supporting FrontPage in 2003.’,

Whatever one’s individual opinion about the nature of childbirth practices in the US, both professionals and consumers agree that the current maternity care system is far from ideal  — we spend far too much and get much too little. To be precise, the US spends 98 billion dollars annually — that\’s billion with a \”B\” — on hospitalization for pregnancy and childbirth — twice as much as any other on country.

In particular our country spends more on childbirth-related hospitalization than any other hospital-based service</strong> provided in American hospitals.  Our C-section rate is essentially 33%. Since Cesarean surgeries are twice as expensive as normal childbirth, the overuse of operative delivery accounts for more than its fair share of that $98 billion bill. 1.3 million Cesarean surgeries are performed annually, which is approximately the same number as college students that graduate each year in the US.

 

The rate for Cesareans is more than double that for all other operations and other procedures performed in a sterile environment. A healthy childbearing woman in the prime of life is more likely to see the inside of an operating room than someone who is acutely ill, elderly or injured.\r\n\r\nHow can such a technologically sophisticated system that serves a remarkably healthy childbearing population in one of the world\’s wealthiest countries be <strong>1st in spending while ranking 50th in the rate of maternal mortality</strong>?   That means 49 other, mostly less wealthy countries have a much lower rate of mothers dying during or after they give birth than the USA.  The April 24th, 2013 Huffington Post: Dying to Have A Child.

The article notes that the our MMR had DOUBLED in the past 25 years. Interestingly enough, so has our Cesarean section rate.\r\n\r\nThe fundamental question is why our maternity care system is so dysfunctional?\r\n\r\nWhat are the forces that created such highly medicalized system of obstetrical care for healthy women?

\r\n<div>\r\n<div>\r\n\r\nEqually if not more important is the positive aspect of the issue. What are the essential qualities of a maternity care system designed to provide cost-effective care to healthy women with normal pregnancies? How do we identify the characteristics of success when it comes to safety? What professions, places and policies make for the best maternal-infant outcomes?

When it comes to the 70% of American women who are healthy and have normal pregnancies, there is the question of whether governments, other 3rd party payers and those who must pay out-of-pocket are getting an appropriate ‘bang for their buck’. Is the current configuration of medical and midwifery care making the kind of cost-effective contribution that economists refer to as ‘value added’?

Relative to the price paid, ‘value-added‘ describes the positive contributions of a service that is suppose to make something \”better\” that it would be without that particular set of services. To identify that quality in maternity care, we must first be able to determine the innate risky-ness of normal childbearing and then track the same outcome criteria for all categories of birth attendants and all birth settings. As a result, the relative benefits of each category of maternity care can be directly quantified without falling back on place-of-birth as a proxy for anything else. This is the most direct way to establish the manner and magnitude of medicine and midwifery\’s ability improve maternal-infant outcomes in a safe and cost-effective fashion.\r\n\r\n

The passage of health insurance reform legislation in the US makes it even more crucial to determine if what we are doing – the theories, policies and practices developed early in the 20th century – is the best configuration for maternity care in the 21st century.\r\n\r\nMinding the Gap: In an effort to address those questions, this commentary takes a fresh look at our aging 20th century maternity care system and the 21st century debate about its reform. At the heart of this controversy are two pivotal issues: \’place-of-birth\’ as proxy for the efficacy of intrapartum management and the lack of ‘standard care’ characteristics among birth attendants and birth settings.\r\n\r\nOur current configuration of childbirth services is a smorgasbord of non-standard care characteristics as provided by midwives, family practice physicians and obstetricians in a variety of small, medium and large hospitals and in OOH settings that include independent birth centers and planned home birth (PHB). When combined with the economic and political complexities of modern healthcare, this unsystematic system creates a large gap between what is known about ‘best practices’ and what is consistently being provided to childbearing women and paid for by us all.\r\n\r\nOf these two issues, the controversy over place-of-birth has made the most mischief and continues to direct our attention to a set of questions that, as currently formulated, cannot be answered. A hundred years after this brouhaha started, it continues to distract us from the questions about childbirth safety that can be answered.\r\n<h3>Evaluating ‘quality of care’ &amp; ‘standard’ vs. ‘non-standard’ care characteristics of practitioners &amp; facilities:</h3>\r\nAn abundant source of data is already available, including studies provided in this commentary. This type of information can and should be used to rationally evaluate quality of care issues and standard care characteristics by distinguishing effective forms of care from customary practices that are not directly associated with better outcomes for mothers, babies and those who pay the bill.\r\n\r\nThe necessary precursor to safe and cost-effective maternity care in North America lies is distinguishing between safe and unsafe practices in each setting and for each type of birth attendant. This allows the essential qualities of maternity care to be determined and standard characteristics of practice be developed for all places and persons provide maternity care to health women.\r\n\r\nTo do that, evidence-based policies and a consensus for action must be developed among all stakeholders – childbearing parents and consumer activists, birth attendants, other maternity care professionals, hospitals, 3rd party payers and public health officials. The goal is nothing less than an integrated, cooperative and \’minimalist\’ model based on “best practices”.\r\n\r\nTo paraphrase from a popular religious text: “Who among you if his child should ask for bread, would give instead a stone?” We must make sure the maternity care system does not unintentionally offer a stone in place of kindly extended helping hand.\r\n\r\n<a title=\”Identifying the Essential Qualities of Maternity Care: part 2 of Evidence-based policies &amp; a plan for action\” href=\”http://faithgibson.org/identifying-the-essential-qualities-of-maternity-care-part-2-of-evidence-based-policies-a-plan-for-action/1094/\”>Link to next in series ~ Part 2:  <strong>The Optimal Purpose of Maternity Care</strong></a>\r\n\r\noriginal URL:\r\n<h3>http://www.healthcare2point0.com/MCDG_contrast-studies_feedback_28Aug2010.htm</h3>\r\n</div>\r\n</div>\r\n</div>\r\n</div>\r\n</div>’, ‘Identifying the Essential Qualities of Maternity Care: Intro-Part 1 –> Evidence-based policies and a plan for action’, ”, ‘publish’, ‘closed’, ‘open’, ”, ‘identify-essential-qualities-maternity-care’, ”, ‘\nhttp://faithgibson.org/identifying-the-essential-qualities-of-maternity-care-part-2-of-evidence-based-policies-a-plan-for-action/1094/’, ‘2013-04-27 01:48:28’, ‘2013-04-27 08:48:28’, ”, ‘0’, ‘http://faithgibson.org/?p=89’, ‘0’, ‘post’, ”, ‘0’);
INSERT INTO `wp_posts` VALUES(’11’, ‘1’, ‘2012-06-21 03:49:09’, ‘2012-06-21 03:49:09’, ‘This article was first posted on the Canadian <strong>Maternity Care Discussion Group</strong> (MCDG) by Dr. Michael Klein, professor Emeritus of Family Practice &amp; Pediatrics (University British Columbia) and listmaster of the MCDG.\r\n\r\nIt tells the story of how total, prolonged, flat-on-your-back bed rest became the standard of care for heart attack patients without any scientific evaluation. It seemed \’so logical\’ to cardiologists that they strenuously opposed doing any research about it. Unfortunately, enforced bed rest turned out to dramatically increase the death rate for such patients. It is a prime example among many of how medical practices, from the perspective of the medical profession, many seem \’appropriate\’ but prove to be very harmful.\r\n\r\nConfining women in labor to bed is a routine part of the medicalization of normal labor and birth.  Like bed rest in cardiac patients, the obstetrical profession also strenuously opposed research on the various practices and protocols (immobilization in bed being just one of dozens) that were imposed to supplant physiological management. These protocols all seemed so \’logical\’ to obstetricians that they were never scientifically evaluated prior to their imposition.\r\n\r\nWhile immobilization and other labor-related medical interventions rarely results in death or permanent damage for laboring women and their babies, these non-physiological practices profoundly disrupt the biological process required for a normal childbirth. They make it substantially harder (sometimes impossible) to meet the physical and psychological needs of laboring women without resorting to powerful drugs and other medical and surgical interventions.\r\n\r\nThe following reposted article is a \’case in point\’ for why we should <strong>not allow medical practices to become \’standard of care\’ without appropriate scientific evaluation. </strong>\r\n\r\n<strong></strong>It also <strong>encourages us to keep trying</strong> to change unscientific practices, <em>even when they are popular with the medical professional, the media and most of the lay public. </em> Truth does eventually come forward and win out.\r\n\r\nfaith ^O^\r\n\r\n<strong>A Chair to the Rescue</strong>\r\nPosted on February 3, 2011\r\nBernard Lown, MD\r\n\r\nNot so long ago, doctors bled, purged, cupped, and performed all sorts of mayhem to cure diseases about which they had not a clue. With the advent of scientific medicine in the late 19th and early 20th centuries, evidence increasingly guided medical practice. This was particularly true for acute illness. Science, though, remained a porous veneer overlaying the treatment of chronic diseases , especially those afflicting the elderly. With the best of intentions, doctors over-treated their patients with unproven procedures and polypharmacy. These exacted an inordinate toll in suffering, morbidity, and death.\r\n\r\nThe advent of scientific medicine did not stop doctors from breaching the hallowed moral injunction of their profession, Primum nihil nocere (“first do no harm”). Early in my medical career I became keenly aware of how doctors — though committed to benefiting their patients — unwittingly harmed them. The insight derived from a transformative experience. It occurred sixty years ago, shortly after I began a cardiovascular fellowship under the mentorship of Dr. Samuel A. Levine at the Peter Bent Brigham Hospital (now the Brigham and Women’s Hospital) in Boston. Dr. Levine was a clinician without peer — astute in diagnosis, innovative in managing intractable clinical problems — and a riveting teacher.\r\n\r\nAt the time, the major challenge in hospital-based cardiology was dealing with the steady inflow of patients with acute heart attacks. Care was largely palliative: to relieve chest pain, to prevent blood clots, to ease the breathlessness and edema provoked by a failing heart muscle. Patients were confined to strict bed rest for four to six weeks. Sitting in a chair was prohibited. They were not allowed to turn from side to side without assistance. During the first week, they were fed. Moving their bowels and urinating required a bedpan. For the constipated, which included nearly every patient, precariously balancing on a bedpan was agonizing as well as embarrassing.\r\n\r\nBecause world events might provoke unease, some physicians prohibited their patients from listening to the radio or reading a newspaper. Visits by family members were limited. Since recumbency provoked much restiveness and anxiety, patients required heavy sedation, which contributed to a pervasive sense of hopelessness and depression. Around one in three patients died. Not surprisingly, many died from blood clots migrating to their lungs.\r\n\r\nIn addition to the pain [KS3] stemming from the heart attack and the accompanying fear of dying, patients had to cope with the torment of isolation, the indignity of infantilization, and the unbearable distress of excessive bed rest. Physicians convinced themselves and their patients that complete bed rest was the price of survival. Visiting Martians, witnessing this travail, might have judged the scene differently, regarding hospitals as prisons where inmates were subjected to a unique form of torture.\r\n\r\nTo a medical novice like me, the justification for enforced bed rest was persuasive. It was based on a sacrosanct therapeutic principle, the need to rest a diseased body part, be it a fractured limb or a tuberculosis-afflicted lung. Unlike a broken bone, which could be immobilized in a cast, or a lung lobe, which could be collapsed by inflating the chest cavity with air, the heart could not be cradled into quietude. The only approximation for a diseased heart was to diminish its workload. It was long known that during recumbency the heart rate slows and blood pressure drops, both indices of less oxygen usage and therefore of decreased cardiac work. Heart rest was therefore equated with bed rest.\r\n\r\nBut was this the case with those who had sustained a heart attack? In perusing medical journals I could find no reports on the subject, which was surprising, because the literature was dense with articles for managing patients with heart attacks. Being involved with the daily care of these patients, I became rapidly aware of the harm wrought by enforced bed rest.\r\n\r\nDr. Levine frequently discussed the adverse effects of prolonged bed rest. Among the possible complications were atelectasis, or a collapse of the lung lobes, predisposing the patient to pneumonia; peripheral vein phlebitis that could lead to fatal pulmonary emboli; lung congestion; prostatism; urinary retention; the thinning of bones; bed sores; frozen shoulders; and constipation. Yet so strong was the weight of tradition that Dr. Levine dared not move to reverse it, even though the harm exacted was evident. This was another illustration of medical tradition derailing healthy skepticism and impeding commonsense measures. Lacking was a categorical moral urgency among physicians, without which tradition is rarely altered.\r\n\r\nExperience with two patients compelled me to rebel against the entrenched practice of bed rest. The first involved a man in his early fifties. Mr. J. had been a robust, hustling, successful salesman. He bragged about not having had a sick day in his life until felled by the heart attack. Though not a patient on our service, Mr. J. would call me over during morning rounds and relate his tale of woe. He conveyed a sense of itching restiveness, seemed prone to ready tears, and was markedly depressed. He beseeched me to speak to his doctor to get him out of bed. “This bed is killing me,” he moaned.\r\n\r\nOne morning, after he had been in bed continuously for about a week, we were having the same forlorn conversation. It was two weeks before Thanksgiving. By happenstance his doctor appeared. More as a plea than question, Mr. J. asked, “Will I soon be out of bed to go home for Thanksgiving?” After all these years I still recall the doctor’s abrupt and peremptory answer: “With your massive heart attack, you’ll be lucky to be home for Christmas.” Mr. J. shuddered, closed his eyes, convulsed, and died. At the time we knew nothing about cardiopulmonary resuscitation or defibrillation. The doctor mumbled as he walked away, “I was right about his prognosis.”\r\n\r\nAt about the same time, a patient of Dr. Levine’s who had had a heart attack developed intractable congestive heart failure. The usual measures — digitalis, diuretics, and oxygen — did not alleviate the breathlessness. Dr. Levine ordered the patient into a chair for two hours daily. He reasoned that gravity would shift the excess fluid from lungs to extremities. In the lungs fluid starves the body of oxygen; in the ankles it is cosmetically unattractive but harmless. Within two days after this new regimen, the patient improved remarkably and went on to recover.\r\n\r\nDr. Levine felt his theory confirmed, though I was not persuaded. In the first place, it was unlikely that gravity could have been effective when the patient spent the majority of time in bed. Other factors must have operated, since his improvement was almost immediate after he sat up in a chair. Most decisively, he did not develop pitting edema in the ankles. When the patient was pressed for an explanation for his turnabout, he answered, “For the first time, I knew I would survive.” The remarkable change in his demeanor confirmed a renewed hold on life. His voice stopped wavering, dropping off at midsentence; his conversation was no longer self-pitying; and his despondent facial expression was replaced by a ready smile.\r\n\r\nThese two experiences undermined my belief in bed rest as an appropriate treatment for heart attack victims. In fact, I agreed with the proverbial Martian visitor. We were torturing patients. In the words of the American theologian Reinhold Niebuhr, “We mean well and do ill, and justify our ill-doing by our well-meaning.” Such justification inhibits a recognition and an acknowledgment of misdeeds. Observing a sudden unnecessary death as well as a seemingly miraculous recovery clinched my resolve to undertake a study that would clarify the merits, if any, of enforced bed rest.\r\n\r\nI suggested to Dr. Levine that we investigate whether treating heart attack patients in a chair altered their prognosis. Each of his newly admitted patients with an acute heart attack would be given the option to spend increasing amounts of time in a chair daily. This was to be carried out on all newly hospitalized patients on his service. Dr. Levine agreed with this protocol.\r\n\r\nAlthough I knew that the project would be a chore, I didn’t expect it to be an act of martyrdom. Little did I realize that violating firmly held traditions can raise a tsunami of opposition. The idea of moving critically ill patients into a chair was regarded as off‑the‑wall. Initially the house staff refused to cooperate and strenuously resisted getting patients out of bed. They accused me of planning to commit crimes not unlike those of the heinous Nazi experimentations in concentration camps. Arriving on the medical ward one morning I was greeted by interns and residents lined up with hands stretched out in a Nazi salute and a “Heil Hitler!” shouted in unison.\r\n\r\nThe study involved getting patients into a comfortable chair for increasing durations on succeeding days. Compared with recumbent patients, ours required fewer narcotics for chest pain, less sedation for anxiety, and fewer sleeping medications. Nurses commented that the patients’ demeanor changed from anxious and depressed to an eagerness to resume normal living. Witnessing even one patient in a chair rapidly won converts from the house staff, who soon became enthusiastic adherents. Patients in chairs promptly began to harangue their doctors to let them walk and pressed for an early discharge.\r\n\r\nDespite dire predictions by senior medical attendants that these patients would experience fatal arrhythmias, heart rupture, or congestive heart failure from an overstressed heart muscle, none of those complications were encountered. Comments by patients experiencing their second or third coronary artery occlusion confirmed that we were on the right track. Invariably they indicated that the current episode was the easiest to bear.\r\n\r\nOur first publication to reach a wide medical audience involved 81 consecutive patients, 61 males and 13 females.(1) Only 8 patients, or 9.9 percent, died during the month of hospitalization. This outcome was impressive, since half the patients on admission were in congestive heart failure, and a quarter had life-threatening disturbances of heart rhythm, findings associated with a high mortality. It was striking that not a single patient experienced thrombophlebitis or pulmonary embolism. At the time this was a dreaded complication, accounting for a quarter of the fatalities among heart attack patients.\r\n\r\nOur sample size was small, the data was largely anecdotal, and there was no simultaneous matched control population, but the findings were so impressive that no other study was ever conducted on the chair treatment. There were grumblings from some senior physicians. I overheard one leading academic joke that the proper name for this new radical management should be the “Boston electric chair treatment for heart attacks.”\r\n\r\nPracticing physicians rapidly abandoned the use of strict bed rest. Until our work, patients were kept in the hospital for a month or longer. Within a few years after our publication, the period of hospitalization was reduced by half. The range of activities permitted to patients was extended, and self‑care became the norm. The hateful and dangerous bedpan was abandoned; walking was allowed earlier; hospital mortality was reduced by about a third. Rehabilitation was hastened, and the return to work was accelerated. The time required for full recovery was reduced from three months to one month. Considering the fact that in the United States about one million people suffer heart attacks annually, perhaps as many as one hundred thousand lives were salvaged each year by this simple strategy.\r\n\r\nOne might ask, why didn’t the victims of the earlier treatment protest? As soon as I posed this question I realized its absurdity. After all, power is tilted largely in favor of doctors. When one entrusts one’s well-being and life to another, scant space is left for questioning the other’s knowledge or behavior. This is especially true for victims of a heart attack. They are well one minute and at death’s door the next. The bed-bound victims, paralyzed in a cocoon of dread, are led to believe that total inactivity and a hibernation-like state is the sole ticket for survival. The prohibition of any movement or exertion reinforces their helplessness and unquestioning submission. Patients are abruptly thrust upon the mercy of forces over which they have no control. The daily visits of their doctors are anticipated with impatience and unease. Moses descending from Mount Sinai could not have been greeted with more reverence. Every syllable is regarded as divine revelation. Bed rest is therefore accepted as mandated from on high.\r\n\r\nThe passage of these many years has not lessened my disquiet about the adherence to a form of care not only without merit but draconian to boot. [KS4] Why subject patients afflicted with a life‑threatening condition to a treatment that could only increase their misery and lead to major complications? This was not just a small error; it was a colossal misjudgment. Why were the deleterious consequences of strict bed rest not detected sooner? Why had this aspect of patient management never been investigated? Why had doctors not sought the opinions of patients and nurses who were intimate witnesses to the harm being inflicted? Until our publication, no systematic investigations of bed rest for heart attack patients had been reported in the medical literature.\r\n\r\nMedical dogmatism is sustained by a multiplicity of factors. Foremost is the fact that doctors traverse an uncertain terrain. Nearly every diagnosis is an act of discovery. Faced with a myriad of variables, a doctor can never be certain which measures will heal. Some remedies that work for one patient are not only ineffective for another but may be injurious or even lethal. In fact, an experienced physician appreciates that outcomes are never predictable except statistically in a large population. Yet the doctor has to treat a particular and distinctive individual. And when confronting pain, infection, hemorrhage, diabetic crisis, life‑threatening arrhythmias, and other serious conditions, doctors cannot delay action until indubitable evidence is available. One might as well be waiting for Godot. Paradoxically, human beings, when compelled to act, learn to justify a chosen course with an assurance unwarranted by the evidence for the course chosen.