Monday, December 21, 2009

A New Jersey Hospital Announces L&D Closure

Lourdes Hospital in southern New Jersey has announced that it is closing its L&D unit.

(Click here to read story).

The closure announcement starts to sound like a broken record. “They can no longer absorb the financial losses from low reimbursements!”

The state of New Jersey is concerned that more hospitals in the state are on shaky ground and could follow Lourdes’ lead and also shutter L&D.

Folks, we have to find a better model.


Friday, December 18, 2009

“Scrap the Health Care Bill -- Your Man Said So”

Over the past few months I have tried to give a unique perspective on the health care reform debate. Rather than take sides, I have asked questions about the bills, that neither the Democrats nor Republicans have addressed.

I have stated that we need healthcare reform, but that I do not believe that the current bills were getting us where we needed to go.

Yesterday, I introduced you to the time honored tradition of "Your Man Said So." Basically, when somebody on the other side agrees with you, the argument is over.

Democratic National Committee Chairman, Dr. Howard Dean M.D., has come out and said that it is time to scrap the healthcare bill.

In an editorial he said: (Click Here to Read Washington Post Editorial)

“If I were a senator, I would not vote for the current health-care bill.”

“In Washington, when major bills near final passage, an inside-the-Beltway mentality takes hold. Any bill becomes a victory. Clear thinking is thrown out the window for political calculus. In the heat of battle, decisions are being made that set an irreversible course for how future health reform is done. The result is legislation that has been crafted to get votes, not to reform health care.”

“I know health reform when I see it, and there isn't much left in the Senate bill. I reluctantly conclude that, as it stands, this bill would do more harm than good to the future of America.”

As you can see by reading the full editorial, there were some things in the bill he liked and others he could not stomach. However at the end of the day, he is concluded that this bill as written “would do more harm than good to the future of America.”

Because of, "Your Man Said So," I now will take a position and urge you to do the same. "Scrap the current health-care legislation and start over."

Have a great weekend


Thursday, December 17, 2009

"Your Man Said So"-- the Ultimate Debate Ender

Growing up on the streets of Brooklyn, New York, we did not play everyday sports with organized teams or umpires. Somebody had a football, somebody brought a rubber ball, maybe a softball with some bats, we chose the teams and we started playing.

Within a short time, a play would occur, and an argument would start. "It was fair!”No, It was foul!” or, "He ran out of bounds." “No, he was in-bounds."

People would yell, they would point, re-create, and deliver arguments that would make Clarence Darrow proud.

Inevitably, someone on the opposing team would pipe up and agree with you. Your team says “fair, ” their team says “foul,” and all of a sudden, someone on their team agrees with you and says, "FAIR!"
That's it! Argument over! It was “fair” “YOUR MAN SAID SO”

“Your Man Said So,” is the ultimate conflict ender. It didn't matter, who on the other teams agreed. Their best player? Their worst player? It made no difference! “Your Man Said So,” was more was more powerful than the 10 Commandments themselves.

So what does this have to do with birth? Tomorrow, I will point out the ultimate “Your Man Said So,” in the healthcare debate.


Wednesday, December 16, 2009

Is Midwife Care Superior to Physician Care?

Whatever shortfalls are pointed out in our maternity care system, the birth advocates sing the usual response, "Midwives, all we need is more midwives."

In England, where midwives are still the norm for delivering babies, it seems every day there is another horror story coming out of the maternity wards. They all revolve around midwife and funding shortages.

In the attached article, (click here to read MailOnline article), a former hospital midwife reveals what type of care women are getting in England by the midwives.

My take on the story is that the "midwifery model of care." that is extolled by advocates in the United States is no longer being given at NHS hospitals due to resource allocations.

I want to make clear, that I am a huge supporter of midwives and the midwives model of care. I also have no intention of EVEN trying  to answer the question: "Is midwifery care superior to physician care?"

I want to point out that if midwifery care were to become the norm in this country, the midwives would come under the same huge time and dollar pressures as physicians . It is quite possible that what what today is heralded as the standard that midwives give their patients, tomorrow could become a distant memory.

If tomorrow the physicians agreed that midwives (CNM's, CMS, CPM's, LMS, etc.) would deliver half the babies that are born in the U.S., and if there are 7500 practicing midwives (Dr. Robbie Davis-Floyd informs me that no one really knows the number of midwives in the US actually delivering babies) than each midwife would have to deliver almost 600 babies per year.

How much time do you think a midwife could spend with each pregnant woman if she had to deliver 600 babies per year?


Bean Counters Look at Only Half the Story

We often ask why Medicaid and insurance companies don't see the full results of their actions? Why do they NOT understand that their procedures and policies when it comes to childbirth, produces less healthy babies and cost them much more money in the long run?

A recent article about the single-mindedness of airline accountants has cost the airlines millions, yet they think they are actually making money. We are talking about baggage fees. A few years ago, the airlines (with the exception of Southwest and JetBlue) started charging for checking in. even one bag.

For the second quarter of 2009, this amounted to almost $670 million in baggage fee revenue. The bean counters were jubilant! Look how much money we've brought in, just from charging baggage fees.

Of course, the bean counters had no way of calculating how many passengers chose. NOT to fly the airlines that charged baggage fees. Second quarter revenue dropped by almost $130 billion. Those airlines that do not charge baggage fees suffered losses that were less than half of what the baggage fee charging airlines suffered. (Not to mention how hard it is to get back a customer that has left you for the competition)

(Click here to read article).

Very often when looking for solutions to improve birth, the bean counters, as well as the birth advocates view only one side of the financial equation. It is important to look at all sides when making decisions.


Monday, December 14, 2009

Yet Another Hospital to Close L&D in January

The Philadelphia area has had 18 L&D. closures since 1997, limiting women's choices and putting a severe strain on remaining L&D units.

Mercy Suburban Hospital in Norristown PA, will close L&D, January 18, 2010.

(Click here to read article).

To those birth advocates that believe L&D is a profitable part of a hospital's operations, I would ask one question: "Why would a hospital that interested in maximizing revenue. close a profitable unit?"


Friday, December 11, 2009

2.2 Million Reasons Not to Do a Vaginal Birth

An upstate New York jury awarded the family of a baby who died of seizures following the mishandled birth a $2.2 million verdict against, the obstetricians involved.

(Click here to read article).

It appears that a hospital nurse told the obstetrician on duty that she was concerned about the baby's heart rate, but rather than do an immediate C-section, the OB gave orders to monitor and continue the vaginal delivery.

The baby became stuck during the delivery, suffered oxygen deprivation and brain damage.

Does anyone believe that the next time the doctors involved are faced with a similar situation, they will not immediately say "C-section now!”?

Have a great weekend.


Thursday, December 10, 2009

Another Hospital Closes L&D

I interrupt the discussion about health care and higher education comparisons, to report another. L&D. closing.

Southeast Baptist Hospital in San Antonio is closing their L&D unit effective January 1, 2010.

(Click here for news article).

A new hospital is scheduled to open (hopefully if there are no delays) .in 2011. Meanwhile, the people in the southeast community will not have an L&D unit for at least two years.

Do you believe that if L&D were a profitable service, they would close the unit?


Wednesday, December 9, 2009

No Post Today

Due to a technical glitch, today's blog did not post.

Tuesday, December 8, 2009

Comparing Healthcare Financing and Higher Education Financing

Every time there is an election, some candidate accuses the other candidate of wanting to cut higher education spending, and promises that he or she will fight for more money on higher education, and say “Because our young people are the promise for tomorrow” or something similar.

Let's imagine what would happen if in fact, government higher education financing was reduced or removed. No government student loans, No Pell grants, other German grants, etc.
And let's just say that tuition at College X. is $15,000 per year. (Some of you will say that's too cheap, and others will say way too expensive.) And now, there is no government aid.

Do you believe the colleges will all shut their doors? Do you believe that every student that does not have $15,000 at the beginning of the year will be unable to attend? Will they fire every professor? Will the University of Texas and University of Alabama shut down their football programs?