\r\n\r\nIn pondering other reasons for the practice of strict bed rest, I believe they reflected the sad truth that doctors sixty years ago had little to offer heart attack victims. When good answers are unavailable, bad answers may replace them. Bed rest seemed a logical treatment to reduce the burden on the ever-beating heart. Don’t we go to bed when we are tired? Doesn’t sleep rejuvenate? Don’t doctors plaster‑cast a broken limb to protect it from physical activity? Yet such simplistic reasoning has been responsible for blood letting, stomach freezing, using X-rays for peptic ulcers, impaling catheters in the heart to gauge its function, dispensing hormone therapy to menopausal women, administering lobotomies to the mentally ill. The list seems unending.\r\n\r\nThere was another reason that the detrimental effects of prolonged bed rest were not discovered earlier: the anti-psychology mind-set of medical practitioners. Doctors inadequately appreciate that churning emotions affect every bodily organ. Emotions alter our chemistry, our immune system, our neural traffic; they predispose us to all sorts of illnesses and may even precipitate sudden cardiac death. Even now, when cardiologists list the risk factors for heart disease, the key role of psychosocial and behavioral stress is left unmentioned. No wonder the adverse consequences of enforced bed rest, predominantly emotional, were misperceived and largely ignored.\r\n\r\nWhen a new paradigm takes hold in medicine, its acceptance is extraordinarily rapid. Few acknowledge that they once adhered to a discarded method. This was succinctly captured by the German philosopher Schopenhauer. He maintained that all truth passes through three stages: first, it is ridiculed; second, it is violently opposed; and finally, it is accepted as having always been self‑evident. When recently searching the medical literature, I could find no references to bed rest as a treatment option for those with heart attacks. Perhaps this embarrassment for the medical profession was deemed best forgotten.\r\n\r\n*This subject is discussed in “The Lost Art of Healing” (Ballantine Books 1999) as well as in the Lown Forum, Winter 2011.\r\n\r\n1. Levine SA, Lown B: “Armchair” treatment of acute coronary thrombosis. JAMA 148: 1365‑1369, 1952.\r\n\r\nThis entry was posted in Healthcare and tagged Bed rest, Heart attack treatment. Bookmark the permalink.\r\n3 RESPONSES TO A CHAIR TO THE RESCUE*\r\n\r\nNigel Paneth | February 4, 2011 at 5:47 pm |\r\nDear Dr. Lown:\r\nAs a former student of yours (one week of rounds at the Brigham in 1971) I want to tell you how much I enjoyed your piece on the perils of bed rest in myocardial infarction. I am a collector of examples of low cost-high benefit medical and public health interventions (at an epidemiology meeting presentation, I once called them “cheap thrills”) that contrast very favorably with the latest billion-dollar-a-year pharmacologic innovation.\r\nMy favorite examples (I am a pediatrician) have been folic acid for neural tube defects (less than a penny a day); keeping prematures warm (analagously to heart attack bed rest, it replaced the disaster of keeping them cold) and putting babies to sleep on their backs (halving the sudden infant death rate at no cost at all!). I am very pleased to add your “chair for heart attacks” to this list.\r\n\r\nBarbara Roberts, MD | February 7, 2011 at 10:44 am |\r\nDear Bernard: Thank you for this trip down memory lane. Thank you for pointing out our profession’s frequent hubris. I have to wonder how many of the current “dogmas” in vogue today are harming our patients.\r\n\r\nBarbara Roberts, MD\r\n\r\nSarah Burke (@smrburke) | May 3, 2012 at 10:55 am |\r\nDear Dr. Lown,\r\n\r\nThank you for sharing your experience! I am a public health student with interest in childbirth practices, some might say a bit alternative, and I see this type of ‘protective care’ much too often. From routine episiotomies (much less frequent now than in the 80s-90s, but then again c-sections have risen tremendously), to laboring in bed without continuous support, and directed pushing in supine positions. Most of these practices have no benefits and even harms, according to the literature, yet are routinely used in North American hospitals. Women who arrive in hospital with a birth plan and doula can even be ridiculed for wanting to ‘do what their body does naturally’.\r\n\r\nI admire your courage to change the system of care from the inside, especially in facing the challenges, ridicule, and perhaps even insults from colleagues.’, ‘Lessons from 1950s cardiology ~ why a non-evidence-based medical practice should never be allowed to become the standard of care’, ”, ‘publish’, ‘closed’, ‘closed’, ”, ‘lessons-1950s-cardiology’, ”, ”, ‘2012-08-01 11:39:54’, ‘2012-08-01 11:39:54’, ”, ‘0’, ‘http://faithgibson.org/?p=11’, ‘0’, ‘post’, ”, ‘0’);
INSERT INTO `wp_posts` VALUES(’13’, ‘1’, ‘2012-08-01 11:39:17’, ‘2012-08-01 11:39:17’, ‘This article was first posted on the Canadian <strong>Maternity Care Discussion Group</strong> (MCDG) by Dr. Michael Klein, professor Emeritus of Family Practice &amp; Pediatrics (University British Columbia) and listmaster of the MCDG.\n\nIt tells the story of how total, prolonged, flat-on-your-back bed rest became the standard of care for heart attack patients without any scientific evaluation. It seemed \’so logical\’ to cardiologists that they strenuously opposed doing any research about it. Unfortunately, enforced bed rest turned out to dramatically increase the death rate for such patients. It is a prime example among many of how medical practices, from the perspective of the medical profession, many seem \’appropriate\’ but prove to be very harmful.\n\nConfining women in labor to bed is a routine part of the medicalization of normal labor and birth.  Like bed rest in cardiac patients, the obstetrical profession also strenuously opposed research on the various practices and protocols (immobilization in bed being just one of dozens) that were imposed to supplant physiological management. These protocols all seemed so \’logical\’ to obstetricians that they were never scientifically evaluated prior to their imposition.\n\nWhile immobilization and other labor-related medical interventions rarely results in death or permanent damage for laboring women and their babies, these non-physiological practices profoundly disrupt the biological process required for a normal childbirth. They make it substantially harder (sometimes impossible) to meet the physical and psychological needs of laboring women without resorting to powerful drugs and other medical and surgical interventions.\n\nThe following reposted article is a \’case in point\’ for why we should <strong>not allow medical practices to become \’standard of care\’ without appropriate scientific evaluation. </strong>\n\n<strong></strong>It also <strong>encourages us to keep trying</strong> to change unscientific practices, <em>even when they are popular with the medical professional, the media and most of the lay public. </em> Truth does eventually come forward and win out.\n\nfaith ^O^\n\n<strong>A Chair to the Rescue</strong>\nPosted on February 3, 2011\nBernard Lown, MD\n\nNot so long ago, doctors bled, purged, cupped, and performed all sorts of mayhem to cure diseases about which they had not a clue. With the advent of scientific medicine in the late 19th and early 20th centuries, evidence increasingly guided medical practice. This was particularly true for acute illness. Science, though, remained a porous veneer overlaying the treatment of chronic diseases , especially those afflicting the elderly. With the best of intentions, doctors over-treated their patients with unproven procedures and polypharmacy. These exacted an inordinate toll in suffering, morbidity, and death.\n\nThe advent of scientific medicine did not stop doctors from breaching the hallowed moral injunction of their profession, Primum nihil nocere (“first do no harm”). Early in my medical career I became keenly aware of how doctors — though committed to benefiting their patients — unwittingly harmed them. The insight derived from a transformative experience. It occurred sixty years ago, shortly after I began a cardiovascular fellowship under the mentorship of Dr. Samuel A. Levine at the Peter Bent Brigham Hospital (now the Brigham and Women’s Hospital) in Boston. Dr. Levine was a clinician without peer — astute in diagnosis, innovative in managing intractable clinical problems — and a riveting teacher.\n\nAt the time, the major challenge in hospital-based cardiology was dealing with the steady inflow of patients with acute heart attacks. Care was largely palliative: to relieve chest pain, to prevent blood clots, to ease the breathlessness and edema provoked by a failing heart muscle. Patients were confined to strict bed rest for four to six weeks. Sitting in a chair was prohibited. They were not allowed to turn from side to side without assistance. During the first week, they were fed. Moving their bowels and urinating required a bedpan. For the constipated, which included nearly every patient, precariously balancing on a bedpan was agonizing as well as embarrassing.\n\nBecause world events might provoke unease, some physicians prohibited their patients from listening to the radio or reading a newspaper. Visits by family members were limited. Since recumbency provoked much restiveness and anxiety, patients required heavy sedation, which contributed to a pervasive sense of hopelessness and depression. Around one in three patients died. Not surprisingly, many died from blood clots migrating to their lungs.\n\nIn addition to the pain [KS3] stemming from the heart attack and the accompanying fear of dying, patients had to cope with the torment of isolation, the indignity of infantilization, and the unbearable distress of excessive bed rest. Physicians convinced themselves and their patients that complete bed rest was the price of survival. Visiting Martians, witnessing this travail, might have judged the scene differently, regarding hospitals as prisons where inmates were subjected to a unique form of torture.\n\nTo a medical novice like me, the justification for enforced bed rest was persuasive. It was based on a sacrosanct therapeutic principle, the need to rest a diseased body part, be it a fractured limb or a tuberculosis-afflicted lung. Unlike a broken bone, which could be immobilized in a cast, or a lung lobe, which could be collapsed by inflating the chest cavity with air, the heart could not be cradled into quietude. The only approximation for a diseased heart was to diminish its workload. It was long known that during recumbency the heart rate slows and blood pressure drops, both indices of less oxygen usage and therefore of decreased cardiac work. Heart rest was therefore equated with bed rest.\n\nBut was this the case with those who had sustained a heart attack? In perusing medical journals I could find no reports on the subject, which was surprising, because the literature was dense with articles for managing patients with heart attacks. Being involved with the daily care of these patients, I became rapidly aware of the harm wrought by enforced bed rest.\n\nDr. Levine frequently discussed the adverse effects of prolonged bed rest. Among the possible complications were atelectasis, or a collapse of the lung lobes, predisposing the patient to pneumonia; peripheral vein phlebitis that could lead to fatal pulmonary emboli; lung congestion; prostatism; urinary retention; the thinning of bones; bed sores; frozen shoulders; and constipation. Yet so strong was the weight of tradition that Dr. Levine dared not move to reverse it, even though the harm exacted was evident. This was another illustration of medical tradition derailing healthy skepticism and impeding commonsense measures. Lacking was a categorical moral urgency among physicians, without which tradition is rarely altered.\n\nExperience with two patients compelled me to rebel against the entrenched practice of bed rest. The first involved a man in his early fifties. Mr. J. had been a robust, hustling, successful salesman. He bragged about not having had a sick day in his life until felled by the heart attack. Though not a patient on our service, Mr. J. would call me over during morning rounds and relate his tale of woe. He conveyed a sense of itching restiveness, seemed prone to ready tears, and was markedly depressed. He beseeched me to speak to his doctor to get him out of bed. “This bed is killing me,” he moaned.\n\nOne morning, after he had been in bed continuously for about a week, we were having the same forlorn conversation. It was two weeks before Thanksgiving. By happenstance his doctor appeared. More as a plea than question, Mr. J. asked, “Will I soon be out of bed to go home for Thanksgiving?” After all these years I still recall the doctor’s abrupt and peremptory answer: “With your massive heart attack, you’ll be lucky to be home for Christmas.” Mr. J. shuddered, closed his eyes, convulsed, and died. At the time we knew nothing about cardiopulmonary resuscitation or defibrillation. The doctor mumbled as he walked away, “I was right about his prognosis.”\n\nAt about the same time, a patient of Dr. Levine’s who had had a heart attack developed intractable congestive heart failure. The usual measures — digitalis, diuretics, and oxygen — did not alleviate the breathlessness. Dr. Levine ordered the patient into a chair for two hours daily. He reasoned that gravity would shift the excess fluid from lungs to extremities. In the lungs fluid starves the body of oxygen; in the ankles it is cosmetically unattractive but harmless. Within two days after this new regimen, the patient improved remarkably and went on to recover.\n\nDr. Levine felt his theory confirmed, though I was not persuaded. In the first place, it was unlikely that gravity could have been effective when the patient spent the majority of time in bed. Other factors must have operated, since his improvement was almost immediate after he sat up in a chair. Most decisively, he did not develop pitting edema in the ankles. When the patient was pressed for an explanation for his turnabout, he answered, “For the first time, I knew I would survive.” The remarkable change in his demeanor confirmed a renewed hold on life. His voice stopped wavering, dropping off at midsentence; his conversation was no longer self-pitying; and his despondent facial expression was replaced by a ready smile.\n\nThese two experiences undermined my belief in bed rest as an appropriate treatment for heart attack victims. In fact, I agreed with the proverbial Martian visitor. We were torturing patients. In the words of the American theologian Reinhold Niebuhr, “We mean well and do ill, and justify our ill-doing by our well-meaning.” Such justification inhibits a recognition and an acknowledgment of misdeeds. Observing a sudden unnecessary death as well as a seemingly miraculous recovery clinched my resolve to undertake a study that would clarify the merits, if any, of enforced bed rest.\n\nI suggested to Dr. Levine that we investigate whether treating heart attack patients in a chair altered their prognosis. Each of his newly admitted patients with an acute heart attack would be given the option to spend increasing amounts of time in a chair daily. This was to be carried out on all newly hospitalized patients on his service. Dr. Levine agreed with this protocol.\n\nAlthough I knew that the project would be a chore, I didn’t expect it to be an act of martyrdom. Little did I realize that violating firmly held traditions can raise a tsunami of opposition. The idea of moving critically ill patients into a chair was regarded as off‑the‑wall. Initially the house staff refused to cooperate and strenuously resisted getting patients out of bed. They accused me of planning to commit crimes not unlike those of the heinous Nazi experimentations in concentration camps. Arriving on the medical ward one morning I was greeted by interns and residents lined up with hands stretched out in a Nazi salute and a “Heil Hitler!” shouted in unison.\n\nThe study involved getting patients into a comfortable chair for increasing durations on succeeding days. Compared with recumbent patients, ours required fewer narcotics for chest pain, less sedation for anxiety, and fewer sleeping medications. Nurses commented that the patients’ demeanor changed from anxious and depressed to an eagerness to resume normal living. Witnessing even one patient in a chair rapidly won converts from the house staff, who soon became enthusiastic adherents. Patients in chairs promptly began to harangue their doctors to let them walk and pressed for an early discharge.\n\nDespite dire predictions by senior medical attendants that these patients would experience fatal arrhythmias, heart rupture, or congestive heart failure from an overstressed heart muscle, none of those complications were encountered. Comments by patients experiencing their second or third coronary artery occlusion confirmed that we were on the right track. Invariably they indicated that the current episode was the easiest to bear.\n\nOur first publication to reach a wide medical audience involved 81 consecutive patients, 61 males and 13 females.(1) Only 8 patients, or 9.9 percent, died during the month of hospitalization. This outcome was impressive, since half the patients on admission were in congestive heart failure, and a quarter had life-threatening disturbances of heart rhythm, findings associated with a high mortality. It was striking that not a single patient experienced thrombophlebitis or pulmonary embolism. At the time this was a dreaded complication, accounting for a quarter of the fatalities among heart attack patients.\n\nOur sample size was small, the data was largely anecdotal, and there was no simultaneous matched control population, but the findings were so impressive that no other study was ever conducted on the chair treatment. There were grumblings from some senior physicians. I overheard one leading academic joke that the proper name for this new radical management should be the “Boston electric chair treatment for heart attacks.”\n\nPracticing physicians rapidly abandoned the use of strict bed rest. Until our work, patients were kept in the hospital for a month or longer. Within a few years after our publication, the period of hospitalization was reduced by half. The range of activities permitted to patients was extended, and self‑care became the norm. The hateful and dangerous bedpan was abandoned; walking was allowed earlier; hospital mortality was reduced by about a third. Rehabilitation was hastened, and the return to work was accelerated. The time required for full recovery was reduced from three months to one month. Considering the fact that in the United States about one million people suffer heart attacks annually, perhaps as many as one hundred thousand lives were salvaged each year by this simple strategy.\n\nOne might ask, why didn’t the victims of the earlier treatment protest? As soon as I posed this question I realized its absurdity. After all, power is tilted largely in favor of doctors. When one entrusts one’s well-being and life to another, scant space is left for questioning the other’s knowledge or behavior. This is especially true for victims of a heart attack. They are well one minute and at death’s door the next. The bed-bound victims, paralyzed in a cocoon of dread, are led to believe that total inactivity and a hibernation-like state is the sole ticket for survival. The prohibition of any movement or exertion reinforces their helplessness and unquestioning submission. Patients are abruptly thrust upon the mercy of forces over which they have no control. The daily visits of their doctors are anticipated with impatience and unease. Moses descending from Mount Sinai could not have been greeted with more reverence. Every syllable is regarded as divine revelation. Bed rest is therefore accepted as mandated from on high.\n\nThe passage of these many years has not lessened my disquiet about the adherence to a form of care not only without merit but draconian to boot. [KS4] Why subject patients afflicted with a life‑threatening condition to a treatment that could only increase their misery and lead to major complications? This was not just a small error; it was a colossal misjudgment. Why were the deleterious consequences of strict bed rest not detected sooner? Why had this aspect of patient management never been investigated? Why had doctors not sought the opinions of patients and nurses who were intimate witnesses to the harm being inflicted? Until our publication, no systematic investigations of bed rest for heart attack patients had been reported in the medical literature.\n\nMedical dogmatism is sustained by a multiplicity of factors. Foremost is the fact that doctors traverse an uncertain terrain. Nearly every diagnosis is an act of discovery. Faced with a myriad of variables, a doctor can never be certain which measures will heal. Some remedies that work for one patient are not only ineffective for another but may be injurious or even lethal. In fact, an experienced physician appreciates that outcomes are never predictable except statistically in a large population. Yet the doctor has to treat a particular and distinctive individual. And when confronting pain, infection, hemorrhage, diabetic crisis, life‑threatening arrhythmias, and other serious conditions, doctors cannot delay action until indubitable evidence is available. One might as well be waiting for Godot. Paradoxically, human beings, when compelled to act, learn to justify a chosen course with an assurance unwarranted by the evidence for the course chosen.\n\nIn pondering other reasons for the practice of strict bed rest, I believe they reflected the sad truth that doctors sixty years ago had little to offer heart attack victims. When good answers are unavailable, bad answers may replace them. Bed rest seemed a logical treatment to reduce the burden on the ever-beating heart. Don’t we go to bed when we are tired? Doesn’t sleep rejuvenate? Don’t doctors plaster‑cast a broken limb to protect it from physical activity? Yet such simplistic reasoning has been responsible for blood letting, stomach freezing, using X-rays for peptic ulcers, impaling catheters in the heart to gauge its function, dispensing hormone therapy to menopausal women, administering lobotomies to the mentally ill. The list seems unending.\n\nThere was another reason that the detrimental effects of prolonged bed rest were not discovered earlier: the anti-psychology mind-set of medical practitioners. Doctors inadequately appreciate that churning emotions affect every bodily organ. Emotions alter our chemistry, our immune system, our neural traffic; they predispose us to all sorts of illnesses and may even precipitate sudden cardiac death. Even now, when cardiologists list the risk factors for heart disease, the key role of psychosocial and behavioral stress is left unmentioned. No wonder the adverse consequences of enforced bed rest, predominantly emotional, were misperceived and largely ignored.\n\nWhen a new paradigm takes hold in medicine, its acceptance is extraordinarily rapid. Few acknowledge that they once adhered to a discarded method. This was succinctly captured by the German philosopher Schopenhauer. He maintained that all truth passes through three stages: first, it is ridiculed; second, it is violently opposed; and finally, it is accepted as having always been self‑evident. When recently searching the medical literature, I could find no references to bed rest as a treatment option for those with heart attacks. Perhaps this embarrassment for the medical profession was deemed best forgotten.\n\n*This subject is discussed in “The Lost Art of Healing” (Ballantine Books 1999) as well as in the Lown Forum, Winter 2011.\n\n1. Levine SA, Lown B: “Armchair” treatment of acute coronary thrombosis. JAMA 148: 1365‑1369, 1952.\n\nThis entry was posted in Healthcare and tagged Bed rest, Heart attack treatment. Bookmark the permalink.\n3 RESPONSES TO A CHAIR TO THE RESCUE*\n\nNigel Paneth | February 4, 2011 at 5:47 pm |\nDear Dr. Lown:\nAs a former student of yours (one week of rounds at the Brigham in 1971) I want to tell you how much I enjoyed your piece on the perils of bed rest in myocardial infarction. I am a collector of examples of low cost-high benefit medical and public health interventions (at an epidemiology meeting presentation, I once called them “cheap thrills”) that contrast very favorably with the latest billion-dollar-a-year pharmacologic innovation.\nMy favorite examples (I am a pediatrician) have been folic acid for neural tube defects (less than a penny a day); keeping prematures warm (analagously to heart attack bed rest, it replaced the disaster of keeping them cold) and putting babies to sleep on their backs (halving the sudden infant death rate at no cost at all!). I am very pleased to add your “chair for heart attacks” to this list.\n\nBarbara Roberts, MD | February 7, 2011 at 10:44 am |\nDear Bernard: Thank you for this trip down memory lane. Thank you for pointing out our profession’s frequent hubris. I have to wonder how many of the current “dogmas” in vogue today are harming our patients.\n\nBarbara Roberts, MD\n\nSarah Burke (@smrburke) | May 3, 2012 at 10:55 am |\nDear Dr. Lown,\n\nThank you for sharing your experience! I am a public health student with interest in childbirth practices, some might say a bit alternative, and I see this type of ‘protective care’ much too often. From routine episiotomies (much less frequent now than in the 80s-90s, but then again c-sections have risen tremendously), to laboring in bed without continuous support, and directed pushing in supine positions. Most of these practices have no benefits and even harms, according to the literature, yet are routinely used in North American hospitals. Women who arrive in hospital with a birth plan and doula can even be ridiculed for wanting to ‘do what their body does naturally’.\n\nI admire your courage to change the system of care from the inside, especially in facing the challenges, ridicule, and perhaps even insults from colleagues.’, ‘Lessons from 1950s cardiology ~ why a non-evidence-based medical practice should never be allowed to become the standard of care’, ”, ‘inherit’, ‘open’, ‘open’, ”, ’11-autosave’, ”, ”, ‘2012-08-01 11:39:17’, ‘2012-08-01 11:39:17′, ”, ’11’, ‘http://faithgibson.org/11-autosave/13/’, ‘0’, ‘revision’, ”, ‘0’);
INSERT INTO `wp_posts` VALUES(’20’, ‘1’, ‘2012-06-22 23:28:19’, ‘2012-06-22 23:28:19’, ‘This article was first posted on the Canadian <strong>Maternity Care Discussion Group</strong> (MCDG) by Dr. Michael Klein, professor Emeritus of Family Practice &amp; Pediatrics (University British Columbia) and listmaster of the MCDG.\r\n\r\nIt tells the story of how total, prolonged, flat-on-your-back bed rest became the standard of care for heart attack patients without any scientific evaluation. It seemed \’so logical\’ to cardiologists that they strenuously opposed doing any research about it. Unfortunately, enforced bed rest turned out to dramatically increase the death rate for such patients. It is a prime example among many of how medical practices, from the perspective of the medical profession, many seem \’appropriate\’ but prove to be very harmful.\r\n\r\nConfining women in labor to bed is a routine part of the medicalization of normal labor and birth.  Like bed rest in cardiac patients, the obstetrical profession also strenuously opposed research on the various practices and protocols (immobilization in bed being just one of dozens) that were imposed to supplant physiological management. These protocols all seemed so \’logical\’ to obstetricians that they were never scientifically evaluated prior to their imposition.\r\n\r\nWhile immobilization and other labor-related medical interventions rarely results in death or permanent damage for laboring women and their babies, these non-physiological practices profoundly disrupt the biological process required for a normal childbirth. They make it substantially harder (sometimes impossible) to meet the physical and psychological needs of laboring women without resorting to powerful drugs and other medical and surgical interventions.\r\n\r\nThe following reposted article is a \’case in point\’ for why we should <strong>not allow medical practices to become \’standard of care\’ without appropriate scientific evaluation. </strong>\r\n\r\n<strong></strong>It also <strong>encourages us to keep trying</strong> to change unscientific practices, <em>even when they are popular with the medical professional, the media and most of the lay public. </em> Truth does eventually come forward and win out.\r\n\r\nfaith ^O^\r\n\r\n<strong>A Chair to the Rescue</strong>\r\nPosted on February 3, 2011\r\nBernard Lown, MD\r\n\r\nNot so long ago, doctors bled, purged, cupped, and performed all sorts of mayhem to cure diseases about which they had not a clue. With the advent of scientific medicine in the late 19th and early 20th centuries, evidence increasingly guided medical practice. This was particularly true for acute illness. Science, though, remained a porous veneer overlaying the treatment of chronic diseases , especially those afflicting the elderly. With the best of intentions, doctors over-treated their patients with unproven procedures and polypharmacy. These exacted an inordinate toll in suffering, morbidity, and death.\r\n\r\nThe advent of scientific medicine did not stop doctors from breaching the hallowed moral injunction of their profession, Primum nihil nocere (“first do no harm”). Early in my medical career I became keenly aware of how doctors — though committed to benefiting their patients — unwittingly harmed them. The insight derived from a transformative experience. It occurred sixty years ago, shortly after I began a cardiovascular fellowship under the mentorship of Dr. Samuel A. Levine at the Peter Bent Brigham Hospital (now the Brigham and Women’s Hospital) in Boston. Dr. Levine was a clinician without peer — astute in diagnosis, innovative in managing intractable clinical problems — and a riveting teacher.\r\n\r\nAt the time, the major challenge in hospital-based cardiology was dealing with the steady inflow of patients with acute heart attacks. Care was largely palliative: to relieve chest pain, to prevent blood clots, to ease the breathlessness and edema provoked by a failing heart muscle. Patients were confined to strict bed rest for four to six weeks. Sitting in a chair was prohibited. They were not allowed to turn from side to side without assistance. During the first week, they were fed. Moving their bowels and urinating required a bedpan. For the constipated, which included nearly every patient, precariously balancing on a bedpan was agonizing as well as embarrassing.\r\n\r\nBecause world events might provoke unease, some physicians prohibited their patients from listening to the radio or reading a newspaper. Visits by family members were limited. Since recumbency provoked much restiveness and anxiety, patients required heavy sedation, which contributed to a pervasive sense of hopelessness and depression. Around one in three patients died. Not surprisingly, many died from blood clots migrating to their lungs.\r\n\r\nIn addition to the pain [KS3] stemming from the heart attack and the accompanying fear of dying, patients had to cope with the torment of isolation, the indignity of infantilization, and the unbearable distress of excessive bed rest. Physicians convinced themselves and their patients that complete bed rest was the price of survival. Visiting Martians, witnessing this travail, might have judged the scene differently, regarding hospitals as prisons where inmates were subjected to a unique form of torture.\r\n\r\nTo a medical novice like me, the justification for enforced bed rest was persuasive. It was based on a sacrosanct therapeutic principle, the need to rest a diseased body part, be it a fractured limb or a tuberculosis-afflicted lung. Unlike a broken bone, which could be immobilized in a cast, or a lung lobe, which could be collapsed by inflating the chest cavity with air, the heart could not be cradled into quietude. The only approximation for a diseased heart was to diminish its workload. It was long known that during recumbency the heart rate slows and blood pressure drops, both indices of less oxygen usage and therefore of decreased cardiac work. Heart rest was therefore equated with bed rest.\r\n\r\nBut was this the case with those who had sustained a heart attack? In perusing medical journals I could find no reports on the subject, which was surprising, because the literature was dense with articles for managing patients with heart attacks. Being involved with the daily care of these patients, I became rapidly aware of the harm wrought by enforced bed rest.\r\n\r\nDr. Levine frequently discussed the adverse effects of prolonged bed rest. Among the possible complications were atelectasis, or a collapse of the lung lobes, predisposing the patient to pneumonia; peripheral vein phlebitis that could lead to fatal pulmonary emboli; lung congestion; prostatism; urinary retention; the thinning of bones; bed sores; frozen shoulders; and constipation. Yet so strong was the weight of tradition that Dr. Levine dared not move to reverse it, even though the harm exacted was evident. This was another illustration of medical tradition derailing healthy skepticism and impeding commonsense measures. Lacking was a categorical moral urgency among physicians, without which tradition is rarely altered.\r\n\r\nExperience with two patients compelled me to rebel against the entrenched practice of bed rest. The first involved a man in his early fifties. Mr. J. had been a robust, hustling, successful salesman. He bragged about not having had a sick day in his life until felled by the heart attack. Though not a patient on our service, Mr. J. would call me over during morning rounds and relate his tale of woe. He conveyed a sense of itching restiveness, seemed prone to ready tears, and was markedly depressed. He beseeched me to speak to his doctor to get him out of bed. “This bed is killing me,” he moaned.\r\n\r\nOne morning, after he had been in bed continuously for about a week, we were having the same forlorn conversation. It was two weeks before Thanksgiving. By happenstance his doctor appeared. More as a plea than question, Mr. J. asked, “Will I soon be out of bed to go home for Thanksgiving?” After all these years I still recall the doctor’s abrupt and peremptory answer: “With your massive heart attack, you’ll be lucky to be home for Christmas.” Mr. J. shuddered, closed his eyes, convulsed, and died. At the time we knew nothing about cardiopulmonary resuscitation or defibrillation. The doctor mumbled as he walked away, “I was right about his prognosis.”\r\n\r\nAt about the same time, a patient of Dr. Levine’s who had had a heart attack developed intractable congestive heart failure. The usual measures — digitalis, diuretics, and oxygen — did not alleviate the breathlessness. Dr. Levine ordered the patient into a chair for two hours daily. He reasoned that gravity would shift the excess fluid from lungs to extremities. In the lungs fluid starves the body of oxygen; in the ankles it is cosmetically unattractive but harmless. Within two days after this new regimen, the patient improved remarkably and went on to recover.\r\n\r\nDr. Levine felt his theory confirmed, though I was not persuaded. In the first place, it was unlikely that gravity could have been effective when the patient spent the majority of time in bed. Other factors must have operated, since his improvement was almost immediate after he sat up in a chair. Most decisively, he did not develop pitting edema in the ankles. When the patient was pressed for an explanation for his turnabout, he answered, “For the first time, I knew I would survive.” The remarkable change in his demeanor confirmed a renewed hold on life. His voice stopped wavering, dropping off at midsentence; his conversation was no longer self-pitying; and his despondent facial expression was replaced by a ready smile.\r\n\r\nThese two experiences undermined my belief in bed rest as an appropriate treatment for heart attack victims. In fact, I agreed with the proverbial Martian visitor. We were torturing patients. In the words of the American theologian Reinhold Niebuhr, “We mean well and do ill, and justify our ill-doing by our well-meaning.” Such justification inhibits a recognition and an acknowledgment of misdeeds. Observing a sudden unnecessary death as well as a seemingly miraculous recovery clinched my resolve to undertake a study that would clarify the merits, if any, of enforced bed rest.\r\n\r\nI suggested to Dr. Levine that we investigate whether treating heart attack patients in a chair altered their prognosis. Each of his newly admitted patients with an acute heart attack would be given the option to spend increasing amounts of time in a chair daily. This was to be carried out on all newly hospitalized patients on his service. Dr. Levine agreed with this protocol.\r\n\r\nAlthough I knew that the project would be a chore, I didn’t expect it to be an act of martyrdom. Little did I realize that violating firmly held traditions can raise a tsunami of opposition. The idea of moving critically ill patients into a chair was regarded as off‑the‑wall. Initially the house staff refused to cooperate and strenuously resisted getting patients out of bed. They accused me of planning to commit crimes not unlike those of the heinous Nazi experimentations in concentration camps. Arriving on the medical ward one morning I was greeted by interns and residents lined up with hands stretched out in a Nazi salute and a “Heil Hitler!” shouted in unison.\r\n\r\nThe study involved getting patients into a comfortable chair for increasing durations on succeeding days. Compared with recumbent patients, ours required fewer narcotics for chest pain, less sedation for anxiety, and fewer sleeping medications. Nurses commented that the patients’ demeanor changed from anxious and depressed to an eagerness to resume normal living. Witnessing even one patient in a chair rapidly won converts from the house staff, who soon became enthusiastic adherents. Patients in chairs promptly began to harangue their doctors to let them walk and pressed for an early discharge.\r\n\r\nDespite dire predictions by senior medical attendants that these patients would experience fatal arrhythmias, heart rupture, or congestive heart failure from an overstressed heart muscle, none of those complications were encountered. Comments by patients experiencing their second or third coronary artery occlusion confirmed that we were on the right track. Invariably they indicated that the current episode was the easiest to bear.\r\n\r\nOur first publication to reach a wide medical audience involved 81 consecutive patients, 61 males and 13 females.(1) Only 8 patients, or 9.9 percent, died during the month of hospitalization. This outcome was impressive, since half the patients on admission were in congestive heart failure, and a quarter had life-threatening disturbances of heart rhythm, findings associated with a high mortality. It was striking that not a single patient experienced thrombophlebitis or pulmonary embolism. At the time this was a dreaded complication, accounting for a quarter of the fatalities among heart attack patients.\r\n\r\nOur sample size was small, the data was largely anecdotal, and there was no simultaneous matched control population, but the findings were so impressive that no other study was ever conducted on the chair treatment. There were grumblings from some senior physicians. I overheard one leading academic joke that the proper name for this new radical management should be the “Boston electric chair treatment for heart attacks.”\r\n\r\nPracticing physicians rapidly abandoned the use of strict bed rest. Until our work, patients were kept in the hospital for a month or longer. Within a few years after our publication, the period of hospitalization was reduced by half. The range of activities permitted to patients was extended, and self‑care became the norm. The hateful and dangerous bedpan was abandoned; walking was allowed earlier; hospital mortality was reduced by about a third. Rehabilitation was hastened, and the return to work was accelerated. The time required for full recovery was reduced from three months to one month. Considering the fact that in the United States about one million people suffer heart attacks annually, perhaps as many as one hundred thousand lives were salvaged each year by this simple strategy.\r\n\r\nOne might ask, why didn’t the victims of the earlier treatment protest? As soon as I posed this question I realized its absurdity. After all, power is tilted largely in favor of doctors. When one entrusts one’s well-being and life to another, scant space is left for questioning the other’s knowledge or behavior. This is especially true for victims of a heart attack. They are well one minute and at death’s door the next. The bed-bound victims, paralyzed in a cocoon of dread, are led to believe that total inactivity and a hibernation-like state is the sole ticket for survival. The prohibition of any movement or exertion reinforces their helplessness and unquestioning submission. Patients are abruptly thrust upon the mercy of forces over which they have no control. The daily visits of their doctors are anticipated with impatience and unease. Moses descending from Mount Sinai could not have been greeted with more reverence. Every syllable is regarded as divine revelation. Bed rest is therefore accepted as mandated from on high.\r\n\r\nThe passage of these many years has not lessened my disquiet about the adherence to a form of care not only without merit but draconian to boot. [KS4] Why subject patients afflicted with a life‑threatening condition to a treatment that could only increase their misery and lead to major complications? This was not just a small error; it was a colossal misjudgment. Why were the deleterious consequences of strict bed rest not detected sooner? Why had this aspect of patient management never been investigated? Why had doctors not sought the opinions of patients and nurses who were intimate witnesses to the harm being inflicted? Until our publication, no systematic investigations of bed rest for heart attack patients had been reported in the medical literature.\r\n\r\nMedical dogmatism is sustained by a multiplicity of factors. Foremost is the fact that doctors traverse an uncertain terrain. Nearly every diagnosis is an act of discovery. Faced with a myriad of variables, a doctor can never be certain which measures will heal. Some remedies that work for one patient are not only ineffective for another but may be injurious or even lethal. In fact, an experienced physician appreciates that outcomes are never predictable except statistically in a large population. Yet the doctor has to treat a particular and distinctive individual. And when confronting pain, infection, hemorrhage, diabetic crisis, life‑threatening arrhythmias, and other serious conditions, doctors cannot delay action until indubitable evidence is available. One might as well be waiting for Godot. Paradoxically, human beings, when compelled to act, learn to justify a chosen course with an assurance unwarranted by the evidence for the course chosen.\r\n\r\nIn pondering other reasons for the practice of strict bed rest, I believe they reflected the sad truth that doctors sixty years ago had little to offer heart attack victims. When good answers are unavailable, bad answers may replace them. Bed rest seemed a logical treatment to reduce the burden on the ever-beating heart. Don’t we go to bed when we are tired? Doesn’t sleep rejuvenate? Don’t doctors plaster‑cast a broken limb to protect it from physical activity? Yet such simplistic reasoning has been responsible for blood letting, stomach freezing, using X-rays for peptic ulcers, impaling catheters in the heart to gauge its function, dispensing hormone therapy to menopausal women, administering lobotomies to the mentally ill. The list seems unending.\r\n\r\nThere was another reason that the detrimental effects of prolonged bed rest were not discovered earlier: the anti-psychology mind-set of medical practitioners. Doctors inadequately appreciate that churning emotions affect every bodily organ. Emotions alter our chemistry, our immune system, our neural traffic; they predispose us to all sorts of illnesses and may even precipitate sudden cardiac death. Even now, when cardiologists list the risk factors for heart disease, the key role of psychosocial and behavioral stress is left unmentioned. No wonder the adverse consequences of enforced bed rest, predominantly emotional, were misperceived and largely ignored.\r\n\r\nWhen a new paradigm takes hold in medicine, its acceptance is extraordinarily rapid. Few acknowledge that they once adhered to a discarded method. This was succinctly captured by the German philosopher Schopenhauer. He maintained that all truth passes through three stages: first, it is ridiculed; second, it is violently opposed; and finally, it is accepted as having always been self‑evident. When recently searching the medical literature, I could find no references to bed rest as a treatment option for those with heart attacks. Perhaps this embarrassment for the medical profession was deemed best forgotten.\r\n\r\n*This subject is discussed in “The Lost Art of Healing” (Ballantine Books 1999) as well as in the Lown Forum, Winter 2011.\r\n\r\n1. Levine SA, Lown B: “Armchair” treatment of acute coronary thrombosis. JAMA 148: 1365‑1369, 1952.\r\n\r\nThis entry was posted in Healthcare and tagged Bed rest, Heart attack treatment. Bookmark the permalink.\r\n3 RESPONSES TO A CHAIR TO THE RESCUE*\r\n\r\nNigel Paneth | February 4, 2011 at 5:47 pm |\r\nDear Dr. Lown:\r\nAs a former student of yours (one week of rounds at the Brigham in 1971) I want to tell you how much I enjoyed your piece on the perils of bed rest in myocardial infarction. I am a collector of examples of low cost-high benefit medical and public health interventions (at an epidemiology meeting presentation, I once called them “cheap thrills”) that contrast very favorably with the latest billion-dollar-a-year pharmacologic innovation.\r\nMy favorite examples (I am a pediatrician) have been folic acid for neural tube defects (less than a penny a day); keeping prematures warm (analagously to heart attack bed rest, it replaced the disaster of keeping them cold) and putting babies to sleep on their backs (halving the sudden infant death rate at no cost at all!). I am very pleased to add your “chair for heart attacks” to this list.\r\n\r\nBarbara Roberts, MD | February 7, 2011 at 10:44 am |\r\nDear Bernard: Thank you for this trip down memory lane. Thank you for pointing out our profession’s frequent hubris. I have to wonder how many of the current “dogmas” in vogue today are harming our patients.\r\n\r\nBarbara Roberts, MD\r\n\r\nSarah Burke (@smrburke) | May 3, 2012 at 10:55 am |\r\nDear Dr. Lown,\r\n\r\nThank you for sharing your experience! I am a public health student with interest in childbirth practices, some might say a bit alternative, and I see this type of ‘protective care’ much too often. From routine episiotomies (much less frequent now than in the 80s-90s, but then again c-sections have risen tremendously), to laboring in bed without continuous support, and directed pushing in supine positions. Most of these practices have no benefits and even harms, according to the literature, yet are routinely used in North American hospitals. Women who arrive in hospital with a birth plan and doula can even be ridiculed for wanting to ‘do what their body does naturally’.\r\n\r\nI admire your courage to change the system of care from the inside, especially in facing the challenges, ridicule, and perhaps even insults from colleagues.’, ‘Lessons from 1950s cardiology ~ why a non-evidence-based medical practice should never be allowed to become the standard of care’, ”, ‘inherit’, ‘open’, ‘open’, ”, ’11-revision-8′, ”, ”, ‘2012-06-22 23:28:19’, ‘2012-06-22 23:28:19′, ”, ’11’, ‘http://faithgibson.org/11-revision-8/20/’, ‘0’, ‘revision’, ”, ‘0’);