After 9/11, the airlines were facing the equivalent of the government shutting down student aid. "America was afraid to fly." Some airlines filed bankruptcy, others did not. Most kept flying. They cut everybody's pay between 25% and 50%, if not more, and had substantial layoffs. BUT, they kept flying.

What will colleges and universities do?

Offer their own loans? Cut salaries? Lay off staff? Merge and consolidate? Stop offering ridiculous electives? Re-evaluate how many credits are needed for a degree? Go to online classes? Sell some buildings? Reduce services?

The answer is, they will probably do ALL of the above. They will get creative. They may reduce tuition. They will do everything not to close the doors, and still offer quality education and profitable sports programs.

So your next question should be: "If they can do this without student loans and aid, why don't they?"

When you were a kid and your allowance was $2.00, you spent it. When it was raised to $5.00, you spent it. If you got $10, you spent it.

In other words, as long as the money is there, you will find a way of justifying and spending it. It’s the same with colleges and universities.

Do you think health insurance has had any effect on the cost of medical procedures? (answer tomorrow)


Monday, December 7, 2009

Health Insurance Was Never Intended to Pay for Birth

Why's it so hard to buy maternity coverage?

(Click Here for Article)

As this article in the Colorado Independent points out, it is difficult to buy maternity coverage for individual health insurance, and most the time. It's not worth it.


The answer is very simple: Do you want to have a car accident? Would like cancer? Do you want your plane to crash? Do you want your house to burn down? Do you want to be sued? Do you want to die?

I'm assuming the answers to the above are, "NO"

Anybody want to have a baby??

For many the answer to having a baby is "YES"

The whole concept of insurance, is to protect against things that might happen, but you don't want to happen. In most cases, maternity coverage protects against something you want to happen.

Insurance actuaries go nuts when asked to calculate desirable risk as opposed to undesirable risk. Had normal maternity coverage never been included in health insurance, then I believe that our entire system of labor and delivery would have evolved differently.

What many of you don't realize is that “complications of pregnancy”, which usually meant needing a cesarean section, was always covered by your policy, EVEN it had no maternity coverage.

I guess times have changed.


Friday, December 4, 2009

Affect of Super Simple Health Plan on Birth

For the past two days, I've written about the super simple two line health plan, which I put forward, not as a proposal, but rather as an example of how a major change could be made without a 2000 page bill.

The super simple plan is:
1) All US citizens and legal residents are automatically enrolled in the Medicaid program and will pay a fee equal to 5% of adjusted gross income, unless exempt by paragraph #2.

2) Persons having proof of health insurance or who have sufficient assets not to need health insurance are exempt from the requirements of paragraph #1.

So now the question is: “How would this plan affect. birth practices?”

The most obvious answer would be that with everyone being covered, less malpractice suits will be filed, since a large number of suits for birth injury are for the purpose of getting medical bills paid for the baby's treatment. Since medical bills a re covered under Medicaid, or insurance, r than alleviates the need for these lawsuits.

As an incentive for people to buy health insurance as opposed to Medicaid, the insurance companies might offer to pay obstetricians and family physicians and midwives a lot more money per birth in the hope that they would then refuse the meager Medicaid reimbursement amounts.

Medicaid might have to increase their payments to birth care providers, so they will continue to accept Medicaid patients.

Insurance companies might embrace concierge birth facilities as a way of keeping insured’s with private insurance from changing to Medicaid.

This is not comprehensive analysis, but then remember, the original proposal is only two paragraphs.

Have a great weekend.


Thursday, December 3, 2009

Defending the. Two Paragraph Health Reform System

Yesterday, I put forward a super simplified health reform plan:

1) All US citizens and legal residents are automatically enrolled in the Medicaid program and will pay a fee equal to 5% of adjusted gross income, unless exempt by paragraph #2.

2) Persons having proof of health insurance or who have sufficient assets not to need health insurance are exempt from the requirements of paragraph #1.

Although I'm not proposing or supporting it. I've had a number of people ask me questions regarding it. So, I will post some questions and some responses.

1) Q. Won't expending Medicaid cause everyone to drop private insurance and move to the public program?
     A. As long as providers and facilities are free to accept or refuse Medicaid patients Medicaid patients, then private insurers will offer plans with richer and better payment structures. Quite simply, their sales pitch is: “your doctor will not accept Medicaid, they will accept our insurance”..

2) Q. Your program is only available to US citizens and legal residents. What about the illegal immigrants?
    A. Nothing prohibits private insurers from offering policies to no citizens, and non legal residents. A provision could be added, that if someone other than the US citizen or legal resident is given medical care and they do not pay for it, that could be a deportable offense.

3) Q. There is no exemption for the poor paying the 5% health fee?
     A. There is no exemption for the poor to pay sales taxes or property taxes. Since everyone has the benefit of the expanded Medicaid program, why should they not have to pay something? On a $12,000 year income, the premium is $50 per month, regardless of how many children in the family.

4) Q. Why should a rich person have to pay such a high amount? A person earning $1 million / year would have to pay $50,000?
    A. Since this program makes healthcare a right, then funding healthcare, becomes an obligation of all Americans. In other words, we now call it what it is “A TAX” and not an insurance premium. The fact is the wealthy pay more in taxes than the poor.

Again, I am not proposing, supporting or endorsing the two paragraph health plan. I am simply pointing out that if we really wanted to solve healthcare, we could do it, and it would be a lot easier than what is going on in Washington today.


Wednesday, December 2, 2009

If You're so Smart, What Would You Propose for Health Reform?

Yesterday, I talked about 60 votes in the Senate being the most important criteria for the 2000+ pages of health care reform.

Someone just asked me how I would tackle it?

Here is my 2 paragraph starting point:

1) All US citizens and legal residents are automatically enrolled in the Medicaid program and will pay a fee equal to 5% of adjusted gross income, unless exempt by paragraph #2.

2) Persons having proof of health insurance or who have sufficient assets not to need health insurance are exempt from the requirements of paragraph #1.

The above can be tweaked, amended and improved, and it should not take more than 50 pages. Perhaps the premium charge is 4% or 7%, the number is irrelevant. Two paragraphs is about concept not specifics.

Providers would be free not to accept Medicaid patients and insurance companies would compete on that basis.

I am not proposing the above as a solution for healthcare, but, if you're really serious about solving the health insurance mess, then my suggestiosn would be a starting point and we work from there.

My analysis of the political parties involved, is that the Republicans are trying to defend an indefensible system, while the Democrats are trying to manage an unmanageable system.


Tuesday, December 1, 2009

Why Congress Can't Write a Good Health-Care Bill

Due to the Senate starting to the debate on healthcare reform, I'm going to hold off “Institutional Versus Entrepreneurial Financials” a day or two to comment on health reform.

Question: what is the most overriding concern regarding health reform legislation? Is it a bill that covers all Americans? Is it reducing insurance premiums? Is it a public option? Is it reducing long-term costs? Is it tort reform? Is it making the United States the best healthcare system in the world?

The answer to all of the above is “NO!”

The only single overriding criteria for Health Care Reform is: “Can the Democrats get 60 votes to allow the bill to be voted on”

That’s right, the only criteria is: “Can 60 votes be found”

Am I the only one that thinks this is a crummy way of changing or improving our health care system?


Monday, November 30, 2009

Entrepreneurial Birth Versus Institutional Birth

Why are women, generally happier with the care they received at a birth center or homebirth as opposed to the hospital?

Many of you will list reasons such as: less interventions, empowerment of women, comfortable surroundings, individual care, and a host of others.

Allow me to introduce a different concept. In fact, it is a business concept. A hospital is an institutional form of business, while a birth center or homebirth is entrepreneurial. Quite simply, the birth center midwife or homebirth midwife is an entrepreneur (some midwives are birth center employees, however, birth centers usually operate at or near breakeven, thus a midwife employee feels like an owner or manager) , where the hospital is an institution.