INSERT INTO `wp_posts` VALUES(’21’, ‘1’, ‘2012-06-25 06:19:51’, ‘2012-06-25 06:19:51’, ‘<strong>Court-Ordered Care — A Complication of Pregnancy to Avoid</strong>\r\n\r\nJulie D. Cantor, M.D., J.D.\r\n\r\nN Engl J Med 2012; 366:2237-2240 <a href=\”http://www.nejm.org/toc/nejm/366/24/\”>June 14, 2012</a>\r\n\r\n<dl><dd id=\”article\”>\r\n<div>\r\n<div>\r\n\r\n<a href=\”http://www.nejm.org/action/showMediaPlayer?doi=10.1056%2FNEJMp1203742&amp;aid=NEJMp1203742_attach_1&amp;area=\”><img src=\”http://www.nejm.org/na102/home/ACS/publisher/mms/journals/content/nejm/2012/nejm_2012.366.issue-24/nejmp1203742/production/images/nejm_cantorp_06-14-2012.jpg\” alt=\”Interview with Dr. Julie Cantor on court-ordered care for pregnant women in the United States.\” /></a>\r\n\r\nInterview with Dr. Julie Cantor on court-ordered care for pregnant women in the United States. (14:03)\r\n<ul>\r\n <li><a href=\”http://www.nejm.org/action/showMediaPlayer?doi=10.1056%2FNEJMp1203742&amp;aid=NEJMp1203742_attach_1&amp;area=\” rel=\”10.1056/NEJMp1203742\”>Listen</a></li>\r\n <li><a href=\”http://www.nejm.org/doi/media/10.1056/NEJMp1203742/NEJM_CantorP_06-14-2012.mp3?area=\” rel=\”10.1056/NEJMp1203742\”>Download</a></li>\r\n</ul>\r\n</div>\r\n</div>\r\n<strong>S</strong>amantha Burton was 25 weeks pregnant when her membranes ruptured. Burton\’s obstetrician admitted her to Tallahassee Memorial Hospital (TMH) and prescribed continuous inpatient bed rest. But with two young children and a job to consider, Burton found the prospect of a 3-month hospital stay overwhelming. She decided to go home. When she tried to leave, authorities barred her exit.\r\n\r\nSoon, the machinery of court-ordered care started rolling. TMH\’s outside counsel, deputized by the local state attorney to act on Florida\’s behalf, petitioned for judicial approval to force Burton to follow doctors\’ orders. Within hours, the court heard argument from the hospital–state attorney and testimony from the obstetrician — now considered “the unborn child\’s attending physician.”<a href=\”http://www.nejm.org/doi/full/10.1056/NEJMp1203742?query=TOC#ref1\” rel=\”#refLayer\”>1</a> Burton testified by phone from the hospital, without counsel.\r\n\r\nThe next day, the <strong>judge gave TMH, any attending health care provider, and members and employees of the original obstetrician\’s practice permission to administer any care they deemed necessary</strong> to preserve the fetus\’s life and health.<a href=\”http://www.nejm.org/doi/full/10.1056/NEJMp1203742?query=TOC#ref1\” rel=\”#refLayer\”>1</a> He ordered Burton to comply and denied her request to change hospitals. Within days, <strong>doctors delivered a dead fetus by cesarean section.</strong>\r\n\r\nThe prevalence of such orders is unclear. One scholar found that “between 1973 and 1992 courts in at least twenty-five states and the District of Columbia granted orders to doctors seeking to overrule their pregnant patients\’ refusal to consent to medical treatment.”<a href=\”http://www.nejm.org/doi/full/10.1056/NEJMp1203742?query=TOC#ref2\” rel=\”#refLayer\”>2</a> A 2003 survey of directors of fellowship programs in maternal–fetal medicine reported nine forced-care cases, and orders for cesarean section or blood transfusion were obtained in eight.<a href=\”http://www.nejm.org/doi/full/10.1056/NEJMp1203742?query=TOC#ref3\” rel=\”#refLayer\”>3</a> A 2007 study of 229 obstetricians and 126 health lawyers showed that 51% “were highly likely to support the use of judicial authority” to force a patient to undergo an unwanted cesarean section.<a href=\”http://www.nejm.org/doi/full/10.1056/NEJMp1203742?query=TOC#ref4\” rel=\”#refLayer\”>4</a> In 2004, a Pennsylvania hospital obtained a court order for doctors to do just that (see the <a href=\”http://www.nejm.org/doi/suppl/10.1056/NEJMp1203742/suppl_file/nejmp1203742_appendix.pdf\”>Supplementary Appendix</a>, available with the full text of this article at NEJM.org), but the patient had already left that hospital and <strong>had an uneventful vaginal delivery at another hospital.</strong>\r\n\r\nForced-care advocates argue that the state has strong interests in fetal well-being that must be balanced against the mother\’s rights, that pregnant women must defer to health care providers who conclude that fetal health or life is at risk, and that women have special obligations to fetuses they choose to carry to term. Physicians may believe that judicial intervention will protect them from litigation if a pregnant woman refuses care and the fetus is harmed.\r\n\r\nBut why should pregnancy diminish a competent adult woman\’s right to refuse care? Citizens have no legal duty to use their bodies to save one another; even parents have no such legal duty to their children. It follows, then, that “a fetus cannot have rights in this respect superior to those of a person who has already been born” (<em>In re A.C</em>.).\r\n\r\nMoreover, the due-process considerations are profound. Because these cases are usually heard on an emergency basis, judicial decisions are made without full briefing on relevant law, medicine, and policy. Unlike alleged criminals, patients have no Sixth Amendment right to counsel, and they cannot instantaneously find expert witnesses to testify on their behalf. And hospital lawyers acting as state attorneys have a clear conflict of interest: as even the Supreme Court of Florida has noted, it is inappropriate for a hospital “to argue zealously against the wishes of its own patient,” and “it cannot act on behalf of the State to assert the state interests” when a competent adult refuses care (<em>Matter of Dubreuil</em>).\r\n\r\nCoerced care also devalues the inherent risks to maternal health and life. Cesarean sections and blood transfusions are not risk-free, and bed rest is neither benign nor evidence-based. Obstetricians aren\’t omniscient and may defer to culture over data. Forced care also ignores individuals\’ and families\’ values, reinforces inequality between the sexes, threatens to drive women from care, and condones a culture of coercion. And the notion that court-ordered care will insulate providers from litigation seems misguided — courts should be unsympathetic to patients with refusal remorse, lest they eviscerate the concept of informed consent, and an informed refusal, unaccompanied by malpractice, should be a shield from civil and criminal liability. Of course, subjecting a patient to forced care, even court-ordered care, may lead to a lawsuit for violations of civil and constitutional rights.\r\n\r\nFinally, there\’s the slippery slope. As a Florida Supreme Court justice explained, forced care that is designed “to protect the health of the fetus creates its own universe of troubling questions. Should the State have the authority to prohibit a pregnant woman from smoking cigarettes or drinking alcohol, both legal activities with recognized health risks to the unborn?” (<em>In re Guardianship of J.D.S</em>.). Should pregnant women be prosecuted for adverse outcomes when they reject medical care? Should they be jailed until delivery? Such cases have already arisen.\r\n\r\nA handful of forced-care orders have been reviewed by higher courts (see <a href=\”http://www.nejm.org/action/showImage?doi=10.1056%2FNEJMp1203742&amp;iid=t01\”>table</a><a href=\”http://www.nejm.org/action/showImage?doi=10.1056%2FNEJMp1203742&amp;iid=t01\”><img src=\”http://www.nejm.org/na102/home/ACS/publisher/mms/journals/content/nejm/2012/nejm_2012.366.issue-24/nejmp1203742/production/images/small/nejmp1203742_t1.gif\” alt=\”\” /></a>Published Opinions Reviewing Order, or Request for Order, for Forced Medical Interventions during Pregnancy.). The courts\’ opinions generally begin with the premise that “every person of adult years and sound mind has the right to determine what shall be done with his body” (<em>Schloendorff v. Society of N.Y. Hospital</em>). But the extent to which pregnant women retain that right has varied: in Illinois, “the State may not override a pregnant woman\’s competent decision, including refusal of recommended invasive medical procedures, to potentially save the life of the viable fetus” (<em>In re Brown</em>); the U.S. Court of Appeals for the District of Columbia Circuit, a federal appellate court, has held that court-ordered care is rarely appropriate and that the pregnant patient\’s wishes “must be followed in virtually all cases, unless there are truly extraordinary or compelling reasons to override them” (<em>In re A.C.</em>); in Florida, a state appellate court has determined that the state may override the patient\’s right to refuse medical treatment when its interests in a viable fetus\’s well-being are compelling and the intervention is narrowly tailored to meet its goal (<em>Burton v. State</em>).\r\n\r\nA balancing standard is troubling. Among other things, it pits doctors against patients, ignores due process, defers to physicians\’ fallible predictions, and imposes heightened obligations on pregnant women — including the sweeping and unique duty to submit their bodies to the state. The “extraordinary” circumstances rule is no better. It, too, inherently involves balancing, and it offers physicians little clinical guidance. What is an exceptional case? Is it the same in all states? Should it be? Although the Committee on Ethics of the American College of Obstetricians and Gynecologists endorses the “extraordinary circumstances” approach, even it “cannot currently imagine” what that scenario could be.<a href=\”http://www.nejm.org/doi/full/10.1056/NEJMp1203742?query=TOC#ref5\” rel=\”#refLayer\”>5</a>\r\n\r\nThe Illinois approach — to respect informed refusals — should be the rule for courts, hospitals, and physicians. Physicians should discuss and revisit the risks, benefits, and alternatives of recommended care, and they should adequately document an informed refusal. But they should not involve courts. These cases begin at the bedside, and that is where they should end.\r\n\r\nPhysicians who seek judicial intervention should disclose that practice so patients can seek care elsewhere. For many, though, alternatives are illusory. In Tallahassee, there may be no safe harbor. In 1996, after laboring at home and becoming dehydrated, Laura Pemberton sought intravenous fluids at TMH, but physicians conditioned her medical care on agreement to a cesarean section. She declined and left. TMH then obtained a court order to retrieve her from her home (she was found laboring in her bedroom) and bring her to TMH by ambulance, where she was forced to undergo an apparently unnecessary cesarean section.\r\n\r\nIn 1976, a man dying of aplastic anemia sued his cousin, asking a court to order the forcible extraction of his potentially matching — and lifesaving — bone marrow. The court refused and explained, “For our law to <em>compel</em> defendant to submit to an intrusion of his body would change every concept and principle upon which our society is founded. To do so would defeat the sanctity of the individual” and “raise the spectre of the swastika and the Inquisition, reminiscent of the horrors this portends” (<em>McFall v. Shimp</em>).\r\n\r\nThose horrors are no less salient here. Forced interventions undermine the liberty, privacy, and equality of pregnant women. But they are far more insidious. Because they betray foundational legal principles of our free society, they endanger the liberty of us all.\r\n<div></div>\r\n<a href=\”http://www.nejm.org/doi/suppl/10.1056/NEJMp1203742/suppl_file/nejmp1203742_disclosures.pdf\”>Disclosure forms</a> provided by the author are available with the full text of this article at NEJM.org.\r\n<div>\r\n<div>\r\n<h3>SOURCE INFORMATION</h3>\r\nFrom the UCLA School of Law, Los Angeles.\r\n\r\n</div>\r\n</div>\r\n</dd></dl>’, ‘Report on Forced Obstetrical Care ~ New England Journal of Medicine’, ”, ‘publish’, ‘open’, ‘open’, ”, ‘report-on-forced-obstetrical-care-new-england-journal-of-medicine’, ”, ”, ‘2012-06-25 06:27:04’, ‘2012-06-25 06:27:04’, ”, ‘0’, ‘http://faithgibson.org/?p=21’, ‘0’, ‘post’, ”, ‘0’);
INSERT INTO `wp_posts` VALUES(’23’, ‘1’, ‘2012-06-25 06:26:53’, ‘2012-06-25 06:26:53’, ‘Court-Ordered Care — A Complication of Pregnancy to Avoid\n\nJulie D. Cantor, M.D., J.D.\n\nN Engl J Med 2012; 366:2237-2240 <a href=\”http://www.nejm.org/toc/nejm/366/24/\”>June 14, 2012</a>\n\n<dl><dd id=\”article\”>\n<div>\n<div>\n\n<a href=\”http://www.nejm.org/action/showMediaPlayer?doi=10.1056%2FNEJMp1203742&amp;aid=NEJMp1203742_attach_1&amp;area=\”><img src=\”http://www.nejm.org/na102/home/ACS/publisher/mms/journals/content/nejm/2012/nejm_2012.366.issue-24/nejmp1203742/production/images/nejm_cantorp_06-14-2012.jpg\” alt=\”Interview with Dr. Julie Cantor on court-ordered care for pregnant women in the United States.\” /></a>\n\nInterview with Dr. Julie Cantor on court-ordered care for pregnant women in the United States. (14:03)\n<ul>\n <li><a href=\”http://www.nejm.org/action/showMediaPlayer?doi=10.1056%2FNEJMp1203742&amp;aid=NEJMp1203742_attach_1&amp;area=\” rel=\”10.1056/NEJMp1203742\”>Listen</a></li>\n <li><a href=\”http://www.nejm.org/doi/media/10.1056/NEJMp1203742/NEJM_CantorP_06-14-2012.mp3?area=\” rel=\”10.1056/NEJMp1203742\”>Download</a></li>\n</ul>\n</div>\n</div>\n<strong>S</strong>amantha Burton was 25 weeks pregnant when her membranes ruptured. Burton\’s obstetrician admitted her to Tallahassee Memorial Hospital (TMH) and prescribed continuous inpatient bed rest. But with two young children and a job to consider, Burton found the prospect of a 3-month hospital stay overwhelming. She decided to go home. When she tried to leave, authorities barred her exit.\n\nSoon, the machinery of court-ordered care started rolling. TMH\’s outside counsel, deputized by the local state attorney to act on Florida\’s behalf, petitioned for judicial approval to force Burton to follow doctors\’ orders. Within hours, the court heard argument from the hospital–state attorney and testimony from the obstetrician — now considered “the unborn child\’s attending physician.”<a href=\”http://www.nejm.org/doi/full/10.1056/NEJMp1203742?query=TOC#ref1\” rel=\”#refLayer\”>1</a> Burton testified by phone from the hospital, without counsel.\n\nThe next day, the <strong>judge gave TMH, any attending health care provider, and members and employees of the original obstetrician\’s practice permission to administer any care they deemed necessary</strong> to preserve the fetus\’s life and health.<a href=\”http://www.nejm.org/doi/full/10.1056/NEJMp1203742?query=TOC#ref1\” rel=\”#refLayer\”>1</a> He ordered Burton to comply and denied her request to change hospitals. Within days, <strong>doctors delivered a dead fetus by cesarean section.</strong>\n\nThe prevalence of such orders is unclear. One scholar found that “between 1973 and 1992 courts in at least twenty-five states and the District of Columbia granted orders to doctors seeking to overrule their pregnant patients\’ refusal to consent to medical treatment.”<a href=\”http://www.nejm.org/doi/full/10.1056/NEJMp1203742?query=TOC#ref2\” rel=\”#refLayer\”>2</a> A 2003 survey of directors of fellowship programs in maternal–fetal medicine reported nine forced-care cases, and orders for cesarean section or blood transfusion were obtained in eight.<a href=\”http://www.nejm.org/doi/full/10.1056/NEJMp1203742?query=TOC#ref3\” rel=\”#refLayer\”>3</a> A 2007 study of 229 obstetricians and 126 health lawyers showed that 51% “were highly likely to support the use of judicial authority” to force a patient to undergo an unwanted cesarean section.<a href=\”http://www.nejm.org/doi/full/10.1056/NEJMp1203742?query=TOC#ref4\” rel=\”#refLayer\”>4</a> In 2004, a Pennsylvania hospital obtained a court order for doctors to do just that (see the <a href=\”http://www.nejm.org/doi/suppl/10.1056/NEJMp1203742/suppl_file/nejmp1203742_appendix.pdf\”>Supplementary Appendix</a>, available with the full text of this article at NEJM.org), but the patient had already left that hospital and <strong>had an uneventful vaginal delivery at another hospital.</strong>\n\nForced-care advocates argue that the state has strong interests in fetal well-being that must be balanced against the mother\’s rights, that pregnant women must defer to health care providers who conclude that fetal health or life is at risk, and that women have special obligations to fetuses they choose to carry to term. Physicians may believe that judicial intervention will protect them from litigation if a pregnant woman refuses care and the fetus is harmed.\n\nBut why should pregnancy diminish a competent adult woman\’s right to refuse care? Citizens have no legal duty to use their bodies to save one another; even parents have no such legal duty to their children. It follows, then, that “a fetus cannot have rights in this respect superior to those of a person who has already been born” (<em>In re A.C</em>.).\n\nMoreover, the due-process considerations are profound. Because these cases are usually heard on an emergency basis, judicial decisions are made without full briefing on relevant law, medicine, and policy. Unlike alleged criminals, patients have no Sixth Amendment right to counsel, and they cannot instantaneously find expert witnesses to testify on their behalf. And hospital lawyers acting as state attorneys have a clear conflict of interest: as even the Supreme Court of Florida has noted, it is inappropriate for a hospital “to argue zealously against the wishes of its own patient,” and “it cannot act on behalf of the State to assert the state interests” when a competent adult refuses care (<em>Matter of Dubreuil</em>).\n\nCoerced care also devalues the inherent risks to maternal health and life. Cesarean sections and blood transfusions are not risk-free, and bed rest is neither benign nor evidence-based. Obstetricians aren\’t omniscient and may defer to culture over data. Forced care also ignores individuals\’ and families\’ values, reinforces inequality between the sexes, threatens to drive women from care, and condones a culture of coercion. And the notion that court-ordered care will insulate providers from litigation seems misguided — courts should be unsympathetic to patients with refusal remorse, lest they eviscerate the concept of informed consent, and an informed refusal, unaccompanied by malpractice, should be a shield from civil and criminal liability. Of course, subjecting a patient to forced care, even court-ordered care, may lead to a lawsuit for violations of civil and constitutional rights.\n\nFinally, there\’s the slippery slope. As a Florida Supreme Court justice explained, forced care that is designed “to protect the health of the fetus creates its own universe of troubling questions. Should the State have the authority to prohibit a pregnant woman from smoking cigarettes or drinking alcohol, both legal activities with recognized health risks to the unborn?” (<em>In re Guardianship of J.D.S</em>.). Should pregnant women be prosecuted for adverse outcomes when they reject medical care? Should they be jailed until delivery? Such cases have already arisen.\n\nA handful of forced-care orders have been reviewed by higher courts (see <a href=\”http://www.nejm.org/action/showImage?doi=10.1056%2FNEJMp1203742&amp;iid=t01\”>table</a><a href=\”http://www.nejm.org/action/showImage?doi=10.1056%2FNEJMp1203742&amp;iid=t01\”><img src=\”http://www.nejm.org/na102/home/ACS/publisher/mms/journals/content/nejm/2012/nejm_2012.366.issue-24/nejmp1203742/production/images/small/nejmp1203742_t1.gif\” alt=\”\” /></a>Published Opinions Reviewing Order, or Request for Order, for Forced Medical Interventions during Pregnancy.). The courts\’ opinions generally begin with the premise that “every person of adult years and sound mind has the right to determine what shall be done with his body” (<em>Schloendorff v. Society of N.Y. Hospital</em>). But the extent to which pregnant women retain that right has varied: in Illinois, “the State may not override a pregnant woman\’s competent decision, including refusal of recommended invasive medical procedures, to potentially save the life of the viable fetus” (<em>In re Brown</em>); the U.S. Court of Appeals for the District of Columbia Circuit, a federal appellate court, has held that court-ordered care is rarely appropriate and that the pregnant patient\’s wishes “must be followed in virtually all cases, unless there are truly extraordinary or compelling reasons to override them” (<em>In re A.C.</em>); in Florida, a state appellate court has determined that the state may override the patient\’s right to refuse medical treatment when its interests in a viable fetus\’s well-being are compelling and the intervention is narrowly tailored to meet its goal (<em>Burton v. State</em>).\n\nA balancing standard is troubling. Among other things, it pits doctors against patients, ignores due process, defers to physicians\’ fallible predictions, and imposes heightened obligations on pregnant women — including the sweeping and unique duty to submit their bodies to the state. The “extraordinary” circumstances rule is no better. It, too, inherently involves balancing, and it offers physicians little clinical guidance. What is an exceptional case? Is it the same in all states? Should it be? Although the Committee on Ethics of the American College of Obstetricians and Gynecologists endorses the “extraordinary circumstances” approach, even it “cannot currently imagine” what that scenario could be.<a href=\”http://www.nejm.org/doi/full/10.1056/NEJMp1203742?query=TOC#ref5\” rel=\”#refLayer\”>5</a>\n\nThe Illinois approach — to respect informed refusals — should be the rule for courts, hospitals, and physicians. Physicians should discuss and revisit the risks, benefits, and alternatives of recommended care, and they should adequately document an informed refusal. But they should not involve courts. These cases begin at the bedside, and that is where they should end.\n\nPhysicians who seek judicial intervention should disclose that practice so patients can seek care elsewhere. For many, though, alternatives are illusory. In Tallahassee, there may be no safe harbor. In 1996, after laboring at home and becoming dehydrated, Laura Pemberton sought intravenous fluids at TMH, but physicians conditioned her medical care on agreement to a cesarean section. She declined and left. TMH then obtained a court order to retrieve her from her home (she was found laboring in her bedroom) and bring her to TMH by ambulance, where she was forced to undergo an apparently unnecessary cesarean section.\n\nIn 1976, a man dying of aplastic anemia sued his cousin, asking a court to order the forcible extraction of his potentially matching — and lifesaving — bone marrow. The court refused and explained, “For our law to <em>compel</em> defendant to submit to an intrusion of his body would change every concept and principle upon which our society is founded. To do so would defeat the sanctity of the individual” and “raise the spectre of the swastika and the Inquisition, reminiscent of the horrors this portends” (<em>McFall v. Shimp</em>).\n\nThose horrors are no less salient here. Forced interventions undermine the liberty, privacy, and equality of pregnant women. But they are far more insidious. Because they betray foundational legal principles of our free society, they endanger the liberty of us all.\n<div></div>\n<a href=\”http://www.nejm.org/doi/suppl/10.1056/NEJMp1203742/suppl_file/nejmp1203742_disclosures.pdf\”>Disclosure forms</a> provided by the author are available with the full text of this article at NEJM.org.\n<div>\n<div>\n<h3>SOURCE INFORMATION</h3>\nFrom the UCLA School of Law, Los Angeles.\n\n</div>\n</div>\n</dd></dl>’, ‘Report on Forced Obstetrical Care ~ New England Journal of Medicine’, ”, ‘inherit’, ‘open’, ‘open’, ”, ’21-autosave’, ”, ”, ‘2012-06-25 06:26:53’, ‘2012-06-25 06:26:53′, ”, ’21’, ‘http://faithgibson.org/21-autosave/23/’, ‘0’, ‘revision’, ”, ‘0’);