You are dealing with Mary the midwife, who may be the birth center owner. In the hospital, most of your contact is with a L&D nurse, who you probably do not know. You probably do not know her, nurse manager, and most definitely do not know the hospital CEO or president.

Mary the midwife will treat you well, not only because she really cares about your birth, but also because she cares about her business. If you have had a problem with your care, you will tspeak to Mary. If you have a problem in the hospital, you will speak with some bureaucrat. To Mary, you are special! To the hospital, you are another patient.

Some physicians practices are still entrepreneurial and others are now owned by the hospital and are institutional.

Which model is more likely to try to meet your needs? Institutional or entrepreneurial?

Tomorrow, we will put some dollar signs into the models.


Wednesday, November 25, 2009

Happy Thanksgiving to You and Yours

As people are heading out of town to see loved ones for the holiday, let me take a moment to put my Blog in perspective.

I am thankful to live in the greatest country in the world. We can argue ways of improving birth, ways to improve paying for it, ways to give women more options and who is the best care provider.

A mother of a 25 week preemie is thankful that we have the technology to give her baby a chance.

A woman with severe PPH is thankful that in this country that there is no shortage of anti-hemorrhage drugs or safe blood for transfusion

We don't worry about sterile instruments and clean gloves.

No hospital threatens to keep the baby if the bill is not paid (not true in some parts of the world)

Our doctors and nurses are well-trained, even though we can argue about birth interventions.

The illegal immigrant is so thankful that her newborn baby is automatically a citizen of these United States.

Enjoy the holiday! Enjoy the food, the warmth, the family and the traditions. On Monday, I will again be exposing, prodding and picking apart our birth care system. For this weekend, "Be Thankful." Many people do not have the blessings and abundance that we have, even in these bad times.


Tuesday, November 24, 2009

A Death Panel by Any Other Name

On November 15th, the Wall Street Journal published an article entitled: "The Rationing Commission -- Meet the Unelected Body That Will Dictate Future Medical Decisions."

(Click Here for Full Article)

The Journal points out some things that are extremely troubling:

“In other words, the Medicare commission would come to function much like the National Institute for Health and Clinical Excellence, which rations care in England. Or a similar Washington state board created in 2003 to control costs. Its handiwork isn't pretty

So far, the commission has banned knee arthroscopy for osteoarthritis, discography for chronic back pain, and implantable infusion pumps for pain not related to cancer. This year, it is targeting such frivolous luxuries as knee replacements, spinal cord stimulation, a specialized autism therapy and MRIs of the abdomen, pelvis or breasts for cancer…

Currently, the commission is pushing through the most restrictive payment policy in the nation for drug-eluting cardiac stents—simply because bare metal stents are cheaper, even as they result in worse outcomes. If a patient is wheeled into the operating room with chest pains in an emergency, doctors will first have to determine if he's covered by a state plan, then the diameter of his blood vessels and his diabetic condition to decide on the appropriate stent. If they don't, Washington will not reimburse them for "inappropriate care."”

There is a lot concerning the current Senate Healthcare reform bill, and I will discuss this over the next week or two. I just wanted to share what the Wall Street Journal is saying, because I'm sure you have not heard about this. If you watch the news on healthcare reform, all you would know is that Sen. Lieberman will filibuster the bill if it contains a public option.

2000+ pages, and the media boils it down to, "Sen. Lieberman and the public option !!”

Think about that!!


Monday, November 23, 2009

Cash or Accrual??...... What Does This Have To Do with Babies?

There are two methods of accounting, cash or accrual. Most households use cash and large businesses generally use accrual. What does this have to do with birth issues, you may be asking? Give me a moment, I promise it will all fit.

Cash is simple! You charge a client $200 they pay you $200, you record $200 as revenue. You receive a bill for $100, you mail a check for $100 and record $100 as the expense. "Simple!"

Accrual,…. not so simple! You send a client a bill for $1000, and record $1000 as revenue, even if you have not collected any money. You receive a bill for $500 and record a $500 expense, even if you have not paid the bill yet. A little more complicated.

Try this: you send an insurance company a bill for $5000. Under the accrual system, you record $5000 as income. Three months later, the insurance company sends you a check for $1100. You must then go back and make a $3900 adjustment to revenue to reflect the transaction and balance your books.

I think you can see my point! Many smaller businesses (and larger for that matter) can get into trouble with accrual accounting. You send in those $5000 claim form to insurance companies, and you think you've made $5000. It looks really great on the books, until the check comes and you have to make accounting adjustments. I have seen many birth practices get into trouble, because it looked really good in accrual, but really bad in cash.

Very often, when the government makes projections,. they think in terms of accrual. A 10% tax increase will bring in 10% more revenue. So they accrue, the extra 10%, and then they spend it, because in government accrual accounting, you show the revenue you expect to collect and then you spend it. Then the extra 10% does not come in, because people change the way they do business to avoid paying the10%, and now the government has a budget shortfall.

When the federal government has a budget shortfall, they print more money. When you have a budget shortfall in the birth practice, you close your doors!!!

Always keep an eye on the real bottom line.


Friday, November 20, 2009

The 3P's, Which Has the Most Clout?

Yesterday, we discussed whether or not, Rush Limbaugh is worth $400 million. My point being, "your opinion has no bearing on whether or not he is worth $400 million.

Today we'll talk about the 3P's of healthcare: Payer….Provider…..Patient. Whose opinion matters most?

In a perfect world, the answer is easy, "THE PATIENT We do not live in a perfect world..

Some quick definitions:

Provider- usually a physician or hospital who invoices the payer. Providers can be a nurse or therapist, if they bill directly or indirectly through an agency. Usually the services are billed for by the facility, and so they are not normally considered providers.

Patient- the person getting treatment. At times, the relationship extends to family members who make decisions or collaborate on decisions with the patient.

Payer-usually an insurance company or the government; such as Medicare or Medicaid. Occasionally, the patient may be the payer.

We would like to think that providers carry great weight. However, they are constrained by insurance preauthorization, small reimbursements, drug formularies, government and insurance approvals and other parameters that do not always allow them to make the decision that is in the patient's best interests.

Then the patient has the most clout! This would be nice; however in the great majority of cases the patient doesn't pay the bill. It's usually pay by insurance or Medicaid. Interestingly, when the patient wants to pay cash, often obstetricians do not want to accept it.

What if the patient understood how little the obstetrician gets paid from HMO or Medicaid. What if the patient says to the doctor: "I will pay you extra, give me more personalized care.” If the doctor takes the money he/ she would be breaking the law.

I guess the patient does not have much clout.

That leaves us with the payer! The payer can decide to pay more for a physician than midwife, pay for hospital birth but not a homebirth, pay for an anesthesiologist but not a labor coach, pay for infant formula. But not lactation consulting, or the payer can decide to put you, the provider ,in-network BUT require you to carry malpractice insurance which costs over $100,000 per year.

So, who has the most clout? By now, the answer is easy. So how can activists effect change? The answer... learn to speak the language of the payer!!!

Next week, more about hybrid birth centers, also "Are Death Panels. Becoming Reality?"

Have a great weekend


Thursday, November 19, 2009

Is Rush Limbaugh Worth $400 Million?

Your first reaction is probably, "what does this have to do with "birth issues?"

Bear with me a moment, I promise to connect the dots.

About a year ago, controversial radio talk show host Rush Limbaugh signed a contract for $400 million (over eight years). Immediately, every newspaper, magazine,, radio and television talk show asked their viewers, readers and listeners to vote on whether or not, Rush Limbaugh was worth $400 million?.

Anyone who “voted” does not get it!! Their opinion is meaningless. If you hate Rush and voted NO, or love Rush and voted YES, either way, the opinion and the vote has zero meaning and zero value.

The only vote that matters, is that of the producers of Rush Limbaugh's program which writes the check for $400 million. Also, they could not care less what your vote is.

The only factor they consider in determining whether Rush is worth $400 million is: "Will enough listeners in a preferable demographic audience listen to the show, so the advertisers will pay enough money to have their messages heard, to make the show profitable?”

In other words, the only criteria is: are there enough advertisers who will pay enough money so that not only does Rush Limbaugh get$400 million and the staff and expenses are paid, BUT the investors can also make a profit..

Any other consideration of peoples opinions does not play into this mix.

Tomorrow, I will talk about the 3P's: patients, providers and payers. Does my Rush Limbaugh discussion give you any clue which one of the 3P's. has the most clout?


PS-  I try to schedule posts to show up at around 8am CST.  Sometimes the system glitches and I have to manually post.  Sorry for the inconsistancy

Wednesday, November 18, 2009

Comparing the Hybrid Birth Facility and Homebirth

Since Monday, we have been comparing birth centers to homebirth. First, the old one family house birth center. Then the larger, busy birth center compared to homebirth. Today we will discuss the future "hybrid birth facility." compared to homebirth.

As I wrote about on October 30th, the hybrid facility combines the benefits of a large birth center, with the cesarean section and pain relief capabilities. This model will be discussed in depth at the Controversies in Childbirth Conference, February 19-21 in Tampa, Florida.

Remember, there are two types of women that choose homebirth. "Those where homebirth is their first choice, and, those where homebirth is their last choice."

For those women who have researched, studied and re planned for homebirth, birthing at home is their only choices unless some complication causes them to have to go to a hospital.

However, for those women who are intimidated by the hospital, or afraid, they will have a cesarean, when they don't want one, or have heard about poor hospital experiences from their friends, or have tried everything to get the doctor or hospital to give them what they wanted and have been rebuffed, then they have no choice but to choose homebirth.

For those were homebirth is the first choice, they will continue to choose homebirth. For those were homebirth is the only choice that they have left, those women may choose this new birth facility

As I have previously stated, most women coming to our birth center had three questions: "Can I get something for the pain?"… "Is there a doctor available in the event of an emergency?"….. "What if the baby crashes, and I need an emergency cesarean?"

In a hybrid birth facility, the answers to these questions will be YES!!

If the providers running facility , do it right, then the answers to the following questions will also be "YES!"

Can I have a VBAC?
Can I have a natural birth?
Can I have a water birth?
Can I have intermittent fetal monitoring?
Can I deliver in any position I like?
Can a midwife deliver my baby?

There may be many more “YES” answers, but time runs short.

I do believe that this model may have a negative affect on those that choose homebirth as their first choice. That is,: many homebirth midwives may go to work in these hybrid birth facilities, thereby making it harder to find a midwife to deliver you at home.

Again, this model will be thoroughly discussed at the Controversies in Childbirth Conference. Please register today.


PS- I try to schedule posts to show up at around 8am CST. Sometimes the system glitches and I have to manually post. Sorry for the inconsistancy

Tuesday, November 17, 2009

Birth Centers, Past, Present, and Home Birth

Yesterday, I explored the traditional one family house, versus homebirth and agreed there was not much difference.

But what about the model of birth center I have been involved in for many years? This is the larger birth center, with a volume of 25 or 40 or even 100 births a month, depending on which space we had.

Before someone comments about large birth centers can't give one-on-one care, the fact is the model that we had, gave fantastic one-on-one care. In fact, our outcomes in any of our facilities whether in the first world or the developing world exceeded the outcomes in the Netherlands, which is known for the best stats in the world. (Outcomes do not equal one-to-one care, we still gave one-to-one care).

Let's compare this type of birth center to the homebirth arguments (I'm not trying to take anything away from homebirth, just giving a different side to the debate).

Remember, the basic precepts that: “There's nothing you can do in a birth center that cannot be done at home.” This statement will continue to remain true in this blog posting, but you may not now see a difference.

Experience of Staff: Busy birth center staff is generally much more experienced. In Jamaica, our three senior midwives had over 25,000 out of hospital births between them (and only 73 episiotomies). Contrast this with a homebirth midwife, that does only three or four births per month.

Less Experienced Midwife Can Yell "Help”: When a less experienced midwife on staff ran into problem, she would call upon senior midwives, who had over. 5000 out of hospital birth experience to guide them.

No Shortage of Supplies: we were fanatical in making sure we had more than enough oxygen, IVs, sterile gloves, anti-hemorrhage drugs, vitamins, etc. This was a function of the admin staff and not the overworked midwifery staff.

Amazing Students: American and Canadian midwives would visit our facilities and could not believe our students were not experienced midwives. Keep in mind, when you are at 200-400 births in your first year as a student. you get pretty good, really quick.

Consistent Transport Relationships: unlike homebirth, where the nearest hospital changes pending on where a home is located, in a birth center, we usually go to the same hospital over and over. This can make for better communications and relationships between hospital and birth center staff.

Back-up Obstetrician: With our volume, obstetricians would find it financially viable to work with us. This helps in collaborative care or transport situations.

Ability to Integrate Other Healthcare Providers: since the birth center is in one place and quite busy, providers such as pediatricians, chiropractors as well as alternative providers would find it worth their while to keep regular appointments at the birth center or to give birth center moms top priority.

I could go on and on, but I believe, you get the point. There are many advantages to this birth center model over homebirth. This does not mean every mom will choose this birth center model. But now, there are is benefits that families can weigh when making the decision.

Most importantly, the vast majority of women are not going to choose homebirth, but they will consider this type of birth center.

Tomorrow-comparing the hybrid birth facility to these other models.


Monday, November 16, 2009

Birth Centers Versus Homebirth

Over the next few days I will look at birth centers vs. home birth.

Last week, Rixa Freeze asked her readers to comment on her blog about freestanding birth centers as opposed to homebirth. She referenced an article she wrote in 2007 entitled "Worst of Both Worlds."

I would like to thank Rixa for talking about the hybrid birth facility and also mention that Dr. Stuart Fischbein is thinking along the same lines.

In some respects, asking her blog readers their opinion of birth center versus homebirth may not be fair. The reason is that almost all U.S. birth centers were designed to look like home birth, therefore in most instances, there is no major difference between freestanding birth centers and home birth, other than women at homebirth are more comfortable in their own home’s.

It is my personal belief, and I have spoken on it on many occasions, that the U.S. birth center model that most birth centers follow is not a viable, business model. Granted, the outcomes are generally excellent, however, most of these birth centers have been struggling financially.

Today's birth center’s still follows the model that was developed in the mid 1970’s: “Find a one family house, make one or two birth rooms, an exam room , an office and a classroom and you now have a birth center."

With the above model, it's easy to see Rixa’s point of worst of both worlds. In fact, ACOG’s change in its statement accepting birth center's while stating that out of hospital birth is unsafe, would be laughable, since there's almost nothing you can do in a a birth center that cannot be done at a homebirth. This statement, however, is easier to defend, since they limited their acceptance of birth centers to those that are accredited. This does not mean that I believe this statement is right, it just means they can offer a defense. (This does not insinuate that the defense is a good one).

Tomorrow- Birth Centers of the Past VS Birth Centers of the Present


Friday, November 13, 2009

Failed Attempt, Fail to Transport, Failed Defense, and Too Much Pain

Continuing with new sessions that have been announced for the Controversies in Childbirth Conference in sunny Tampa, Florida February 19 to 21st 2010.

Botched Out Of Hospital Birth or Appropriate Transport.?.. Building Working Relationships
As more women choose out of hospital births, mathematically hospitals and on-call obstetricians will see more transports. A transport is the need to take a woman in labor from her out of hospital setting:. (homebirth or birth center) into a hospital environment for whatever reason.

In the past, labor transports have gotten quite ugly with midwives and OB/hospital personnel trading charges of incompetence, negligence, attempted murder, etc.

Now, Melissa (Missy) Cheyney CPM PhD will chair a panel consisting of both midwives that initiate transport, and hospital personnel that receive the transport.