INSERT INTO `wp_posts` VALUES(’24’, ‘1’, ‘2012-06-25 06:19:51’, ‘2012-06-25 06:19:51’, ‘<h1>Court-Ordered Care — A Complication of Pregnancy to Avoid</h1>\r\nJulie D. Cantor, M.D., J.D.\r\n\r\nN Engl J Med 2012; 366:2237-2240 <a href=\”http://www.nejm.org/toc/nejm/366/24/\”>June 14, 2012</a>\r\n\r\n<dl><dd id=\”article\”>\r\n<div>\r\n<div>\r\n\r\n<a href=\”http://www.nejm.org/action/showMediaPlayer?doi=10.1056%2FNEJMp1203742&amp;aid=NEJMp1203742_attach_1&amp;area=\”><img src=\”http://www.nejm.org/na102/home/ACS/publisher/mms/journals/content/nejm/2012/nejm_2012.366.issue-24/nejmp1203742/production/images/nejm_cantorp_06-14-2012.jpg\” alt=\”Interview with Dr. Julie Cantor on court-ordered care for pregnant women in the United States.\” /></a>\r\n\r\nInterview with Dr. Julie Cantor on court-ordered care for pregnant women in the United States. (14:03)\r\n<ul>\r\n <li><a href=\”http://www.nejm.org/action/showMediaPlayer?doi=10.1056%2FNEJMp1203742&amp;aid=NEJMp1203742_attach_1&amp;area=\” rel=\”10.1056/NEJMp1203742\”>Listen</a></li>\r\n <li><a href=\”http://www.nejm.org/doi/media/10.1056/NEJMp1203742/NEJM_CantorP_06-14-2012.mp3?area=\” rel=\”10.1056/NEJMp1203742\”>Download</a></li>\r\n</ul>\r\n</div>\r\n</div>\r\n<div>\r\n\r\nSamantha Burton was 25 weeks pregnant when her membranes ruptured. Burton\’s obstetrician admitted her to Tallahassee Memorial Hospital (TMH) and prescribed continuous inpatient bed rest. But with two young children and a job to consider, Burton found the prospect of a 3-month hospital stay overwhelming. She decided to go home. When she tried to leave, authorities barred her exit.\r\n\r\nSoon, the machinery of court-ordered care started rolling. TMH\’s outside counsel, deputized by the local state attorney to act on Florida\’s behalf, petitioned for judicial approval to force Burton to follow doctors\’ orders. Within hours, the court heard argument from the hospital–state attorney and testimony from the obstetrician — now considered “the unborn child\’s attending physician.”<a href=\”http://www.nejm.org/doi/full/10.1056/NEJMp1203742?query=TOC#ref1\” rel=\”#refLayer\”>1</a> Burton testified by phone from the hospital, without counsel.\r\n\r\nThe next day, the judge gave TMH, any attending health care provider, and members and employees of the original obstetrician\’s practice permission to administer any care they deemed necessary to preserve the fetus\’s life and health.<a href=\”http://www.nejm.org/doi/full/10.1056/NEJMp1203742?query=TOC#ref1\” rel=\”#refLayer\”>1</a> He ordered Burton to comply and denied her request to change hospitals. Within days, doctors delivered a dead fetus by cesarean section.\r\n\r\nThe prevalence of such orders is unclear. One scholar found that “between 1973 and 1992 courts in at least twenty-five states and the District of Columbia granted orders to doctors seeking to overrule their pregnant patients\’ refusal to consent to medical treatment.”<a href=\”http://www.nejm.org/doi/full/10.1056/NEJMp1203742?query=TOC#ref2\” rel=\”#refLayer\”>2</a> A 2003 survey of directors of fellowship programs in maternal–fetal medicine reported nine forced-care cases, and orders for cesarean section or blood transfusion were obtained in eight.<a href=\”http://www.nejm.org/doi/full/10.1056/NEJMp1203742?query=TOC#ref3\” rel=\”#refLayer\”>3</a> A 2007 study of 229 obstetricians and 126 health lawyers showed that 51% “were highly likely to support the use of judicial authority” to force a patient to undergo an unwanted cesarean section.<a href=\”http://www.nejm.org/doi/full/10.1056/NEJMp1203742?query=TOC#ref4\” rel=\”#refLayer\”>4</a> In 2004, a Pennsylvania hospital obtained a court order for doctors to do just that (see the <a href=\”http://www.nejm.org/doi/suppl/10.1056/NEJMp1203742/suppl_file/nejmp1203742_appendix.pdf\”>Supplementary Appendix</a>, available with the full text of this article at NEJM.org), but the patient had already left that hospital and had an uneventful vaginal delivery at another hospital.\r\n\r\nForced-care advocates argue that the state has strong interests in fetal well-being that must be balanced against the mother\’s rights, that pregnant women must defer to health care providers who conclude that fetal health or life is at risk, and that women have special obligations to fetuses they choose to carry to term. Physicians may believe that judicial intervention will protect them from litigation if a pregnant woman refuses care and the fetus is harmed.\r\n\r\nBut why should pregnancy diminish a competent adult woman\’s right to refuse care? Citizens have no legal duty to use their bodies to save one another; even parents have no such legal duty to their children. It follows, then, that “a fetus cannot have rights in this respect superior to those of a person who has already been born” (<em>In re A.C</em>.).\r\n\r\nMoreover, the due-process considerations are profound. Because these cases are usually heard on an emergency basis, judicial decisions are made without full briefing on relevant law, medicine, and policy. Unlike alleged criminals, patients have no Sixth Amendment right to counsel, and they cannot instantaneously find expert witnesses to testify on their behalf. And hospital lawyers acting as state attorneys have a clear conflict of interest: as even the Supreme Court of Florida has noted, it is inappropriate for a hospital “to argue zealously against the wishes of its own patient,” and “it cannot act on behalf of the State to assert the state interests” when a competent adult refuses care (<em>Matter of Dubreuil</em>).\r\n\r\nCoerced care also devalues the inherent risks to maternal health and life. Cesarean sections and blood transfusions are not risk-free, and bed rest is neither benign nor evidence-based. Obstetricians aren\’t omniscient and may defer to culture over data. Forced care also ignores individuals\’ and families\’ values, reinforces inequality between the sexes, threatens to drive women from care, and condones a culture of coercion. And the notion that court-ordered care will insulate providers from litigation seems misguided — courts should be unsympathetic to patients with refusal remorse, lest they eviscerate the concept of informed consent, and an informed refusal, unaccompanied by malpractice, should be a shield from civil and criminal liability. Of course, subjecting a patient to forced care, even court-ordered care, may lead to a lawsuit for violations of civil and constitutional rights.\r\n\r\nFinally, there\’s the slippery slope. As a Florida Supreme Court justice explained, forced care that is designed “to protect the health of the fetus creates its own universe of troubling questions. Should the State have the authority to prohibit a pregnant woman from smoking cigarettes or drinking alcohol, both legal activities with recognized health risks to the unborn?” (<em>In re Guardianship of J.D.S</em>.). Should pregnant women be prosecuted for adverse outcomes when they reject medical care? Should they be jailed until delivery? Such cases have already arisen.\r\n\r\nA handful of forced-care orders have been reviewed by higher courts (see <a href=\”http://www.nejm.org/action/showImage?doi=10.1056%2FNEJMp1203742&amp;iid=t01\”>table</a><a href=\”http://www.nejm.org/action/showImage?doi=10.1056%2FNEJMp1203742&amp;iid=t01\”><img src=\”http://www.nejm.org/na102/home/ACS/publisher/mms/journals/content/nejm/2012/nejm_2012.366.issue-24/nejmp1203742/production/images/small/nejmp1203742_t1.gif\” alt=\”\” /></a>Published Opinions Reviewing Order, or Request for Order, for Forced Medical Interventions during Pregnancy.). The courts\’ opinions generally begin with the premise that “every person of adult years and sound mind has the right to determine what shall be done with his body” (<em>Schloendorff v. Society of N.Y. Hospital</em>). But the extent to which pregnant women retain that right has varied: in Illinois, “the State may not override a pregnant woman\’s competent decision, including refusal of recommended invasive medical procedures, to potentially save the life of the viable fetus” (<em>In re Brown</em>); the U.S. Court of Appeals for the District of Columbia Circuit, a federal appellate court, has held that court-ordered care is rarely appropriate and that the pregnant patient\’s wishes “must be followed in virtually all cases, unless there are truly extraordinary or compelling reasons to override them” (<em>In re A.C.</em>); in Florida, a state appellate court has determined that the state may override the patient\’s right to refuse medical treatment when its interests in a viable fetus\’s well-being are compelling and the intervention is narrowly tailored to meet its goal (<em>Burton v. State</em>).\r\n\r\nA balancing standard is troubling. Among other things, it pits doctors against patients, ignores due process, defers to physicians\’ fallible predictions, and imposes heightened obligations on pregnant women — including the sweeping and unique duty to submit their bodies to the state. The “extraordinary” circumstances rule is no better. It, too, inherently involves balancing, and it offers physicians little clinical guidance. What is an exceptional case? Is it the same in all states? Should it be? Although the Committee on Ethics of the American College of Obstetricians and Gynecologists endorses the “extraordinary circumstances” approach, even it “cannot currently imagine” what that scenario could be.<a href=\”http://www.nejm.org/doi/full/10.1056/NEJMp1203742?query=TOC#ref5\” rel=\”#refLayer\”>5</a>\r\n\r\nThe Illinois approach — to respect informed refusals — should be the rule for courts, hospitals, and physicians. Physicians should discuss and revisit the risks, benefits, and alternatives of recommended care, and they should adequately document an informed refusal. But they should not involve courts. These cases begin at the bedside, and that is where they should end.\r\n\r\nPhysicians who seek judicial intervention should disclose that practice so patients can seek care elsewhere. For many, though, alternatives are illusory. In Tallahassee, there may be no safe harbor. In 1996, after laboring at home and becoming dehydrated, Laura Pemberton sought intravenous fluids at TMH, but physicians conditioned her medical care on agreement to a cesarean section. She declined and left. TMH then obtained a court order to retrieve her from her home (she was found laboring in her bedroom) and bring her to TMH by ambulance, where she was forced to undergo an apparently unnecessary cesarean section.\r\n\r\nIn 1976, a man dying of aplastic anemia sued his cousin, asking a court to order the forcible extraction of his potentially matching — and lifesaving — bone marrow. The court refused and explained, “For our law to <em>compel</em> defendant to submit to an intrusion of his body would change every concept and principle upon which our society is founded. To do so would defeat the sanctity of the individual” and “raise the spectre of the swastika and the Inquisition, reminiscent of the horrors this portends” (<em>McFall v. Shimp</em>).\r\n\r\nThose horrors are no less salient here. Forced interventions undermine the liberty, privacy, and equality of pregnant women. But they are far more insidious. Because they betray foundational legal principles of our free society, they endanger the liberty of us all.\r\n\r\n</div>\r\n<div></div>\r\n<a href=\”http://www.nejm.org/doi/suppl/10.1056/NEJMp1203742/suppl_file/nejmp1203742_disclosures.pdf\”>Disclosure forms</a> provided by the author are available with the full text of this article at NEJM.org.\r\n<div>\r\n<div>\r\n<h3>SOURCE INFORMATION</h3>\r\nFrom the UCLA School of Law, Los Angeles.\r\n\r\n</div>\r\n</div>\r\n</dd></dl>’, ‘Report on Forced Obstetrical Care ~ New England Journal of Medicine’, ”, ‘inherit’, ‘open’, ‘open’, ”, ’21-revision-2′, ”, ”, ‘2012-06-25 06:19:51’, ‘2012-06-25 06:19:51′, ”, ’21’, ‘http://faithgibson.org/21-revision-2/24/’, ‘0’, ‘revision’, ”, ‘0’);
INSERT INTO `wp_posts` VALUES(’25’, ‘1’, ‘2012-06-25 06:24:30’, ‘2012-06-25 06:24:30’, ‘Court-Ordered Care — A Complication of Pregnancy to Avoid\r\n\r\nJulie D. Cantor, M.D., J.D.\r\n\r\nN Engl J Med 2012; 366:2237-2240 <a href=\”http://www.nejm.org/toc/nejm/366/24/\”>June 14, 2012</a>\r\n\r\n<dl><dd id=\”article\”>\r\n<div>\r\n<div>\r\n\r\n<a href=\”http://www.nejm.org/action/showMediaPlayer?doi=10.1056%2FNEJMp1203742&amp;aid=NEJMp1203742_attach_1&amp;area=\”><img src=\”http://www.nejm.org/na102/home/ACS/publisher/mms/journals/content/nejm/2012/nejm_2012.366.issue-24/nejmp1203742/production/images/nejm_cantorp_06-14-2012.jpg\” alt=\”Interview with Dr. Julie Cantor on court-ordered care for pregnant women in the United States.\” /></a>\r\n\r\nInterview with Dr. Julie Cantor on court-ordered care for pregnant women in the United States. (14:03)\r\n<ul>\r\n <li><a href=\”http://www.nejm.org/action/showMediaPlayer?doi=10.1056%2FNEJMp1203742&amp;aid=NEJMp1203742_attach_1&amp;area=\” rel=\”10.1056/NEJMp1203742\”>Listen</a></li>\r\n <li><a href=\”http://www.nejm.org/doi/media/10.1056/NEJMp1203742/NEJM_CantorP_06-14-2012.mp3?area=\” rel=\”10.1056/NEJMp1203742\”>Download</a></li>\r\n</ul>\r\n</div>\r\n</div>\r\n<div>\r\n\r\n<strong>S</strong>amantha Burton was 25 weeks pregnant when her membranes ruptured. Burton\’s obstetrician admitted her to Tallahassee Memorial Hospital (TMH) and prescribed continuous inpatient bed rest. But with two young children and a job to consider, Burton found the prospect of a 3-month hospital stay overwhelming. She decided to go home. When she tried to leave, authorities barred her exit.\r\n\r\nSoon, the machinery of court-ordered care started rolling. TMH\’s outside counsel, deputized by the local state attorney to act on Florida\’s behalf, petitioned for judicial approval to force Burton to follow doctors\’ orders. Within hours, the court heard argument from the hospital–state attorney and testimony from the obstetrician — now considered “the unborn child\’s attending physician.”<a href=\”http://www.nejm.org/doi/full/10.1056/NEJMp1203742?query=TOC#ref1\” rel=\”#refLayer\”>1</a> Burton testified by phone from the hospital, without counsel.\r\n\r\nThe next day, the <strong>judge gave TMH, any attending health care provider, and members and employees of the original obstetrician\’s practice permission to administer any care they deemed necessary</strong> to preserve the fetus\’s life and health.<a href=\”http://www.nejm.org/doi/full/10.1056/NEJMp1203742?query=TOC#ref1\” rel=\”#refLayer\”>1</a> He ordered Burton to comply and denied her request to change hospitals. Within days, <strong>doctors delivered a dead fetus by cesarean section.</strong>\r\n\r\nThe prevalence of such orders is unclear. One scholar found that “between 1973 and 1992 courts in at least twenty-five states and the District of Columbia granted orders to doctors seeking to overrule their pregnant patients\’ refusal to consent to medical treatment.”<a href=\”http://www.nejm.org/doi/full/10.1056/NEJMp1203742?query=TOC#ref2\” rel=\”#refLayer\”>2</a> A 2003 survey of directors of fellowship programs in maternal–fetal medicine reported nine forced-care cases, and orders for cesarean section or blood transfusion were obtained in eight.<a href=\”http://www.nejm.org/doi/full/10.1056/NEJMp1203742?query=TOC#ref3\” rel=\”#refLayer\”>3</a> A 2007 study of 229 obstetricians and 126 health lawyers showed that 51% “were highly likely to support the use of judicial authority” to force a patient to undergo an unwanted cesarean section.<a href=\”http://www.nejm.org/doi/full/10.1056/NEJMp1203742?query=TOC#ref4\” rel=\”#refLayer\”>4</a> In 2004, a Pennsylvania hospital obtained a court order for doctors to do just that (see the <a href=\”http://www.nejm.org/doi/suppl/10.1056/NEJMp1203742/suppl_file/nejmp1203742_appendix.pdf\”>Supplementary Appendix</a>, available with the full text of this article at NEJM.org), but the patient had already left that hospital and <strong>had an uneventful vaginal delivery at another hospital.</strong>\r\n\r\nForced-care advocates argue that the state has strong interests in fetal well-being that must be balanced against the mother\’s rights, that pregnant women must defer to health care providers who conclude that fetal health or life is at risk, and that women have special obligations to fetuses they choose to carry to term. Physicians may believe that judicial intervention will protect them from litigation if a pregnant woman refuses care and the fetus is harmed.\r\n\r\nBut why should pregnancy diminish a competent adult woman\’s right to refuse care? Citizens have no legal duty to use their bodies to save one another; even parents have no such legal duty to their children. It follows, then, that “a fetus cannot have rights in this respect superior to those of a person who has already been born” (<em>In re A.C</em>.).\r\n\r\nMoreover, the due-process considerations are profound. Because these cases are usually heard on an emergency basis, judicial decisions are made without full briefing on relevant law, medicine, and policy. Unlike alleged criminals, patients have no Sixth Amendment right to counsel, and they cannot instantaneously find expert witnesses to testify on their behalf. And hospital lawyers acting as state attorneys have a clear conflict of interest: as even the Supreme Court of Florida has noted, it is inappropriate for a hospital “to argue zealously against the wishes of its own patient,” and “it cannot act on behalf of the State to assert the state interests” when a competent adult refuses care (<em>Matter of Dubreuil</em>).\r\n\r\nCoerced care also devalues the inherent risks to maternal health and life. Cesarean sections and blood transfusions are not risk-free, and bed rest is neither benign nor evidence-based. Obstetricians aren\’t omniscient and may defer to culture over data. Forced care also ignores individuals\’ and families\’ values, reinforces inequality between the sexes, threatens to drive women from care, and condones a culture of coercion. And the notion that court-ordered care will insulate providers from litigation seems misguided — courts should be unsympathetic to patients with refusal remorse, lest they eviscerate the concept of informed consent, and an informed refusal, unaccompanied by malpractice, should be a shield from civil and criminal liability. Of course, subjecting a patient to forced care, even court-ordered care, may lead to a lawsuit for violations of civil and constitutional rights.\r\n\r\nFinally, there\’s the slippery slope. As a Florida Supreme Court justice explained, forced care that is designed “to protect the health of the fetus creates its own universe of troubling questions. Should the State have the authority to prohibit a pregnant woman from smoking cigarettes or drinking alcohol, both legal activities with recognized health risks to the unborn?” (<em>In re Guardianship of J.D.S</em>.). Should pregnant women be prosecuted for adverse outcomes when they reject medical care? Should they be jailed until delivery? Such cases have already arisen.\r\n\r\nA handful of forced-care orders have been reviewed by higher courts (see <a href=\”http://www.nejm.org/action/showImage?doi=10.1056%2FNEJMp1203742&amp;iid=t01\”>table</a><a href=\”http://www.nejm.org/action/showImage?doi=10.1056%2FNEJMp1203742&amp;iid=t01\”><img src=\”http://www.nejm.org/na102/home/ACS/publisher/mms/journals/content/nejm/2012/nejm_2012.366.issue-24/nejmp1203742/production/images/small/nejmp1203742_t1.gif\” alt=\”\” /></a>Published Opinions Reviewing Order, or Request for Order, for Forced Medical Interventions during Pregnancy.). The courts\’ opinions generally begin with the premise that “every person of adult years and sound mind has the right to determine what shall be done with his body” (<em>Schloendorff v. Society of N.Y. Hospital</em>). But the extent to which pregnant women retain that right has varied: in Illinois, “the State may not override a pregnant woman\’s competent decision, including refusal of recommended invasive medical procedures, to potentially save the life of the viable fetus” (<em>In re Brown</em>); the U.S. Court of Appeals for the District of Columbia Circuit, a federal appellate court, has held that court-ordered care is rarely appropriate and that the pregnant patient\’s wishes “must be followed in virtually all cases, unless there are truly extraordinary or compelling reasons to override them” (<em>In re A.C.</em>); in Florida, a state appellate court has determined that the state may override the patient\’s right to refuse medical treatment when its interests in a viable fetus\’s well-being are compelling and the intervention is narrowly tailored to meet its goal (<em>Burton v. State</em>).\r\n\r\nA balancing standard is troubling. Among other things, it pits doctors against patients, ignores due process, defers to physicians\’ fallible predictions, and imposes heightened obligations on pregnant women — including the sweeping and unique duty to submit their bodies to the state. The “extraordinary” circumstances rule is no better. It, too, inherently involves balancing, and it offers physicians little clinical guidance. What is an exceptional case? Is it the same in all states? Should it be? Although the Committee on Ethics of the American College of Obstetricians and Gynecologists endorses the “extraordinary circumstances” approach, even it “cannot currently imagine” what that scenario could be.<a href=\”http://www.nejm.org/doi/full/10.1056/NEJMp1203742?query=TOC#ref5\” rel=\”#refLayer\”>5</a>\r\n\r\nThe Illinois approach — to respect informed refusals — should be the rule for courts, hospitals, and physicians. Physicians should discuss and revisit the risks, benefits, and alternatives of recommended care, and they should adequately document an informed refusal. But they should not involve courts. These cases begin at the bedside, and that is where they should end.\r\n\r\nPhysicians who seek judicial intervention should disclose that practice so patients can seek care elsewhere. For many, though, alternatives are illusory. In Tallahassee, there may be no safe harbor. In 1996, after laboring at home and becoming dehydrated, Laura Pemberton sought intravenous fluids at TMH, but physicians conditioned her medical care on agreement to a cesarean section. She declined and left. TMH then obtained a court order to retrieve her from her home (she was found laboring in her bedroom) and bring her to TMH by ambulance, where she was forced to undergo an apparently unnecessary cesarean section.\r\n\r\nIn 1976, a man dying of aplastic anemia sued his cousin, asking a court to order the forcible extraction of his potentially matching — and lifesaving — bone marrow. The court refused and explained, “For our law to <em>compel</em> defendant to submit to an intrusion of his body would change every concept and principle upon which our society is founded. To do so would defeat the sanctity of the individual” and “raise the spectre of the swastika and the Inquisition, reminiscent of the horrors this portends” (<em>McFall v. Shimp</em>).\r\n\r\nThose horrors are no less salient here. Forced interventions undermine the liberty, privacy, and equality of pregnant women. But they are far more insidious. Because they betray foundational legal principles of our free society, they endanger the liberty of us all.\r\n\r\n</div>\r\n<div></div>\r\n<a href=\”http://www.nejm.org/doi/suppl/10.1056/NEJMp1203742/suppl_file/nejmp1203742_disclosures.pdf\”>Disclosure forms</a> provided by the author are available with the full text of this article at NEJM.org.\r\n<div>\r\n<div>\r\n<h3>SOURCE INFORMATION</h3>\r\nFrom the UCLA School of Law, Los Angeles.\r\n\r\n</div>\r\n</div>\r\n</dd></dl>’, ‘Report on Forced Obstetrical Care ~ New England Journal of Medicine’, ”, ‘inherit’, ‘open’, ‘open’, ”, ’21-revision-3′, ”, ”, ‘2012-06-25 06:24:30’, ‘2012-06-25 06:24:30′, ”, ’21’, ‘http://faithgibson.org/21-revision-3/25/’, ‘0’, ‘revision’, ”, ‘0’);
INSERT INTO `wp_posts` VALUES(’82’, ‘1’, ‘2012-07-16 04:10:25’, ‘2012-07-16 04:10:25’, ‘<h2><span class=\”Apple-style-span\” style=\”font-size: 13px; font-weight: normal;\”><strong>Suzanne is a long-time friend and fellow birth activist.  I thought others might be interested in her most recent work on behalf of the ecology of normal childbirth</strong></span></h2>\r\n<p style=\”text-align: center;\”>@@ @ @@</p>\r\n\r\n<h2>Birthing the Future</h2>\r\n<div>Repost from <a title=\”1:33 pm\” href=\”http://anngwyn.wisrville.org/2012/07/13/birthing-the-future/\” rel=\”bookmark\”>July 13, 2012</a> by <a title=\”View all posts by anngwyn\” href=\”http://anngwyn.wisrville.org/author/anngwyn/\”>anngwyn</a> (Dr. Anngwyn St Just, PhD\r\n<div></div>\r\n</div>\r\n<div>\r\n\r\n<em>The health care system as we have known it is in chaos, and this includes maternity care. The system, and the mindset that created it, are going through a painful and dysfunctional labor, struggling to stay in control. </em>(Suzanne Arms)\r\n\r\nMy long- time colleague, film maker and fellow keyboard activist,Suzanne Arms has a new project. Her latest DVD“The Time is Now”, the first volume in a global project, roundtable film series, includes important information about preventing trauma during pregnancy, the birthing process and delicate post-natal period. For those unfamiliar with Suzanne’s work , obstetrician and gynecologist Christiane Northrup, M.D. describes Suzanne’s vision as a tapestry woven of knowledge from ancient and cross cultural wisdom to modern science (cellular biology, neurobiology, psycho-immunology, and attachment theory) together with ecology, feminism and spirituality. Suzanne’s seven books are based upon her belief that love and fear and peace and violence begin in the womb and this is where one finds our roots of faith or alienation. As she describes her work:\r\n\r\n“I work at the beginning of life where patterns are set. We must transform how we bring human beings into the world and care for each childbearing woman and mother- baby pair from conception to the first birthday, when they are one biological system and the baby’s developing brain and nervous system are laying down patterns for a lifetime.”\r\n\r\nSuzanne Arms’ insights are important for all us, for as she says, women’s experiences and their feelings about themselves, their babies, and motherhood translate directly into thoughts and biochemistry that lay down patterns in the human nervous system. These patterns shape how we see ourselves as children as well as the relationship that we form as adults and how we care for others and our world. How we treat women who bring children into the world, with honor and tenderness, or neglect and abuse, profoundly influences the direction of local and global society. (<a href=\”http://www.birthingthefuture.org/\” target=\”_blank\”>www.birthingthefuture.org</a>, <a href=\”mailto:suzannebirthing@gmail.com\” target=\”_blank\”>suzannebirthing@gmail.com</a>)\r\n\r\n</div>’, ‘Birth Activist Suzanne Arms ~ Words from a long-time friend’, ”, ‘publish’, ‘open’, ‘open’, ”, ‘birth-activist-suzanne-arms-on-normal-childbirth-as-a-transformational-ecology’, ”, ”, ‘2012-07-16 04:19:43’, ‘2012-07-16 04:19:43’, ”, ‘0’, ‘http://faithgibson.org/?p=82’, ‘0’, ‘post’, ”, ‘0’);