This session will examine how the distrust between the midwife and hospitals developed and strengthened over time. How midwives and hospital personnel have sat down and come together to reduce the animosity when a transport occurs. Devise ways of better care for the patient, and even develop cordial relationships and understandings of the roles that each professional plays as venue and responsibility for birth, changes in a transport.

Is Natural Birth Antithetical to the Practice of Nursing?
Most women who become nurses (and also those men) do so out of desire to help sick people get better. There is a kindness and compassion associated with the image of nursing. Nurses are healers and patient advocates.

Many patients who have been admitted to a hospital mention how often nurses coming in the room ask, "how is the pain.?" In fact a major component of the practice of nursing is pain management. Most nurses feel fulfilled when they can give some medication to relieve the pain, thus making the patient "feel better." Generally, the greater the pain, the more the nurse wants to help.

So how do nurses feel when women choose unmedicated natural birth? Do they have difficulty listening to the pain increase? Does the yelling as contractions get stronger emotionally bother the nurse? Is not giving the patient anything for the pain, contrary to the nurses beliefs?

Case Study: Lessons Learned from a Failed Attempt to Open a Natural Birth Center
Robyn Thompson, MPH, MSW, LMSW, formed an organization in San Antonio Texas to try to open a natural birth center. A coalition representing midwives, physicians, consumers, legal interests, business interests, and public health advocates was brought together to try to make this dream a reality.

This birth center never got off the ground. At the conference, Robin will explore the reasons it did not happen, lessons learned, and what changes need to be made to make the concept viable.

Protecting Yourself From Investigations By Your Regulatory Board
Attorney Max Price is back, and will give amazing insight into litigating professional board, licensure and discipline actions. How you interact with the board from the time of receiving your “Initial Notice” can have a significant effect on the outcome and cost of your case.

Do you respond to their initial request for information, do you ignore it, or do you hire an attorney? What happens when you receive a subpoena for your documents? Do you comply, and if you do, have you hurt the case? If you don't turn over the documents, can you lose your license?

Does signing a plea agreement make you more likely to be investigated in the future as opposed to someone who fights tooth and nail every time they're wrongfully accused by the licensing board?

I have first-hand experience with Max, and can tell you that if when you receive a “Letter of Investigation,” IMMEDIATELY call Max Price, no matter what state you're in.

Have a great weekend and don't forget to register today Controversies in Childbirth Conference.


Next week, more discussion about the seminars on the hybrid birth facility, and a look at,: birth centers versus homebirth.

Thursday, November 12, 2009

Birth Centers, Birth Plans, Doulas and the Internet

Today we'll discuss some more seminars that have been added to the Controversies in Childbirth Conference.

What Birthing Couples Are Saying About Their….OBs, Midwives, Doulas & Hospitals, On the Internet.
Do you think that anyone under age 40 makes a hotel reservation without checking the reviews on websitea like TripAdvisor? What about a cruise? Would you go on a cruise without reading the reviews? Would you buy a car today withoutt reading reviews and ratings?

The Internet can be a friend or a foe to someone's business. Since you're reading this on my blog, you already know this. What do you think patients/clients and potential patients/clients of birth care providers are saying about the obstetrician, midwife, doula or the hospital they plan on having their baby at?

Uber-geek and birth activists, Laureen Hudson is going to show us what patients / clients are saying about their birth providers. We will also look at whether or not the providers or facilities really care. Laureen will also explore if there is a correlation between what appears on the Internet, and a loss of business in the practice.

Why Obstetricians Hate Birth Plans?
A pregnant woman goes online, communicating with her friends and new online friends to discuss the perfect birth plan. More planning may have gone into the birth plan then her wedding. She proudly shows it on her next visit to her obstetrician, whose reaction may range from slight annoyance to pointing to the sign in the office that says: "If you have a birth plan, we invite you to find another doctor."

Why do OBs feel the way they do about birth plans? Is it extra work? Unrealistic expectations? Barriers to effective communication? Lack of trust by the patient? This panel will explore these questions from both the OB and consumer perspective.

Why Hospital Staff Are Confused by the Role of the Doula
If you ask a room full of: obstetricians, midwives, nurses, neonatologists, anesthesiologists, physician assistants, and anyone else in the hospital, “What is the role of a Doula.?’ You may receive as many answers as there are people in the room.

Physician reactions to doulas run the gamut from recommending them to pregnant women, all the way to firing a patient that hires a doula. Even midwives who generally appear supportive are split on the issue. Some love labor Doulas, while others feel that the Doula infringes on the care the midwife gives.

Some Doulas sell their services as cesarean section insurance , while others will not attend a mother, who plans a hospital birth.

Doula trainers Rae Davies and Candy Mueller will lead a panel that will explore doula confusion and hopefully provide solutions to end this confusion.

Can Chiropractors Safely Turn Breeches, Or Are They Endangering Babies?
Since a breech presentation means an almost automatic cesarean section, many women are searching for methods of turning the breech. This can range from slant boards, to playing loud music with the speakers on the belly, to external version.

Chiropractors have devised a method of allowing the breech to turn, known as "The Webster Technique," a chiropractic technique designed to relieve the causes of intrauterine constraint, thus causing the baby to turn.

So why do obstetricians NOT routinely refer women with breech presentations to chiropractors? This session will not only explore and analyze the Webster technique, but will also delve into the distrust between chiropractors and physicians.

Dr. Alexa Fagan is a Tampa area chiropractor and member of The International Chiropractic Pediatric Association (ICPA) who has a successful record of adjusting women, so the baby can turn from breech to vertex. An obstetrician will round out the panel, allowing for a lively discussion.

For more information go to the conference website

Tune in tomorrow for more seminar announcements.


Wednesday, November 11, 2009

From VBAC to NHS to Health Freedom Acts

On the 11th hour of the 11th day of the 11th month,  World War I ended.
Today is Veterans Day! Whether it's a World War II Vet, Korean Vet,  Vietnam Vet, Gulf War I, or returning from Iraq or Afghanistan, remember to thank them for their service to this great country.


Over a dozen amazing seminars and speakers have been announced for the 2010. Controversies in Childbirth Conference, February 19th through 21st in Tampa, Florida.

Over the next few days. I'll be blogging about the seminars, but you can go to the website today at:

Using Health Freedom Acts to Give Pregnant Patients What They Want
Are you tired of all the hand wringing and finger-pointing that occurs when a pregnant woman asks her, midwife, doctor or hospital for something and they say “NO” such as: no fetal monitor, vaginal breech delivery, or VBAC? Then they blame each other for the prohibition.

A few states have enacted, "Health Freedom Acts" that allows healthcare providers. under certain circumstances, to go against the conventional wisdom of their college or regulatory boards.

Florida attorney Max R. Price, was instrumental in passing and defending the law in the State of Florida. Obstetricians, midwives, chiropractors and other healthcare professionals have an amazing weapon at their disposal to help their clients/patients, yet many do not know that the law exists or that it can be easily lobbied for in those states that have not yet and. enacted As legislation.

Max will explain the scope and limits of these laws, and who your allies would be in trying to bring these laws to your state.

The VBAC Issue From the Obstetricians’ Point of View
ICAN and other birth advocates can give a litany of stories and cases where women have been traumatized, lied to, misled, misinformed, and perhaps even assaulted, in their effort NOT to have a repeat cesarean section.

Kim J. Cox, PhD, CNM, is an Assistant Professor in the Nurse-Midwifery program at the University of Florida College of Nursing.

Kim has interviewed and compiled a study of how obstetricians and midwives view of the VBAC issue, who they blame for it, and how they would like to deal with it. This will be an amazing seminar, because it brings the collective voices of the obstetricians to the table.

Are Birth Care Professionals Responsible for Women Choosing Unassisted Homebirth?
What can almost every obstetrician, nurse midwife, homebirth midwife, doula, family physician or childbirth educators agree on? They don't recommend unassisted homebirth.