INSERT INTO `wp_posts` VALUES(’29’, ‘1’, ‘2012-06-27 01:31:06’, ‘2012-06-27 01:31:06’, ‘A California licensed midwife emailed me the news that journalist Michelle Goldberg was writing an article for publication on the \”home birth debate\”. My friend provided the journalist\’s email address and suggested that I contact her.\r\n\r\nMs. Goldberg is someone I actually know of from the MSNBC week-end news program \”<strong>UP W/ Chris Hayes</strong>\”, which I regularly watch. She comes across as an interesting person who speaks up on behalf of good government, economic and gender equality issues, especially rejecting policies that discriminate against women in regard to healthcare.\r\n\r\nI figured Ms. Goldberg was on our side and was so excited to think this accomplished woman activist would devote her consider talents to writing a thoughtful, fact-based article. I looked forward to her addressing the specific issues of PHB (relative safety, the bias of the medical profession, efforts to marginalize or criminal traditional midwifery). I wanted someone identify and describe the gender and economic politics that for 30+ years has rightfully triggered many women to reject highly medicalized, hospital-based obstetrical care and seek out different alternatives, including PHB. That should be the focus of any national debate about PBH.\r\n\r\nAs a result, I spent all day yesterday writing an email with information and resources, which I sent off just a few hours ago.\r\n\r\nTurns out the article is already a done-deed and unfortunately, Ms. Goldberg did not do as I\’d hoped — that is, she certainly didn\’t shed the cool light of reason and scientific evaluation on the topic. Instead, her 3,800 word  article, titled \”<a title=\”Home Birth: Increasingly Popular but Dangerous – Michelle Goldberg\” href=\”http://www.thedailybeast.com/articles/2012/06/25/home-birth-increasingly-popular-but-dangerous.html\” target=\”_blank\”>Home Birth: Increasingly Popular, But Dangerous\”</a> pored white-hot heat on this frequently misrepresented and misunderstood subject.\r\n\r\nLike most other bad articles on alternative healthcare choices, it portrays one or two specific practitioners as doing crazy or incompetent things and generally betraying the trust of their patients and leading to a very regrettable outcome. The writer wants us to generalize from those specific persons and assume that all healthcare providers of that type — in this case, midwives providing out-of-hospital care for normal birth — are awful and should be put out of business.\r\n\r\nI actually don\’t have ANY information about the cases Ms. Goldberg discusses — they may or may not have done the awful things she reports. What i know for sure, is that she miss a great opportunity to take a good look at WHY so many women in the US feel unserved by the mainstream system of medicalized maternity care and are moved to make \’alternative arrangements\’.\r\n\r\nAs mentioned above, I worked hard to amass information that would have permitted her to tell the story that so desperatey needs to be told. So here is the first installment of the material i put together for Michelle.\r\n\r\nMaybe she will reconsider. That would be nice. <a href=\”http://faithgibson.org/wp-content/uploads/2012/06/MPj044659500001.jpg\”><img class=\”alignnone size-thumbnail wp-image-33\” title=\”Silly-frog-colorful-graphic\” src=\”http://faithgibson.org/wp-content/uploads/2012/06/MPj044659500001-150×150.jpg\” alt=\”\” width=\”150\” height=\”150\” /></a>\r\n<blockquote>\r\n<div>\r\n\r\nDear Michelle ^0^\r\n\r\nAn acquaintance sent me your email address and suggested I contact you about your article on planned home birth (PHB) as a national debate.\r\n\r\nI am a former L&amp;D nurse, professionally-licensed PHB midwife, and long-time political activist. I was appointed to the California Medical Board\’s Midwifery Advisory Council in 2007 and am currently serving my second 3-yr term.\r\n\r\nI am also a mother of three and have two teenage grandsons. Having spent my adult life as a student of these contemporary and historical issues, I have, for better or worse, become an \’idiot savant\’ on the maternal-infant aspect of our healthcare system.\r\n\r\nMy midwife-friend believes this information would provide helpful background information on \”why American women who could afford an obstetrician-attended birth in the \’safety\’ of a hospital would do something so apparently <em>irrational and dangerous</em> as planning to give birth at home\”. It\’s an important question.\r\n\r\nI don\’t know if you had the privilege of watching the first 10 minutes of the <strong>new</strong> <strong>HBO series \”Newsroom</strong>\” Sunday night, but the same impassioned \’diatribe\’ and fact-based response by its mythical news anchor (actor Jeff Daniels as \’Will McAvoy\’) in relation to the question of America being \”the best in the world\” could (and should) be applied to the critique our maternity care system. Ditto the idea that \”America CAN do better\”.\r\n<div>We aren\’t the 1st, 2nd, 3rd, 4th or even 20th in ANY of the relevant metrics of maternal infant health except for being <strong>1st in how much money we spend on maternity care</strong> (25% of our entire HC budget) and ranking <strong>2nd in how many inductions and Cesareans American doctors perform</strong>.</div>\r\nEach year a third of all babies born in the US — equal to the number of students that graduate from college — are delivered by major abdominal surgery at a cost roughly equivalent to 4 yrs tuition at a public community college. Complications of this tsunami of surgical deliveries include a <strong>substantial increase in maternal mortality</strong> since the mid-1990s.\r\n\r\nAdding insult to injury, these expensive surgical interventions are <strong>not even buying us better babies — </strong>no improvement in neonatal mortality rates or reduction in cerebral palsy. The CP rate in the US has been exactly the same for the last 30-plus yrs, something ACOG is quick to point out in defense of obstetricians.\r\n\r\nFactoring in the many scientific improvements in neonatal care over this time period means we are actually <strong>loosing ground for mothers and babies both</strong>. This is a national issue for many reasons, including the fact that 40% of all births in the US are paid for by the federal Medicaid program and that we want/need our economy to remain competitive in a global economy.\r\n\r\nAs contrasted with the surgical speciality of obstetrics, the stated purpose of normal maternity care is to protect and preserve the health of already healthy childbearing women and their unborn or newborn babies. Society rightfully expects that modern American obstetricians would have the utmost most expertise in this area, but unfortunately, these are the very attributes missing from the current system of medicalized maternity care.\r\n\r\nMastery in normal childbirth services for healthy women with normal pregnancies means bringing about a good outcome without introducing any unnecessary harm or unproductive expense. Logically this is  achieved by seeking out the <strong>point of balance</strong> where the skillful use of physiological management, and the adroit use of medical interventions when necessary (or requested by the mother), provides <strong>the best outcome with the fewest number of medical/surgical procedures</strong> and least expense to the health care system.\r\n\r\nUnfortunately, the 20th century system of ‘pre-emptive’ intervention cannot provide this type of care. However, I don\’t want you to think that I am anti-doctor or anti-hospital. I would never want to live in a place or era without timely access to comprehensive medical and surgical services, which depends on well-equipped hospitals and well-trained doctors.\r\n<div>\r\n\r\nI want hospitals to work and work well. I want physicians of all kinds to be skilled and seamlessly available. I also expect the medical professionals to be knowledgeable about physiologically-based practices and work cooperatively with mothers and midwives. We actually are all <strong>on the same team</strong> — the one that wants to use the best practices all the time for everyone.\r\n\r\nI never see medicine and midwifery as an \’us versus them\’ issue. I am well-known for insisting that healthy women should <strong>never have to choose</strong> between a midwife and a physician, or between home and hospital, in order to received physiologically-based care for a normal childbirth.\r\n\r\nThe current debate about PHB is simply a proxy in a fight that is either for or against normal (non-medical or physiologic) care for normal childbirth. As a principle of care, physiological management is actually not (or should not be) location specific quality.\r\n\r\n</div>\r\nA science-based standard of care would integrate the principles of physiological management with best advances in obstetrical medicine to create <strong>a single, evidence-based standard for all healthy women</strong>with normal pregnancies that reserves obstetric interventions for complications or as requested by the mother. This model of ‘best practices’ would apply to all birth settings and be used universally by all categories of birth attendants when providing care to healthy women.\r\n\r\nUnder those circumstance, place-of-birth would become what it was always suppose to be — the right choice for the particular situation for that specific mother &amp; fetus — with hospital and OOH both seen as responsible choices in an integrated, cooperative and \’minimalist\’ model based on scientifically-established ‘best practices’ and patient consent.\r\n\r\nThese are the many reasons an honest national debate on de-medicalizing normal childbirth is vitally important. We need a debate that is thoughtful and fact-based instead of hysterical or motivated by a political agenda. The real issue isn\’t place-of-birth (home vs. hospital), its the type of care provided for normal childbirth in a healthy population — cost-effective, physiologically-supportive care vs. expensive interventive and invasive care.\r\n\r\nAs mothers and midwives, the heart of the poorly-named \”home birth movement\” is actually to end the unexamined agenda of ever-escalating medicalization of normal childbirth in healthy women, while the obstetrical professional attempts to marginalize and/or criminalize all \’alternatives\’. We seek to replace the early 20th century default of routine medicalization with a science-based normalization of labor and birth, irrespective of the category of birth attendant (physician, midwives, obstetrician) or the setting (home or hospital).\r\n\r\nThis problem can only be fixed by acknowledging physiological management as the universal standard of care for healthy women, while continuing to provide women with unfettered access to obstetrical procedures as they deem necessary for themselves, such as labor induction, epidural anesthesia and elective Cesarean section (abet with full information on associated risks).\r\n\r\nHere is a link to an article to help you make sense of the OOH-PHB safety arguments. Its from a document entitled \”<strong>Evidence-based policies for Maternity care and a plan for action</strong>\”, section II: \”Safety &amp; the Maternity-care Continuum in an essentially healthy population\”.\r\n<div></div>\r\n<a href=\”http://healthcare2point0.com/MCDG_contrast-studies_feedback_28Aug2010.htm#Part_II:\”>http://healthcare2point0.com/MCDG_contrast-studies_feedback_28Aug2010.htm#Part_II:</a>\r\n\r\n&nbsp;\r\n\r\nI\’m happy to provide additional material or reply to questions. I will email (i.e., post) the installment on historical issues – 1910-1940s – in the next 24 hours, unless I am called away by the Stork, who is indeed a jealous and temperamental mistress.\r\n\r\n</div>\r\n<div></div>\r\n<strong>Tomorrow ~ Historical perspective ~ 1910 to 1940s</strong></blockquote>’, ‘Daily Beast blogger slams planned home birth ~ Speaking Truth to \’truth-i-ness\”, ”, ‘publish’, ‘open’, ‘open’, ”, ‘daily-beast-blogger-slams-planned-home-birth-opportunity-to-speak-truth-to-truth-i-ness’, ”, ”, ‘2012-06-28 16:12:49’, ‘2012-06-28 16:12:49’, ”, ‘0’, ‘http://faithgibson.org/?p=29’, ‘0’, ‘post’, ”, ‘0’);
INSERT INTO `wp_posts` VALUES(’45’, ‘1’, ‘2012-06-28 16:08:41’, ‘2012-06-28 16:08:41’, ‘A California licensed midwife emailed me the news that journalist Michelle Goldberg was writing an article for publication on the \”home birth debate\”. My friend provided the journalist\’s email address and suggested that I contact her.\r\n\r\nMs. Goldberg is someone I actually know of from the MSNBC week-end news program \”<strong>UP W/ Chris Hayes</strong>\”, which I regularly watch. She comes across as an interesting person who speaks up on behalf of good government, economic and gender equality issues, especially rejecting policies that discriminate against women in regard to healthcare.\r\n\r\nI figured Ms. Goldberg was on our side and was so excited to think this accomplished woman activist would devote her consider talents to writing a thoughtful, fact-based article. I looked forward to her addressing the specific issues of PHB (relative safety, the bias of the medical profession, efforts to marginalize or criminal traditional midwifery). I wanted someone identify and describe the gender and economic politics that for 30+ years has rightfully triggered many women to reject highly medicalized, hospital-based obstetrical care and seek out different alternatives, including PHB. That should be the focus of any national debate about PBH.\r\n\r\nAs a result, I spent all day yesterday writing an email with information and resources, which I sent off just a few hours ago.\r\n\r\nTurns out the article is already a done-deed and unfortunately, Ms. Goldberg did not do as I\’d hoped — that is, she certainly didn\’t shed the cool light of reason and scientific evaluation on the topic. Instead, her 3,800 word  article, titled \”<a title=\”Home Birth: Increasingly Popular but Dangerous – Michelle Goldberg\” href=\”http://www.thedailybeast.com/articles/2012/06/25/home-birth-increasingly-popular-but-dangerous.html\” target=\”_blank\”>Home Birth: Increasingly Popular, But Dangerous\”</a> pored white-hot heat on this frequently misrepresented and misunderstood subject.\r\n\r\nLike most other bad articles on alternative healthcare choices, it portrays one or two specific practitioners as doing crazy or incompetent things and generally betraying the trust of their patients and leading to a very regrettable outcome. The writer wants us to generalize from those specific persons and assume that all healthcare providers of that type — in this case, midwives providing out-of-hospital care for normal birth — are awful and should be put out of business.\r\n\r\nI actually don\’t have ANY information about the cases Ms. Goldberg discusses — they may or may not have done the awful things she reports. What i know for sure, is that she miss a great opportunity to take a good look at WHY so many women in the US feel unserved by the mainstream system of medicalized maternity care and are moved to make \’alternative arrangements\’.\r\n\r\nAs mentioned above, I worked hard to amass information that would have permitted her to tell the story that so desperatey needs to be told. So here is the first installment of the material i put together for Michelle.\r\n\r\nMaybe she will reconsider. <a href=\”http://faithgibson.org/wp-content/uploads/2012/06/MPj044659500001.jpg\”><img class=\”alignnone size-thumbnail wp-image-33\” title=\”Silly-frog-colorful-graphic\” src=\”http://faithgibson.org/wp-content/uploads/2012/06/MPj044659500001-150×150.jpg\” alt=\”\” width=\”150\” height=\”150\” /></a> That would be nice.\r\n<blockquote>\r\n<div>\r\n\r\nDear Michelle ^0^\r\n\r\nAn acquaintance sent me your email address and suggested I contact you about your article on planned home birth (PHB) as a national debate.\r\n\r\nI am a former L&amp;D nurse, professionally-licensed PHB midwife, and long-time political activist. I was appointed to the California Medical Board\’s Midwifery Advisory Council in 2007 and am currently serving my second 3-yr term.\r\n\r\nI am also a mother of three and have two teenage grandsons. Having spent my adult life as a student of these contemporary and historical issues, I have, for better or worse, become an \’idiot savant\’ on the maternal-infant aspect of our healthcare system.\r\n<div>My midwife-friend believes this information would provide helpful background information on \”why American women who could afford an obstetrician-attended birth in the \’safety\’ of a hospital would do something so apparently <em>irrational and dangerous</em> as planning to give birth at home\”. It\’s an important question.</div>\r\nI don\’t know if you had the privilege of watching the first 10 minutes of the <strong>new</strong> <strong>HBO series \”Newsroom</strong>\” Sunday night, but the same impassioned \’diatribe\’ and fact-based response by its mythical news anchor (actor Jeff Daniels as \’Will McAvoy\’) in relation to the question of America being \”the best in the world\” could (and should) be applied to the critique our maternity care system. Ditto the idea that \”America CAN do better\”.\r\n<div>We aren\’t the 1st, 2nd, 3rd, 4th or even 20th in ANY of the relevant metrics of maternal infant health except for being <strong>1st in how much money we spend on maternity care</strong> (25% of our entire HC budget) and ranking <strong>2nd in how many inductions and Cesareans American doctors perform</strong>.</div>\r\nEach year a third of all babies born in the US — equal to the number of students that graduate from college — are delivered by major abdominal surgery at a cost roughly equivalent to 4 yrs tuition at a public community college. Complications of this tsunami of surgical deliveries include a <strong>substantial increase in maternal mortality</strong> since the mid-1990s.\r\n\r\nAdding insult to injury, these expensive surgical interventions are <strong>not even buying us better babies — </strong>no improvement in neonatal mortality rates or reduction in cerebral palsy. The CP rate in the US has been exactly the same for the last 30-plus yrs, something ACOG is quick to point out in defense of obstetricians.\r\n\r\nFactoring in the many scientific improvements in neonatal care over this time period means we are actually <strong>loosing ground for mothers and babies both</strong>. This is a national issue for many reasons, including the fact that 40% of all births in the US are paid for by the federal Medicaid program and that we want/need our economy to remain competitive in a global economy.\r\n\r\nAs contrasted with the surgical speciality of obstetrics, the stated purpose of normal maternity care is to protect and preserve the health of already healthy childbearing women and their unborn or newborn babies. Society rightfully expects that modern American obstetricians would have the utmost most expertise in this area, but unfortunately, these are the very attributes missing from the current system of medicalized maternity care.\r\n\r\nMastery in normal childbirth services for healthy women with normal pregnancies means bringing about a good outcome without introducing any unnecessary harm or unproductive expense. Logically this is  achieved by seeking out the <strong>point of balance</strong> where the skillful use of physiological management, and the adroit use of medical interventions when necessary (or requested by the mother), provides <strong>the best outcome with the fewest number of medical/surgical procedures</strong> and least expense to the health care system.\r\n\r\nUnfortunately, the 20th century system of ‘pre-emptive’ intervention cannot provide this type of care. However, I don\’t want you to think that I am anti-doctor or anti-hospital. I would never want to live in a place or era without timely access to comprehensive medical and surgical services, which depends on well-equipped hospitals and well-trained doctors.\r\n<div>\r\n\r\nI want hospitals to work and work well. I want physicians of all kinds to be skilled and seamlessly available. I also expect the medical professionals to be knowledgeable about physiologically-based practices and work cooperatively with mothers and midwives. We actually are all <strong>on the same team</strong> — the one that wants to use the best practices all the time for everyone.\r\n\r\nI never see medicine and midwifery as an \’us versus them\’ issue. I am well-known for insisting that healthy women should <strong>never have to choose</strong> between a midwife and a physician, or between home and hospital, in order to received physiologically-based care for a normal childbirth.\r\n\r\nThe current debate about PHB is simply a proxy in a fight that is either for or against normal (non-medical or physiologic) care for normal childbirth. As a principle of care, physiological management is actually not (or should not be) location specific quality.\r\n\r\n</div>\r\nA science-based standard of care would integrate the principles of physiological management with best advances in obstetrical medicine to create <strong>a single, evidence-based standard for all healthy women</strong>with normal pregnancies that reserves obstetric interventions for complications or as requested by the mother. This model of ‘best practices’ would apply to all birth settings and be used universally by all categories of birth attendants when providing care to healthy women.\r\n\r\nUnder those circumstance, place-of-birth would become what it was always suppose to be — the right choice for the particular situation for that specific mother &amp; fetus — with hospital and OOH both seen as responsible choices in an integrated, cooperative and \’minimalist\’ model based on scientifically-established ‘best practices’ and patient consent.\r\n\r\nThese are the many reasons an honest national debate on de-medicalizing normal childbirth is vitally important. We need a debate that is thoughtful and fact-based instead of hysterical or motivated by a political agenda. The real issue isn\’t place-of-birth (home vs. hospital), its the type of care provided for normal childbirth in a healthy population — cost-effective, physiologically-supportive care vs. expensive interventive and invasive care.\r\n\r\nAs mothers and midwives, the heart of the poorly-named \”home birth movement\” is actually to end the unexamined agenda of ever-escalating medicalization of normal childbirth in healthy women, while the obstetrical professional attempts to marginalize and/or criminalize all \’alternatives\’. We seek to replace the early 20th century default of routine medicalization with a science-based normalization of labor and birth, irrespective of the category of birth attendant (physician, midwives, obstetrician) or the setting (home or hospital).\r\n\r\nThis problem can only be fixed by acknowledging physiological management as the universal standard of care for healthy women, while continuing to provide women with unfettered access to obstetrical procedures as they deem necessary for themselves, such as labor induction, epidural anesthesia and elective Cesarean section (abet with full information on associated risks).\r\n<div>Here is a link to an article to help you make sense of the OOH-PHB safety arguments. Its from a document entitled \”<strong>Evidence-based policies for Maternity care and a plan for action</strong>\”, section II: \”Safety &amp; the Maternity-care Continuum in an essentially healthy population\”.</div>\r\n<a href=\”http://healthcare2point0.com/MCDG_contrast-studies_feedback_28Aug2010.htm#Part_II:\”>http://healthcare2point0.com/MCDG_contrast-studies_feedback_28Aug2010.htm#Part_II:</a>\r\n<div>I\’m happy to provide additional material or reply to questions. I will email (i.e., post) the installment on historical issues – 1910-1940s – in the next 24 hours, unless I am called away by the Stork, who is indeed a jealous and temperamental mistress.</div>\r\n</div>\r\n<div></div>\r\n<strong>Tomorrow ~ Historical perspective ~ 1910 to 1940s</strong></blockquote>’, ‘Daily Beast blogger slams planned home birth ~ Speaking Truth to \’truth-i-ness\”, ”, ‘inherit’, ‘open’, ‘open’, ”, ’29-revision-10′, ”, ”, ‘2012-06-28 16:08:41’, ‘2012-06-28 16:08:41′, ”, ’29’, ‘http://faithgibson.org/29-revision-10/45/’, ‘0’, ‘revision’, ”, ‘0’);
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INSERT INTO `wp_posts` VALUES(’36’, ‘1’, ‘2012-06-28 16:12:26’, ‘2012-06-28 16:12:26’, ‘A California licensed midwife emailed me the news that journalist Michelle Goldberg was writing an article for publication on the \”home birth debate\”. My friend provided the journalist\’s email address and suggested that I contact her.\n\nMs. Goldberg is someone I actually know of from the MSNBC week-end news program \”<strong>UP W/ Chris Hayes</strong>\”, which I regularly watch. She comes across as an interesting person who speaks up on behalf of good government, economic and gender equality issues, especially rejecting policies that discriminate against women in regard to healthcare.\n\nI figured Ms. Goldberg was on our side and was so excited to think this accomplished woman activist would devote her consider talents to writing a thoughtful, fact-based article. I looked forward to her addressing the specific issues of PHB (relative safety, the bias of the medical profession, efforts to marginalize or criminal traditional midwifery). I wanted someone identify and describe the gender and economic politics that for 30+ years has rightfully triggered many women to reject highly medicalized, hospital-based obstetrical care and seek out different alternatives, including PHB. That should be the focus of any national debate about PBH.\n\nAs a result, I spent all day yesterday writing an email with information and resources, which I sent off just a few hours ago.\n\nTurns out the article is already a done-deed and unfortunately, Ms. Goldberg did not do as I\’d hoped — that is, she certainly didn\’t shed the cool light of reason and scientific evaluation on the topic. Instead, her 3,800 word  article, titled \”<a title=\”Home Birth: Increasingly Popular but Dangerous – Michelle Goldberg\” href=\”http://www.thedailybeast.com/articles/2012/06/25/home-birth-increasingly-popular-but-dangerous.html\” target=\”_blank\”>Home Birth: Increasingly Popular, But Dangerous\”</a> pored white-hot heat on this frequently misrepresented and misunderstood subject.\n\nLike most other bad articles on alternative healthcare choices, it portrays one or two specific practitioners as doing crazy or incompetent things and generally betraying the trust of their patients and leading to a very regrettable outcome. The writer wants us to generalize from those specific persons and assume that all healthcare providers of that type — in this case, midwives providing out-of-hospital care for normal birth — are awful and should be put out of business.\n\nI actually don\’t have ANY information about the cases Ms. Goldberg discusses — they may or may not have done the awful things she reports. What i know for sure, is that she miss a great opportunity to take a good look at WHY so many women in the US feel unserved by the mainstream system of medicalized maternity care and are moved to make \’alternative arrangements\’.\n\nAs mentioned above, I worked hard to amass information that would have permitted her to tell the story that so desperatey needs to be told. So here is the first installment of the material i put together for Michelle.\n\nMaybe she will reconsider. That would be nice. <a href=\”http://faithgibson.org/wp-content/uploads/2012/06/MPj044659500001.jpg\”><img class=\”alignnone size-thumbnail wp-image-33\” title=\”Silly-frog-colorful-graphic\” src=\”http://faithgibson.org/wp-content/uploads/2012/06/MPj044659500001-150×150.jpg\” alt=\”\” width=\”150\” height=\”150\” /></a>\n<blockquote>\n<div>\n\nDear Michelle ^0^\n\nAn acquaintance sent me your email address and suggested I contact you about your article on planned home birth (PHB) as a national debate.\n\nI am a former L&amp;D nurse, professionally-licensed PHB midwife, and long-time political activist. I was appointed to the California Medical Board\’s Midwifery Advisory Council in 2007 and am currently serving my second 3-yr term.\n\nI am also a mother of three and have two teenage grandsons. Having spent my adult life as a student of these contemporary and historical issues, I have, for better or worse, become an \’idiot savant\’ on the maternal-infant aspect of our healthcare system.\n\nMy midwife-friend believes this information would provide helpful background information on \”why American women who could afford an obstetrician-attended birth in the \’safety\’ of a hospital would do something so apparently <em>irrational and dangerous</em> as planning to give birth at home\”. It\’s an important question.\n\nI don\’t know if you had the privilege of watching the first 10 minutes of the <strong>new</strong> <strong>HBO series \”Newsroom</strong>\” Sunday night, but the same impassioned \’diatribe\’ and fact-based response by its mythical news anchor (actor Jeff Daniels as \’Will McAvoy\’) in relation to the question of America being \”the best in the world\” could (and should) be applied to the critique our maternity care system. Ditto the idea that \”America CAN do better\”.\n<div>We aren\’t the 1st, 2nd, 3rd, 4th or even 20th in ANY of the relevant metrics of maternal infant health except for being <strong>1st in how much money we spend on maternity care</strong> (25% of our entire HC budget) and ranking <strong>2nd in how many inductions and Cesareans American doctors perform</strong>.</div>\nEach year a third of all babies born in the US — equal to the number of students that graduate from college — are delivered by major abdominal surgery at a cost roughly equivalent to 4 yrs tuition at a public community college. Complications of this tsunami of surgical deliveries include a <strong>substantial increase in maternal mortality</strong> since the mid-1990s.\n\nAdding insult to injury, these expensive surgical interventions are <strong>not even buying us better babies — </strong>no improvement in neonatal mortality rates or reduction in cerebral palsy. The CP rate in the US has been exactly the same for the last 30-plus yrs, something ACOG is quick to point out in defense of obstetricians.\n\nFactoring in the many scientific improvements in neonatal care over this time period means we are actually <strong>loosing ground for mothers and babies both</strong>. This is a national issue for many reasons, including the fact that 40% of all births in the US are paid for by the federal Medicaid program and that we want/need our economy to remain competitive in a global economy.\n\nAs contrasted with the surgical speciality of obstetrics, the stated purpose of normal maternity care is to protect and preserve the health of already healthy childbearing women and their unborn or newborn babies. Society rightfully expects that modern American obstetricians would have the utmost most expertise in this area, but unfortunately, these are the very attributes missing from the current system of medicalized maternity care.\n\nMastery in normal childbirth services for healthy women with normal pregnancies means bringing about a good outcome without introducing any unnecessary harm or unproductive expense. Logically this is  achieved by seeking out the <strong>point of balance</strong> where the skillful use of physiological management, and the adroit use of medical interventions when necessary (or requested by the mother), provides <strong>the best outcome with the fewest number of medical/surgical procedures</strong> and least expense to the health care system.\n\nUnfortunately, the 20th century system of ‘pre-emptive’ intervention cannot provide this type of care. However, I don\’t want you to think that I am anti-doctor or anti-hospital. I would never want to live in a place or era without timely access to comprehensive medical and surgical services, which depends on well-equipped hospitals and well-trained doctors.\n<div>\n\nI want hospitals to work and work well. I want physicians of all kinds to be skilled and seamlessly available. I also expect the medical professionals to be knowledgeable about physiologically-based practices and work cooperatively with mothers and midwives. We actually are all <strong>on the same team</strong> — the one that wants to use the best practices all the time for everyone.\n\nI never see medicine and midwifery as an \’us versus them\’ issue. I am well-known for insisting that healthy women should <strong>never have to choose</strong> between a midwife and a physician, or between home and hospital, in order to received physiologically-based care for a normal childbirth.\n\nThe current debate about PHB is simply a proxy in a fight that is either for or against normal (non-medical or physiologic) care for normal childbirth. As a principle of care, physiological management is actually not (or should not be) location specific quality.\n\n</div>\nA science-based standard of care would integrate the principles of physiological management with best advances in obstetrical medicine to create <strong>a single, evidence-based standard for all healthy women</strong>with normal pregnancies that reserves obstetric interventions for complications or as requested by the mother. This model of ‘best practices’ would apply to all birth settings and be used universally by all categories of birth attendants when providing care to healthy women.\n\nUnder those circumstance, place-of-birth would become what it was always suppose to be — the right choice for the particular situation for that specific mother &amp; fetus — with hospital and OOH both seen as responsible choices in an integrated, cooperative and \’minimalist\’ model based on scientifically-established ‘best practices’ and patient consent.\n\nThese are the many reasons an honest national debate on de-medicalizing normal childbirth is vitally important. We need a debate that is thoughtful and fact-based instead of hysterical or motivated by a political agenda. The real issue isn\’t place-of-birth (home vs. hospital), its the type of care provided for normal childbirth in a healthy population — cost-effective, physiologically-supportive care vs. expensive interventive and invasive care.\n\nAs mothers and midwives, the heart of the poorly-named \”home birth movement\” is actually to end the unexamined agenda of ever-escalating medicalization of normal childbirth in healthy women, while the obstetrical professional attempts to marginalize and/or criminalize all \’alternatives\’. We seek to replace the early 20th century default of routine medicalization with a science-based normalization of labor and birth, irrespective of the category of birth attendant (physician, midwives, obstetrician) or the setting (home or hospital).\n\nThis problem can only be fixed by acknowledging physiological management as the universal standard of care for healthy women, while continuing to provide women with unfettered access to obstetrical procedures as they deem necessary for themselves, such as labor induction, epidural anesthesia and elective Cesarean section (abet with full information on associated risks).\n\nHere is a link to an article to help you make sense of the OOH-PHB safety arguments. Its from a document entitled \”<strong>Evidence-based policies for Maternity care and a plan for action</strong>\”, section II: \”Safety &amp; the Maternity-care Continuum in an essentially healthy population\”.\n<div></div>\n<a href=\”http://healthcare2point0.com/MCDG_contrast-studies_feedback_28Aug2010.htm#Part_II:\”>http://healthcare2point0.com/MCDG_contrast-studies_feedback_28Aug2010.htm#Part_II:</a>\n\n&nbsp;\n<div>I\’m happy to provide additional material or reply to questions. I will email (i.e., post) the installment on historical issues – 1910-1940s – in the next 24 hours, unless I am called away by the Stork, who is indeed a jealous and temperamental mistress.</div>\n</div>\n<div></div>\n<strong>Tomorrow ~ Historical perspective ~ 1910 to 1940s</strong></blockquote>’, ‘Daily Beast blogger slams planned home birth ~ Speaking Truth to \’truth-i-ness\”, ”, ‘inherit’, ‘open’, ‘open’, ”, ’29-autosave’, ”, ”, ‘2012-06-28 16:12:26’, ‘2012-06-28 16:12:26′, ”, ’29’, ‘http://faithgibson.org/29-autosave/36/’, ‘0’, ‘revision’, ”, ‘0’);
INSERT INTO `wp_posts` VALUES(’44’, ‘1’, ‘2012-06-28 16:04:25’, ‘2012-06-28 16:04:25’, ‘A California licensed midwife emailed me the news that journalist Michelle Goldberg was writing an article for publication on the \”home birth debate\”. My friend provided the journalist\’s email address and suggested that I contact her.\r\n\r\nMs. Goldberg is someone I actually know of from the MSNBC week-end news program \”<strong>UP W/ Chris Hayes</strong>\”, which I regularly watch. She comes across as an interesting person who speaks up on behalf of good government, economic and gender equality issues, especially rejecting policies that discriminate against women in regard to healthcare.\r\n\r\nI figured Ms. Goldberg was on our side and was so excited to think this accomplished woman activist would devote her consider talents to writing a thoughtful, fact-based article. I looked forward to her addressing the specific issues of PHB (relative safety, the bias of the medical profession, efforts to marginalize or criminal traditional midwifery). I wanted someone identify and describe the gender and economic politics that for 30+ years has rightfully triggered many women to reject highly medicalized, hospital-based obstetrical care and seek out different alternatives, including PHB. That should be the focus of any national debate about PBH.\r\n\r\nAs a result, I spent all day yesterday writing an email with information and resources, which I sent off just a few hours ago.\r\n\r\nTurns out the article is already a done-deed and unfortunately, Ms. Goldberg did not do as I\’d hoped — that is, she certainly didn\’t shed the cool light of reason and scientific evaluation on the topic. Instead, her 3,800 word  article, titled \”<a title=\”Home Birth: Increasingly Popular but Dangerous – Michelle Goldberg\” href=\”http://www.thedailybeast.com/articles/2012/06/25/home-birth-increasingly-popular-but-dangerous.html\” target=\”_blank\”>Home Birth: Increasingly Popular, But Dangerous\”</a> pored white-hot heat on this frequently misrepresented and misunderstood subject.\r\n\r\nLike most other bad articles on alternative healthcare choices, it portrays one or two specific practitioners as doing crazy or incompetent things and generally betraying the trust of their patients and leading to a very regrettable outcome. The writer wants us to generalize from those specific persons and assume that all healthcare providers of that type — in this case, midwives providing out-of-hospital care for normal birth — are awful and should be put out of business.\r\n\r\nI actually don\’t have ANY information about the cases Ms. Goldberg discusses — they may or may not have done the awful things she reports. What i know for sure, is that she miss a great opportunity to take a good look at WHY so many women in the US feel unserved by the mainstream system of medicalized maternity care and are moved to make \’alternative arrangements\’.\r\n\r\nAs mentioned above, I worked hard to amass information that would have permitted her to tell the story that so desperatey needs to be told. So here is the first installment of the material i put together for Michelle.\r\n\r\nMaybe she will reconsider. <a href=\”http://faithgibson.org/wp-content/uploads/2012/06/MPj044659500001.jpg\”><img class=\”alignnone size-thumbnail wp-image-33\” title=\”Silly-frog-colorful-graphic\” src=\”http://faithgibson.org/wp-content/uploads/2012/06/MPj044659500001-150×150.jpg\” alt=\”\” width=\”150\” height=\”150\” /></a> That would be nice.\r\n<blockquote>\r\n<div>\r\n<div>Dear Michelle ^0^</div>\r\n<div></div>\r\nAn acquaintance sent me your email address and suggested I contact you about your article on planned home birth (PHB) as a national debate.\r\n<div></div>\r\nI am a former L&amp;D nurse, professionally-licensed PHB midwife, and long-time political activist. I was appointed to the California Medical Board\’s Midwifery Advisory Council in 2007 and am currently serving my second 3-yr term.\r\n<div></div>\r\nI am also a mother of three and have two teenage grandsons. Having spent my adult life as a student of these contemporary and historical issues, I have, for better or worse, become an \’idiot savant\’ on the maternal-infant aspect of our healthcare system.\r\n<div></div>\r\nMy midwife-friend believes this information would provide helpful background information on \”why American women who could afford an obstetrician-attended birth in the \’safety\’ of a hospital would do something so apparently <em>irrational and dangerous</em> as planning to give birth at home\”. It\’s an important question.\r\n\r\n&nbsp;\r\n<div></div>\r\nI don\’t know if you had the privilege of watching the first 10 minutes of the <strong>new</strong> <strong>HBO series \”Newsroom</strong>\” Sunday night, but the same impassioned \’diatribe\’ and fact-based response by its mythical news anchor (actor Jeff Daniels as \’Will McAvoy\’) in relation to the question of America being \”the best in the world\” could (and should) be applied to the critique our maternity care system. Ditto the idea that \”America CAN do better\”.\r\n<div></div>\r\nWe aren\’t the 1st, 2nd, 3rd, 4th or even 20th in ANY of the relevant metrics of maternal infant health except for being <strong>1st in how much money we spend on maternity care</strong> (25% of our entire HC budget) and ranking <strong>2nd in how many inductions and Cesareans American doctors perform</strong>.\r\n<div></div>\r\nEach year a third of all babies born in the US — equal to the number of students that graduate from college — are delivered by major abdominal surgery at a cost roughly equivalent to 4 yrs tuition at a public community college. Complications of this tsunami of surgical deliveries include a <strong>substantial increase in maternal mortality</strong> since the mid-1990s.\r\n<div></div>\r\nAdding insult to injury, these expensive surgical interventions are <strong>not even buying us better babies — </strong>no improvement in neonatal mortality rates or reduction in cerebral palsy. The CP rate in the US has been exactly the same for the last 30-plus yrs, something ACOG is quick to point out in defense of obstetricians.\r\n<div></div>\r\nFactoring in the many scientific improvements in neonatal care over this time period means we are actually <strong>loosing ground for mothers and babies both</strong>. This is a national issue for many reasons, including the fact that 40% of all births in the US are paid for by the federal Medicaid program and that we want/need our economy to remain competitive in a global economy.\r\n<div></div>\r\nAs contrasted with the surgical speciality of obstetrics, the stated purpose of normal maternity care is to protect and preserve the health of already healthy childbearing women and their unborn or newborn babies. Society rightfully expects that modern American obstetricians would have the utmost most expertise in this area, but unfortunately, these are the very attributes missing from the current system of medicalized maternity care.\r\n<div></div>\r\nMastery in normal childbirth services for healthy women with normal pregnancies means bringing about a good outcome without introducing any unnecessary harm or unproductive expense. Logically this is  achieved by seeking out the <strong>point of balance</strong> where the skillful use of physiological management, and the adroit use of medical interventions when necessary (or requested by the mother), provides <strong>the best outcome with the fewest number of medical/surgical procedures</strong> and least expense to the health care system.\r\n<div></div>\r\nUnfortunately, the 20th century system of ‘pre-emptive’ intervention cannot provide this type of care. However, I don\’t want you to think that I am anti-doctor or anti-hospital. I would never want to live in a place or era without timely access to comprehensive medical and surgical services, which depends on well-equipped hospitals and well-trained doctors.\r\n<div>\r\n<div></div>\r\nI want hospitals to work and work well. I want physicians of all kinds to be skilled and seamlessly available. I also expect the medical professionals to be knowledgeable about physiologically-based practices and work cooperatively with mothers and midwives. We actually are all <strong>on the same team</strong> — the one that wants to use the best practices all the time for everyone.\r\n<div></div>\r\nI never see medicine and midwifery as an \’us versus them\’ issue. I am well-known for insisting that healthy women should <strong>never have to choose</strong> between a midwife and a physician, or between home and hospital, in order to received physiologically-based care for a normal childbirth.\r\n<div></div>\r\nThe current debate about PHB is simply a proxy in a fight that is either for or against normal (non-medical or physiologic) care for normal childbirth. As a principle of care, physiological management is actually not (or should not be) location specific quality.\r\n\r\n</div>\r\n<div></div>\r\nA science-based standard of care would integrate the principles of physiological management with best advances in obstetrical medicine to create <strong>a single, evidence-based standard for all healthy women</strong>with normal pregnancies that reserves obstetric interventions for complications or as requested by the mother. This model of ‘best practices’ would apply to all birth settings and be used universally by all categories of birth attendants when providing care to healthy women.\r\n<div></div>\r\nUnder those circumstance, place-of-birth would become what it was always suppose to be — the right choice for the particular situation for that specific mother &amp; fetus — with hospital and OOH both seen as responsible choices in an integrated, cooperative and \’minimalist\’ model based on scientifically-established ‘best practices’ and patient consent.\r\n<div></div>\r\nThese are the many reasons an honest national debate on de-medicalizing normal childbirth is vitally important. We need a debate that is thoughtful and fact-based instead of hysterical or motivated by a political agenda. The real issue isn\’t place-of-birth (home vs. hospital), its the type of care provided for normal childbirth in a healthy population — cost-effective, physiologically-supportive care vs. expensive interventive and invasive care.\r\n<div></div>\r\nAs mothers and midwives, the heart of the poorly-named \”home birth movement\” is actually to end the unexamined agenda of ever-escalating medicalization of normal childbirth in healthy women, while the obstetrical professional attempts to marginalize and/or criminalize all \’alternatives\’. We seek to replace the early 20th century default of routine medicalization with a science-based normalization of labor and birth, irrespective of the category of birth attendant (physician, midwives, obstetrician) or the setting (home or hospital).\r\n<div></div>\r\nThis problem can only be fixed by acknowledging physiological management as the universal standard of care for healthy women, while continuing to provide women with unfettered access to obstetrical procedures as they deem necessary for themselves, such as labor induction, epidural anesthesia and elective Cesarean section (abet with full information on associated risks).\r\n<div></div>\r\nHere is a link to an article to help you make sense of the OOH-PHB safety arguments. Its from a document entitled \”<strong>Evidence-based policies for Maternity care and a plan for action</strong>\”, section II: \”Safety &amp; the Maternity-care Continuum in an essentially healthy population\”.\r\n<div></div>\r\n<div><a href=\”http://healthcare2point0.com/MCDG_contrast-studies_feedback_28Aug2010.htm#Part_II:\”>http://healthcare2point0.com/MCDG_contrast-studies_feedback_28Aug2010.htm#Part_II:</a></div>\r\n<div></div>\r\nI\’m happy to provide additional material or reply to questions. I will email (i.e., post) the installment on historical issues – 1910-1940s – in the next 24 hours, unless I am called away by the Stork, who is indeed a jealous and temperamental mistress.\r\n\r\n</div>\r\n<div></div>\r\n<div>Tomorrow ~ Historical perspective ~ 1910 to 1940s</div></blockquote>’, ‘Daily Beast blogger slams planned home birth ~ Speaking Truth to \’truth-i-ness\”, ”, ‘inherit’, ‘open’, ‘open’, ”, ’29-revision-9′, ”, ”, ‘2012-06-28 16:04:25’, ‘2012-06-28 16:04:25′, ”, ’29’, ‘http://faithgibson.org/29-revision-9/44/’, ‘0’, ‘revision’, ”, ‘0’);