Yet, planned unassisted homebirth is on the rise in North America. Why is this? Are women so afraid of their provider or their facility, that they will engage in a practice that is considered unsafe by almost every medical professional?

Rixa Freeze , Ph.D. has studied this phenomena and will explore in detail, including: What experiences drive women to consider this option? How are midwives, doctors, nurses, and hospitals implicated in women's choice to avoid birth attendants altogether? Can we or should we outlaw unassisted birth, or prosecute the parents for child abuse or endangerment?

As you can see, this will be a truly controversial subject.

Childbirth Practices: Lessons From Two UK Hospitals
During the health care reform debate, we heard much about the English health care system, where, not only is there full universal coverage, but there is also only one employer, the: "National Health Service." Almost all physicians and nurses and hospitals work for the NHS.

Holly Powell Kennedy, CNM, PhD, FACNM, FAAN is the chair of the Midwifery program at Yale University. She has studied two maternity care hospitals in England that advocates evidence-based care of childbearing women. She will present the results of her study, specifically looking to see if what worked in England can be imported to the United States.

Our speaker: Holly Powell Kennedy is also the President-elect of the American College of Nurse Midwives.

Tomorrow we will discuss some of the more seminars that have been added. Please go to our website at: to view all the seminars


Tuesday, November 10, 2009

Can a Birth Conference Really Be Neutral?

One of the major differences of the Controversies in Childbirth Conference is that we claim to be a neutral venue for inclusive discussion. I have been asked and have heard people asking others, "Can a conference really be neutral?"

One of the things that makes "Controversies" different is that is not produced by a membership organization. It is a totally independent conference. All membership or association conferences are self-serving! They are designed to make you feel good about the job you're doing and to feel good about the association that you belong to and pay your dues to. Therefore, you will probably not see a seminar on the schedule of an association conference that is critical of the association or the profession.

Next, associations are extraordinarily political!!! There are official and unofficial hierarchies. There is generally paid staff who want to keep their jobs and not rock the boat. Often you will hear someone say that they don't submit speaker abstracts, because some officer, director or muckety-muck doesn't like them and has blocked them from appearing on panels in the past.

Rarely will you find debate in a session between the presenters. One reason for this is that the association does not want members leaving the room yelling at other members. Remember, association conferences usually contain business meetings, and someone needs someone else’s support to get elected or to get a project passed through the board or membership.

The Controversies in Childbirth Conference is different. There are no business meetings, there is no hierarchy, and there is no politics. There is a small group of people that help with the conference and also help decide on seminars and speakers. As the conference coordinator, I try very hard to keep these people's identity secret. This avoids the unpleasantness of receiving phone calls from friends, trying to get other friends on the program or get seminar topics approved.

Being neutral also means that there is no agenda hidden or otherwise. It's not about showing homebirth is good, epidural so good, obstetricians are bad, midwives are bad, etc. Many panels are done in debate or panel format with presenters who may not agree with each other. Please know that although there may be disagreement, everyone involved with the conference is committed to professional, civilized discourse and discussion.

If you want to hear how great homebirth is, go to MANA. Want to feel good about doulas? Go to DONA. Want to feel good about the contributions of OB/GYN's ? Goto ACOG. Need a pat on the back for being a nurse midwife? Go to ACNM. I could go on and on.

Do you want to hear the issues that other professionals involved in birth face, in an unbiased professional manner? Come to the Controversies in Childbirth Conference! !


Starting Wednesday, we will talk about the newly announced seminars for the conference.

Monday, November 9, 2009

Whose Job Is It to Prevent Premature Birth?

By now, everyone knows that the US ranks 30th in infant mortality. I could point to the fact that different countries report infant mortality statistics differently, to say that it's not as bad as it sounds. For today's post, let's accept that. #30 is very, very bad.

On Friday, November 6th, I said "Let's stop calling it, "Healthcare Reform" and let's call it "Health Payment Reform." I now propose we change the name From "Health Insurance" to "Sick Insurance!"

Why sick insurance instead of health insurance? Because our system pays the medical expenses for people who are sick or injured. There may be token payments for annual physicals, etc., but the bulk of the payment is for sickness or injury.

So the United States has this high prematurity rate? The media is in a tizzy! The birth advocates are in a tizzy! The health reform advocates are in a tizzy! My question is, "Has anyone proposed anything that will lower the prematurity rate?"

For years I tried convincing HMOs and health insurance companies, as I was negotiating contracts, that our birth center should receive a "Healthy Baby Dividend” because our prematurity rate was 1/2 of 1% (0.05%). Every premature birth that we prevented saved an insurance company at least $100,000.

Needless to say, no insurance company was willing to pay a “Healthy Baby Dividend.” If the baby was born premature, they would happily pay the $100,000 NICU bill, but they would not pay a dime as a reward for preventing prematurity.

If we really want to bring the prematurity rate down, we should pay cash incentives to physicians and midwives who can show a much lower prematurity rate than the national average, with of course a formula to compensate for  high-risk patients.

Only when we are willing to put our money where our mouth is, and pay incentive bonuses for healthy babies as opposed to sick babies, will we start taking steps toward reducing prematurity and making America healthier.


Tomorrow-amazing seminars being announced at Controversies in Childbirth Conference

Friday, November 6, 2009

Some People Just Won't Buy Healthcare

The Congressional Budget Office (CBO) estimates that the fines on individuals and employers for not having health insurance will bring in $167 billion over 10 years, which they are counting on to offset the $1 trillion plus dollar cost of health reform.

(Click here to read this report)

It seems a little perverse that the CBO believes that the IRS can collect fines from people who illegally decide not to carry health insurance. Why do they think the IRS will send out a lot of tax bills to poor people that can’t afford to pay for health insurance and this money will be collected?

This is interesting, but, not the point of today's blog. I'm getting tired of using the term healthcare, when we mean health insurance. Keep in mind that with all the proposals there will still be deductibles and co-pays, because, there is no proposal for true first dollar universal healthcare.

The following quote appears in the above article: "There's just going to be some people who choose rather to pay (the fine) than to pay for health care," said Stephanie Lundberg, spokeswoman for House Majority Leader Steny Hoyer, D-Md. "There's going to be some people that just philosophically don't want to buy health care."

What about all the alternative medical/healthcare providers? If you go chiropractor and pay cash, aren't you buying healthcare? If you pay cash at the dentist, aren’t you buying healthcare? If you go to Wal-Mart for glasses, aren't you buying healthcare? If you go to a reike healer, aren't you buying healthcare? If you go to an acupuncturist, aren't you buying healthcare? If you pay cash to a mental health therapist, aren't you buying healthcare?

I hope you get my point! I vehemently object to the politicians and pundits calling this healthcare reform. We are not reforming healthcare, we are changing the system that pays for some types of healthcare. Why can't we just call it, "Health Payment Reform!"

As things stand now, there is a lot of doubt that a health reform bill will be signed by the President before the Controversies in Childbirth Conference, February 19-21, 2010 in Tampa, Florida. The sad thing is, I really don't know if that's good or bad. The system is broke and needs fixing, I just don’t know for sure whether or not, the proposed cure is better than the perceived disease?

Have a great weekend.


Thursday, November 5, 2009

Same Set of Facts,... Totally Opposite Conclusion

About 15 years ago, the cesarean-section rate was climbing to alarming levels. At that time, insurers and Medicaid paid substantially more for cesarean sections, then for vaginal birth. The payers decreed that henceforth: vaginal birth and cesarean section will pay the same.

The obstetricians said: "Do you expect us to perform surgery for the same amount of money as a vaginal birth?" Thus, for the same amount of money, the obstetricians started doing more vaginal birth and cesarean rates declined.

A generation of obstetricians later, the cesarean section rate is at an all time high and climbs with no end in sight. When asked, “Why the change?”, the response that can be read between the lines is: "For the same amount of money, do you really expect us to go into the hospital at all hours of the night and wait hours to deliver a baby, when we can do a cesarean during normal business hours in 15 minutes?”

The same set of circumstances: “paying equal for cesarean as for vaginal delivery,” yielded totally opposite results. The reason depends on where you started. If you were being paid more for cesareans and the change came paying the same, then you felt that you feel your work is being devalued and you would lean toward non-surgery. However, if you were ALREADY being paid the same, then the amount of extra and unpredictable time that it takes to do a vaginal delivery would be hard to justify.

That is why it is important to understand someone's current mindset and to propose changes based on how things are operating today, and not how they operated years ago. You cannot understand a person, unless you've walked a mile in their shoes (or moccasins, or sneakers, or Birkenstocks).


Wednesday, November 4, 2009

Missouri Natural Birth Center Announces Closing

The Columbia Community Birth Center has announced that it will close its doors at the end of the year. According to media reports, medical director, Elizabeth Allemann, M.D., is leaving the practice and the center is unable to find a replacement physician. Without a physician, the birth center is unable to accept insurance reimbursement.

Click here to read newspaper story.

Other media reports claim that the community and legal acceptance of homebirth , midwives also made it difficult for the birth center to continue.

Columbia Community Birth Center was opened three years and delivered 175 babies.

I do not have first hand information into the closing of the center other than what I have eread in the press, although I have had conversations with Dr. Allemann in the past.

A commentary on the closing of this Missouri birth center is actually quite difficult , because of the mutual distrust in Missouri, between midwives and physicians. Allow me to give a brief history from memory, and my apologies if I get it wrong.

In Missouri it was a felony to act as a midwife without a nursing license. Missouri did not recognize the CPM. A committee chairman in the Missouri legislature put wording into a bill that decriminalized midwifery. The wording was in such archaic language, that the word midwife was not used, (I believe even the terms labor and birth were not used) and no one objected until after the bill was passed. The governor refused to veto the bill after the midwifery clause became publicly known, not because the governor wanted to legalize midwifery, but rather he needed the rest of the bill and would not veto the entire bill. The physicians brought a court case to overturn the new law and were eventually rebuffed at the Missouri Supreme Court, due to "lack of standing."

If one were to look at this as an outsider, you would see everyone did what they needed to do. The homebirth advocates got very creative and found a legislative supporter to push the bill through. The physicians attempted to protect their turf by fighting against it (although they claimed that they were fighting on behalf of moms and babies, which is not their mandate and which the court called them on, when throwing out their case)

My question is: are you surprised that based on the above stated scenario that it would be difficult for the birth center to find physicians who want to work with it?

Yesterday, when discussing agendas,. I talked about battle plans. The problem in political and legal battles, is when the battle is over (although the war may continue) you may actually have to work with your enemy or your friend who is on the other side. It's why in sports it's bad form to run up the score.

When you win your battle, keep an open door to your opponent. You never know when you need them.


Tuesday, November 3, 2009

What's My Hidden Agenda?

In the months before the March 2009 Controversies in Childbirth Conference, I would get some interesting phone calls such as:

A midwife asking if this conference was a propaganda piece for ACOG, and if we will only hear about the poor underpaid obstetrician!
An obstetrician asking if this was one of those natural birth conferences telling us how great midwives are!
A hospital administrator asking if this conference is about preaching homebirth!
A homebirth advocate asking if this conference is to show that homebirth is dangerous!

Even after the conference, when every attendee went home to their communities and raved about learning different viewpoints, and having a fair and frank exchange of ideas, people still could not believe it was nuetral. There must have been an agenda!!

Do I pretend not to have any biases? OF COURSE NOT!! However, if you want a conference where everyone in front of the room will agree with you, you can probably find one every weekend somewhere in the US or North America. However, if you want to learn the issues that the other side faces, so you can become more effective at communicating with your patient/client or advocating for your cause, then the Controversies in Childbirth Conference will give you that..

A number of years ago, I had a conversation with midwifery icon: Ina May Gaskin, who I consider a friend. I said: " Ina May, you have been fighting this battle for 30 years, and by every indicator, be it cesarean section rate, infant mortality, or midwifery access, you are losing." To which she responded, "You're right, we are losing, but we don't know what else to do."

So here is my agenda: To get people that are involved in the birth care process to communicate with other people involved in the birth care process, even if, they vehemently disagree with each other's means and methods. It is my belief that only with, "abortion" (which we do not discuss) can middle ground NOT be found., because the subject is so deeply rooted in people's religious and moral convictions In the arena of birth. I believe it is proven over and over that middle ground is findable and is the preferred way of getting things accomplished.
There's a simple rule of battle that President Bush learned, and Pres. Obama is experiencing. When you are losing: retreat, surrender, or change your battle plan. You do not keep doing the same thing over and over and continue to lose.

How many of you have been fighting this battle for 30 years? Please tell me how many WINS, you can claim credit for. Have you reduced the cesarean section rate? Have you decreased the infant mortality rate? Have you decreased the maternal mortality rate? Have you decreased the number of babies admitted to NICU? Have you decreased the number of women choosing epidurals?

If you have answered “NO” to the questions above, then it's time for you to change your battle plan.

Last Friday, I proposed a different type of physician owned facility. This is now causing discussions in the physician world. This proposal is a game changer to physician’s because it is asking them to change their battle plan, since they also believe that they are losing. They're not happy with the hours they work, the conditions in the hospital, the lack of time they have for each patient and the lack of money they receive for their time as well as a training and expertise.

Changing your battle plan, sounds crazy doesn't it? On the other hand, what do you call repeating the same action over and over and expecting a different result?


Tomorrow- Another birth center announces it’s closing!

Monday, November 2, 2009

1990 And Not a Clue How Much I Will Have To Pay

1990 is not a year, it is the number of pages in the House Health Reform Bill, proposed by Speaker Nancy Pelosi last week.

If you are so inclined, you may download your very own copy by clicking here.

I've written about this before, and I will say it again and again: "How much do I have to pay to buy a policy. under this bill?” I understand that the insurance companies can set their own rates, but since the current bill proposes a "Public Option" the government must surely be able to estimate how much it will cost the average American to buy into this government program and what it will cover.

I believe that the previous House committee bills were about 1100 pages, so in the new 900 pages, could someone take a minute to guesstimate costing coverage? At the end of the day isn't this the most important question. How much will I have to pay for it?

I know the media makes a big deal of the Congressional Budget Office guesstimating $one trillion and a few odd billion dollars, and that is scary to America as a whole. However $1,000,000,000,000 PLUS dollars notwithstanding, please tell me if insurance will cost me $200 month, $500, a month or $1,000 per month for ME!!! Is this asking too much??

I've read the initial reports of what is and is not in this bill. I will await the analysts to go through all 1990 pages and report back their opinions. I've already seen some troubling areas. One of the most troubling is the analysis that the public option may actually cost more than private insurance. I do not know if this is true, but if it is, you can look for the insurance companies to raise their rates..

A little political commentary, if I may: I wish the Republicans would stop telling us that the current system works. It does not! It is unaffordable for individuals and businesses and no one is happy with it. As the economy gets worse, look for employers to reduce coverage, increase deductibles and coinsurance, and increase the portion that the employee must pay.

Likewise, the Democrats must stop turning the insurance companies into the villains. The insurance companies combined profits are reported as 2.2% of revenue, which is not very high. Furthermore, if this was ONLY about insuring the uninsured and uninsurable, it would not need 2,000 pages.  This si about fundementally changing who control's America's health care system.

I am also disappointed in President Obama, because as a candidate he promised transparency in these major issues, even promised the C-SPAN cameras would open the secret congressional negotiations to the public. The Pelosi and Reid, Health Reform Bills were negotiated behind closed doors, and the President encouraged this. It appears and the polls confirm that he has squandered his unprecedented support when he took office, and that Washington is back to business as usual, and it is not pretty.

The media is still not asking the question: How much will I have to pay? Why can the media tell you how much the average American will spend on Thanksgiving dinner? How much the average American will spend on Christmas presents? How much the average American will spend on vacation? But they can't tell us how much the average American will pay for health insurance under this 1990 page bill.