INSERT INTO `wp_posts` VALUES(’39’, ‘1’, ‘2012-06-29 17:03:35’, ‘0000-00-00 00:00:00’, ‘Yesterday  journalist Michelle Goldberg published a blog on <strong>The Daily Beast</strong> characterizing PHB as \’dangerous\’ and CPM midwives to be inadequately trained and dangerous birth attendants. This opinion was formed from interviews and documents about on a midwife-managed OOH labor and hospital transfer with a poor outcome. At issue is whether the circumstances reported by Ms. Goldberg fully and accurately represented these events, and if so,  whether this means that PHB under the care of a professional midwife is  a failed model of maternity care that needlessly risks the lives of healthy women and babies.\r\n\r\nYesterday I posted the text of my email to Michelle Goldberg. Tomorrow I will post additional information to help readers sort facts from hysteria and (I hope) enable childbirth activists who are so moved to post information-based rebuttals on the Daily Beast blog site.\r\n\r\nHowever, today\’s blog takes a critical look behind the idea of a \”national home birth debate\”.\r\n<h3>Lets not be fooled –&gt; the Home Birth Debate is NOT actually about home birth</h3>\r\nOrganized medicine embarked an aggressive media campaign a decade ago that portrays non-nurse midwives and OOH birth (particularly PHB) as dangerous. This is based on the<strong> unproven claim that non-medical care routinely deprives the </strong><strong>babies of </strong><strong>healthy laboring women of the benefit of life-saving medical interventions</strong>. This media campaign started with the pre-publication publicity of the PANG study at ACOG\’s annual convention. Dr. Thomas Benedetti issued a press release at the April 2002 ACOG conference in LA and was interviewed by Reuters’ news service reporter Jacquelyn Stenson. Since the study was not scheduled to be published until August, Reuters was delighted with this exclusive \”scoop\” and ran the story under a headline that boldly proclaimed: “<strong>Home Births Linked to More Infant Deaths</strong>”; the first sentence of the article read: “<strong>Twice as many infant deaths occurred during home births than with hospital deliveries</strong>”. (Sound familiar?) However, if the Reuters\’ reporter had taken its stats from the study instead of ACOG\’s press-release, they headline would have read: “NNM was 99.6 for PHB/HospTransfer and 99.8 for Intended-Hosp — a 0.2 difference in NNM.\r\n\r\nEventually the Pang study was debunked, but when it mattered most – during an active news cycle that plastered “home birth = infant deaths” headlines in newspapers all across the land — there was no way for us to evaluate its methods (deeply flawed) or conclusions, which used soft data to arrive at hard conclusions\r\n\r\nhighly controversial for a number of reasons, most notably, a study on the relative safety of *PLANNED* home birth<span style=\”color: #333333; font-family: Helvetica; font-size: large;\”> </span>used <strong>birth certificate data from a state (Washington<em>) that did NOT record the planned place of birth</em></strong>. The Pang study cast the widest possible net, and confidently \’inferred\’ that a birth was planned to occur at home. Actually, PANG — queen of \’planned home birth\’, included unplanned births, unattended births and unplanned AND unattended births.The authors included pregnancies at 34 wks (which is 6 wks premature) and including of 70 pre-term births in the PHB cohort, while excluding hospital patients that had a Cesarean delivery.\r\n\r\n@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@\r\n\r\nThis the story was picked up by the other wire services and circulated coast to coast for <strong>4 months</strong> before any other professional was able to read the paper and evaluate its methods (deeply flawed) or rebut its starkly misleading its claims. Only after the study was published 5 months later – August 2002 — did it become obvious that the PANG study was a scientifically (fatally) flawed study that reflected a political agenda. The PANG study was eventually debunked but not when it mattered most – when the news cycle was plastering “home birth equals infant death” headlines all across the country.\r\n\r\nBecause birth certificate data was unable to distinguish ‘planned’ from ‘unplanned’ home births, the PANG authors choose to \’infer\’ that any birth occuring after 34 weeks of pregnancy (thus including 70 premature births) was planned by the parent to be a home if a midwife was listed as having provided prenatal care or the birth certificate was signed by a midwife or nurse. As a result of this including this kind of unconfirmed data, the Pang study included unplanned births, unattended births, unplanned AND unattended births, birth attended by untrained persons, premature babies that delivered precipitiously and women who risked out during the latter weeks of pregnancy and were electively transferred to obstetrical care for planned hospital births.\r\n\r\nACOG operatives, have The efforts of ACOG\’s national office have been simultaneously accompanied by the tireless efforts of a retired woman obstetrician-turned-blogger who may well be on the payroll of organized medicine.\r\n\r\nAs a result, a lot of us (myself included have spend a ton of time and talent trying to \’rebut\’ these claims. However, I now see this from a very different perspective, realizing that it is a mistake to think that the real issue is home birth.\r\n\r\nStudies such as the Pang (PHB Outcomes in Washington State) and Wax et al\’s recent meta-analysis merely distract everyone with phony arguments that improperly focus on \”Place of Birth\” as a proxy for management style.\r\n\r\nI now see how the word \”home\” is actually proxy for claim that \”a non-medical environment is bad\”. The word \’non-nurse midwife\’ likewise is proxy for the premise that \”not being a medically=trained doctor or nurse midwife is dangerous\”. To borrow a colorful definition of \’really really bad\’ from MCNBC\’s Rachel Maddow, ACOG used the idea of planned home birth as proxy for: \”Murder, Satan and stubbing your toe all in one\”. However, if you reverse engineer those sentiments, they say that no matter how healthy the mother or normal the labor, medical care as provided by an MD is always the superior choice and anything else is inferior and wrong.\r\n\r\nI believe it is critically important that we (as activists) take charge of  so-called (and imporperly<em><strong> </strong></em>named) \’planned home birth debate\’ because the real issue  is <strong>NOT home birth. </strong>Our knee-jerk reaction — trying to defend childbirth as a stand-alone virtue — is not helpful.  Ultimately it is not and will not work for two reasons. First it misses the real point (providing organized medicine with platform to promote \’The Defense of Medicalized Childbirth Act\’). Second, it paints us into a corner because proving a negative is an impossible uphill fight.\r\n\r\nImagine you were trying to convince people who had a deep-seated fear of flying out of being afraid. In your enthusiasm, you insisted that in the entire history of aviation no planes had ever crashed AND furthermore, you assured them that in the future no planes would ever crash. Of course, such a claim came instantly be discredited, as even the best pilots and most air-worthy aircraft occasionally, tragically crash. Instead of the public debate  being focused on the many positive contributions of  air travel, including the fact that per mile traveled airplanes are actually safer than cars, you, as a defender of flying, would be derailed into an endlessly arguing about relative safety of a system in which planes sometimes crash, and thus can easily be considered \’dangerous\’.\r\n\r\nIs evident from the \’conclusion\’ statement in the Wax meta-analysis that the point of the home birth debate is to defend medicalized birth — the routine use of medical interventions. The authors of the Wax study went to great effort to massage the numbers, bend their findings into a pretzel by leaving out 534,607 births out of a total cohort of 549,607  so they would be able to \”conclude\” that: “Less medical intervention during planned home birth is associated with a tripling of the neonatal mortality rate.”\r\n\r\nA hundred years ago, the obstetrical profession became convinced (and convincing) that it was life-&amp;-death important to replace the care of supportive care of midwives with the medicalized care of normal labor and to conduct spontaneous birth as a surgical procedure by physicians (and only by physicians). For them, their way is medicalized maternity care. To them, medicalized is the right way, only safe and sane way. Any evidence to the contrary is the equivalent of \’fighting words\’, a declaration of war. From this perspective, the success of midwives providing non-medicalized care is a particularly galling example.\r\n\r\nWhen ACOG, and others promoting the contemporary goals of organized medicine, use of the words \’home birth\’, they are really <strong>proxy for a type of care that is specifically NOT what the medical profession provides</strong> — that is, non-medicalized, physiological management of normal labor and birth in a healthy population. Nothing in physiological management is inherently location specific — birth attendants of all backgrounds could (and should) provide physiologic care for healthy women with normal pregnancies. Nonetheless, this normative model of care for normal childbirth has not been available in American hospitals for the entire 20th (and so far 21st) century. It is no more what doctors and hospitals do than we would expect the automobile industry to promote cross-country walking tours or the national association of vintners to provide tasting rooms for bottled water.\r\n\r\nFor a variety of reasons, a substantial number of healthy childbearing families have, over the last 40 years, realized that highly medicalized care for healthy women was not safer, did \’better\’ and in fact, was not what they wanted. When they looked around, and tried to figure out how to get the \’system\’ to take them seriously, they found either total stiff armed resistance OR hospitals that offered flowered bedspreads and \’permitted\’ dads into the labor room  a fact that has triggered to seek an \’alternative\’ use free-standing birth centers or their own home as the only way to avoid unwanted, unnecessary medicalized care. What THE-POWERS-THAT-\r\n\r\nIt is up to us (mothers, midwives and other activists) that we redirect\r\n\r\nUnfortunately the word \”home\” in the context of this debate is being actually a proxy for a type of care and the assertion by the medical profession that physiologically-based care is sub-standard at best and (as described by the Michelle Goldberg blog) \”dangerous\”. The characterization of physiologic care as \’dangerous\’ and medicalization of \’safe\’ is the reason that childbearing women are to totally avoid unwanted medicalization AND to received normal care for normal childbirth (i.e. physiological management in our present hospital-based, obstetric-centric system, which uniformly medicalizes maternity care for healthy women.\r\n\r\n&nbsp;\r\n\r\nIn a few days, I will post materials on the relative of PHB safety and a stand-alone critique of the Wax meta-analysis.\r\n\r\n======================== material for tomorrow\r\n\r\nMost Americans believe we have a world-class maternity care system (best money can buy!) and that American obstetrics, as applied to a HEALTHY childbearing population, has created an effective form of childbirth-related healthcare based on medicalizing normal childbirth. The \’pre-emptive\’ or routine use of obstetrical interventions is credited with enabling American obstetricians to eliminate maternal and infant mortality and morbidity and to have done so without introducing any unnecessary harm or unproductive expense.\r\n\r\nThey are proud of this system.For them the only unsolved problem is how to increase the reach and revenue of obstetrics, and how to solve, finally and for all times, the \’midwife problem\’! Seen from the perspective of modern obstetrics, the current system is \’final solution\’ to the age-old problem of childbirth-related complications. As such, the failure of any childbearing woman to use this safety system is described as the \’earliest form of child abuse\’; many in the medical profession believe both parents and midwives should be criminally prosecuted.\r\n\r\nI don\’t know if you had the privilege of watching the first 10 minutes of the new HBO series \”Newsroom\” last night, but the exact same impassioned \’diatribe\’ and fact-based response by its mythical news anchor (actor Jeff Daniels as \’Will McAvoy\’) in relation to the question of America being \”the best country in the world\” could (and should) be applied to the critique our maternity care system, along with the same (and very important) punch-line \”we CAN do better\”.\r\n\r\nThe United States is not the 1st, 2nd 3rd, 4th or even 20th in ANY of the relevant metrics of maternal infant health except for being 1st how much money we spend on maternity care (25% of our entire HC budget) and ranking 2nd in how many inductions and Cesareans American doctors perform each year.\r\n\r\nBasically 1/3 of all babies — equal to the number of students that graduate from college every year in the US — are delivered by major abdominal surgery at a cost roughly equivalent to 4 yrs tuition at many public community colleges. This surgery rate is NOT accompanied by any reduction in cerebral palsy or equal improvement in neonatal outcomes. However, complications of induction and surgical delivery (many totally elective) are associated with a substantial increase in maternal mortality in the US since the mid-1990s. This is a national issue for many reasons, including the fact that 40% of all births in the US are paid for by the federal Medicaid program — a real problem if our country is to remain competitive in a global economy.\r\n\r\nOdd as it seems, the 1970s PHB/normal care for normal birth movement was triggered by obstetrical policies put in place in 1910. This is when influential obstetricians in the US decided to get rid of the \’old obstetrics\’ — the poor stepsister of medicine described as \’man-midwifery\’, since physician birth attendants were historically called man-midwives throughout out the 17th, 18th and 19th centuries. The medical profession saw attending women during normal birth as a low class form of “woman’s work”. Professionally supporting the normal biological process of labor and birth was not considered to be medical practice, or worthy of the attention of formally educated “medical men”.\r\n\r\nIn 1911, Dr Williams, author of one of the most famous American textbooks on obstetrics, described the \’new obstetrics\’ as an opportunity to gain the respect of their medical colleagues, while elevating the status of obstetricians among the lay public.\r\n\r\n\”… the ideal obstetrician is not a man-midwife, but a broad scientific man with a surgical training who is prepared to cope with most serious clinical responsibilities and at the same time is interested in extending our field of knowledge. No longer would we hear physicians say that they cannot understand how an intelligent man can take up obstetrics, which they regard as about as serious an occupation as a terrier dog sitting before a rathole waiting for the rat to escape.\”\r\n\r\nOn that same note, Dr De Lee\’s 1924 obstetrical textbook redefined normal birth as a surgical operation and expands role of the obstetrician:\r\n\r\n“Let us pause here to take a glance back at the treatment of labor as a whole. It should be regarded as surgical operation: it really is such, and the obstetrician is really a surgeon.\r\n\r\nThe conduct of labor is not a simple matter, safely entrusted to everyone. Let the people know that having a child is an important affair, deserving of the deepest solicitation on the part of friends, needing the watchful attention of a qualified practitioner and that the care of even a normal confinement is worthy the dignity of the greatest surgeon.” [p. 341]\r\n\r\nAs could be expected from these comments, the new obstetrics in American turned healthy women into the patients of a surgical speciality and normal childbirth into a surgical procedure \’performed\’ by physicians. This was the most profound and far-reaching change in childbirth practices in the history of the human species, as invasive medical and surgical procedures replaced principles such as \’patience with nature\’ and \’right use of gravity\’.\r\n\r\nSentient women no longer gave birth under their own power, but instead became passive vehicles from which the doctor (not the mother!) delivered the baby. The mother\’s only job was to be appropriately grateful afterwards. However, none of the policies, practices and protocols that made up the \’new obstetrics\’ in 1910 were based on any prior or subsequent scientific evaluation.\r\n\r\nUnfortunately, this unexamined historical fluke provided us with a so-called \’modern\’ or scientific system that did not improve on the biology of normal childbirth, nor could it deliver on its promise to safe-guard healthy mothers and babies until after the discovery of antibiotics and safer anesthetics the early 1940s. During the decade that obstetricians successfully eliminated the practice of midwives in much of the US (1915-1925), maternal mortality sky-rocked by 15% a year and neonatal birth injuries went up by 40% as risky medical procedures were substituted for physiologically-based care.\r\n\r\nIn 1925, 25,000 newly delivered mothers died — 1,200 per 100,000 live births — which was the highest maternal mortality of any industrialized country at any time in history. This represented a doubling of the 1900 maternal death rate prior the imposition of the new obstetrics. The MMR in 1900 600 per 100K, which was three times higher than the MMR was in Sweden (200 per 100K) for the same time period. The difference was that Sweden had a state-regulated system of physicians and trained midwives who worked together cooperatively, with both using non-interventive (physiologic) care as the standard for normal childbirth.\r\n\r\nWorldwide, the goal of maternity care has always been to protect and preserve the health of already healthy childbearing women and their unborn or newborn babies. This is the area in which we rightfully expected modern American obstetricians to have the most mastery. However, these are the very attributes most missing from our current system of medicalized maternity care.\r\n\r\nOne of the biggest stumbling blocks to a science-based model of maternity care in the US is the current medio-legal system. For the last 100 years, obstetrical policies have been defined by professional groups (ACOG, etc) and legally reflect a \’standards of practice\’ that requires obstetricians, as members of a surgical speciality judged by other members of the same surgical speciality, to use a surgical standard of care.\r\n\r\nHowever, this is not the fault of individual obstetricians. The problem lies with policies that first originated in the pre-antibiotic era of 1910 that have never been re-examined or subjected to  continue to block modern-day obstetricians from providing physiologically-based care, lest they be accused of \’substandard\’ (i.e., negligent) care. This also prevents them from having an open and collegial relationship with community-based midwives and keeps midwives as a group from being integrated into mainstream health care system and obtaining hospital privileges. This is the polar opposite of the system that served Sweden so well in 1900 and continues to make it one of very safest places on earth to have a baby, with one of the highest levels of satisfaction by new moms.\r\n\r\nThis problem needs to be fixed by changing the \’system\’ to acknowledge physiological management as the universal standard of care for healthy women with normal pregnancies. As mothers and midwives, the heart of our counter-culture movement is to do just that — reverse the ever escalating \’medicalization\’ of intrapartum care and re-orient it towards the normalization of labor and birth, irrespective of the category of birth attandent (physician, midwives, obstetrician) or the setting (home or hospital).\r\n\r\n&nbsp;\r\n\r\n&nbsp;\r\n\r\nAn essay recently published in the professional journal BIRTH entitled \”<strong><em>A Time-Traveler\’s Perspective on Normal Childbirth</em></strong>\” provides an overview of the controversy over childbirth from a historical and practical perspective. It should be available on-line for the September 2011 edition.\r\n\r\nMy original (longer) version was called: \”<strong><em>How Normal Childbirth in the US Got Trapped on the Wrong Side of History</em></strong>: The last and most important UNTOLD story of the 20th century — <em>how healthy women in American were turned into the patients of a surgical speciality and normal childbirth into a surgical procedure</em>\”. This was the most profound and far-reaching change in childbirth practices in the history of the human species.’, ‘Daily Beast\’s slam on PHB: Additional comments ~ ‘, ”, ‘draft’, ‘open’, ‘open’, ”, ”, ”, ”, ‘2012-06-29 17:03:35’, ‘2012-06-29 17:03:35’, ”, ‘0’, ‘http://faithgibson.org/?p=39’, ‘0’, ‘post’, ”, ‘0’);
INSERT INTO `wp_posts` VALUES(’72’, ‘1’, ‘2012-06-29 08:09:54’, ‘2012-06-29 08:09:54’, ‘Yesterday  journalist Michelle Goldberg published a blog on <strong>The Daily Beast</strong> characterizing PHB as \’dangerous\’ and CPM midwives to be inadequately trained and dangerous birth attendants. This opinion was formed from interviews and documents about on a midwife-managed OOH labor and hospital transfer with a poor outcome. At issue is whether the circumstances reported by Ms. Goldberg fully and accurately represented these events, and if so,  whether this means that PHB under the care of a professional midwife is  a failed model of maternity care that needlessly risks the lives of healthy women and babies.\n\nYesterday I posted the text of my email to Michelle Goldberg. Tomorrow I will post additional information to help readers sort facts from hysteria and (I hope) enable childbirth activists who are so moved to post information-based rebuttals on the Daily Beast blog site.\n\nHowever, today\’s blog takes a critical look behind the idea of a \”national home birth debate\”.\n<h3>Lets not be fooled –&gt; the Home Birth Debate is NOT actually about home birth</h3>\nOrganized medicine embarked an aggressive media campaign a decade ago that portrays non-nurse midwives and OOH birth (particularly PHB) as dangerous. This is based on the<strong> unproven claim that non-medical care routinely deprives the </strong><strong>babies of </strong><strong>healthy laboring women of the benefit of life-saving medical interventions</strong>. This media campaign started with the pre-publication publicity of the PANG study at ACOG\’s annual convention. Dr. Thomas Benedetti issued a press release at the April 2002 ACOG conference in LA and was interviewed by Reuters’ news service reporter Jacquelyn Stenson. Since the study was not scheduled to be published until August, Reuters was delighted with this exclusive \”scoop\” and ran the story under a headline that boldly proclaimed: “<strong>Home Births Linked to More Infant Deaths</strong>”; the first sentence of the article read: “<strong>Twice as many infant deaths occurred during home births than with hospital deliveries</strong>”. (Sound familiar?) However, if the Reuters\’ reporter had taken its stats from the study instead of ACOG\’s press-release, they headline would have read: “NNM was 99.6 for PHB/HospTransfer and 99.8 for Intended-Hosp — a 0.2 difference in NNM.\n<div></div>\nThis the story was picked up by the other wire services and circulated coast to coast for <strong>4 months</strong> before any other professional was able to read the paper and evaluate its methods (deeply flawed) or rebut its starkly misleading its claims. Only after the study was published 5 months later – August 2002 — did it become obvious that the PANG study was a scientifically (fatally) flawed study that reflected a political agenda. The PANG study was eventually debunked but not when it mattered most – when the news cycle was plastering “home birth equals infant death” headlines all across the country.\n\nACOG operatives, have The efforts of ACOG\’s national office have been simultaneously accompanied by the tireless efforts of a retired w