Friday, October 30, 2009

Why Are Pregnant Women Forced to Choose between X and Y?

Before reading today's posting, please read Wednesday's and Thursday's (October 28 and 29th) posts.

Yesterday, I made the point that whichever choice a woman makes to have her baby, it is not the safest possible choice, BECAUSE the safest choice does not exist.

When I ask obstetricians: “Under what circumstances would you consider performing out of hospital birth?” the usual response is: "If they could have an epidural and have an operating room right there!"

I already hear the out-of-hospital chorus screaming, "The reason for out-of-hospital birth is to AVOID epidurals and operating rooms!"

To which the obstetrician might respond, "Why does a woman's choice have to be: in- hospital without pain or out-of-hospital with pain?"

I can tell you how the out-of-hospital and normal birth community would respond, but instead, let's all take a very long, deep breath, and examine this. As a person that has run birth centers and has had tons of face-to-face interaction with pregnant women seeking alternatives, I would like to tell you what I heard the pregnant women say when they came into the birth center:

"Can I get something for the pain?"… "Is there a doctor available in the event of an emergency?"….. "What if the baby crashes, and I need an emergency cesarean?"

Myself and my staff were thoroughly trained in how to respond to these questions. We extolled the virtues of natural birth, the benefits for the baby, the fact that we monitor and can usually pick up problems before the emergencies and that we get to the hospital. relatively quickly.

Obstetricians are not happy with the current constraints placed upon their practices, especially by hospitals and insurers. But what is their option? A natural birth center, with no cesarean capability? They are not trained to practice like this. More importantly, they don't believe that the pregnant women that they come in contact with really want a natural birth, without pain meds. They believe that they are meeting the demands of the vast majority of their patients.

So why can't a woman choose an out-of-hospital birth with pain medication and emergency cesarean section capability? I'm sure that many of you will start sending me all the reasons that this is bad. I ask you to hold off on that, and bring the list to the Controversies in Childbirth Conference, where this topic will receive a major airing, with all the goods the bads and the uglies.

I want to examine this a bit from a free-market perspective. Assume that physicians are able to open some type of out-of- hospital facility, where epidurals can be given and emergency cesareans can be performed. This will put the physician in the place of the hospital, the same way that midwife-run birth centers replace the hospital. The physician-owner will look for ways of driving business to his birth facility and lowering costs.

Should market research show that women would prefer midwives in this facility, he/she would undoubtedly hire midwives. If a woman has a vaginal birth, she could go home earlier, thereby saving the facility money and thus the facility might work to keep a low cesarean rate. The physician-owner would be very attuned to what his patients are saying on the Internet about him and would probably become more customer- centric, in the same ways that hotels work to avoid negative comments from appearing on TripAdvisor and other comparison sites.

It's estimated that ONLY 27% to 32% of U.S. OB/GYNs are still delivering babies. That means the competition has been severely reduced. Giving physicians a reason to go back to delivering babies will spur competition and give women more choices. How many women do you know have had to choose a new OB because the obstetrician that they loved has stopped delivering babies?

Birth advocacy is about giving women what they want. If obstetricians believe that women want a different experience than the hospital, but will not buy in to homebirth or natural birth centers, why shouldn't they be free to pursue a model that they believe is what patients want?

BUT- the devil is in the details!! There will be much discussion about what you could or should do and not do in one of these facilities. I'm inviting this discussion to be held February 19-21, 2010 at the Controversies in Childbirth Conference in Tampa, Florida. The plan is to have one session with an obstetrician who is experienced in both hospital- and birth center births to discuss from a clinical standpoint what he believes obstetricians and patients want and what could safely be made available to them in this setting. We also hope to have an obstetrician who has a birthing facility in another country, very much like the I am proposing.

The next day, there will be a panel session with representatives of obstetricians midwives. consumer advocates etc. to discuss all the intricate details and to see if people would come together to make this work or oppose it and what the trade-offs would be.

Full conference information is available at:

I myself had a paradigm shift when this model was first described to me. I'm not sure I agree with it! Nor do I think I disagree with it! I do know that I want to discuss it.

Please register today for the conference (

Have a GREAT weekend

Thursday, October 29, 2009

Hospital, Birth Center, Home,…. Which Is Safest?

In yesterday's blog (scroll down a little and read it first). I asked the question: ”Could anything be done, so that obstetricians become hearty supporters of out-of-hospital birth?”

Before I delve into that question, I want to ask a different question: "Where is the safest place to have a baby? In a hospital with physicians? In a hospital with nurse midwives? In a birth center with nurse midwives? In a birth center, with direct entry midwives? At home with nurse midwives? Or at home, with direct entry midwives?" (Let's assume that we are talking about low risk women).

I believe if you ask an obstetrician that works in hospital, he or she will say "in hospital with physicians." If you ask a Licensed Midwife or Certified Professional Midwife, they would say: "at home with direct entry midwives."A birth center CNM would say, "at a birth center with nurse midwives."

Can they all be right? Are they all wrong? I  know that, each discipline will believe, what they do is the safest and is in the best interest of moms and babies.

Is it possible that the reason that everyone can believe that their way is the best, is because the best method does not exist in this country? Is it possible that women do not have the perfect option? Does every one of these choices cause women to sacrifice some degree of safety?

Let's pretend that there was a rather large birthing facility located inside the hospital that operates autonomously from the hospital? This facility follows the majority of the principles and standards of the American Association of Birth Centers. This facility offered a homelike birth setting, water birth, choice of position and even choice of midwife. That means a woman can choose either a nurse midwife or a direct entry midwife. The hospital’s staff, rules and bureaucracy have no influence on this birthing facility. This means that the facility does not even need nurses; it could utilize birth assistants to help midwives. This facility would give fantastic one-on-one care, yet, it operates at a large profit.

Furthermore, this beautiful birth facility would be connected by a short tunnel to the hospital operating suite, where obstetricians and anesthesiologist and OR Nurses were available around the clock. Likewise, this hospital has a top-of-the-line NICU. Of course, in our fantasy the birth facility even has a low transfer rate to the hospital. Furthermore , for the ultimate fantasy, the birth care professionals and staff at the hospital have a great relationship with the clinicians and staff of the adjacent birth facility.

Do you agree that this would be absolutely wonderful and all things being considered would be the safest model for mother and baby? If you're honest, you will agree!

Of course, this is a fairy tale, and does not exist. So why do I bring it up? Because, in tomorrow's blog posting. I will suggest another model. It will start an interesting discussion. Different sides will start taking different positions. You may see people start arguing that this model will not be as safe as the model they currently work in.

And that is my point! The safest model does not exist. For various reasons, the model that I described above is impossible to achieve. Occasionally, hybrids of this model have been tried and seem to fail, therefore, the fairytale that I described above will not be presented, because it is not workable.

It is important to realize that as we analyze the models. there will be pros and cons. Every model has its own set of risks. Each model has its strengths and weaknesses, and the argument will be made that, it is not as good or better than one of the other existing models.

I ask you keep an open mind, because, no matter what your position., we have just admitted that you are trying to preserve a flawed model.

Check back tomorrow.


Wednesday, October 28, 2009

Obstetricians, and Out-Of-Hospital Birth

The terms "obstetrician" and “out-of-hospital birth” are usually oxymorons or cannot be used in the same sentence without becoming the butt of a joke, such as "military" "intelligence."

Obstetricians are against Out-Of-Hospital birth! I know, they made an exception for birth centers, we'll get to that in a moment.

ACOG, originally put out a proclamation stating that “out-of-hospital birth” was unsafe. They later amended that statement and exempted accredited birthing centers. The wording of the ACOG statement is actually bit confusing on its face, because it only considers Certified Nurse Midwives or Certified Midwives (CMs have passed the American Midwifery Certification Board exam) , which excludes the CPM or licensed midwife. The wording allows for accredited free standing birth centers, but emphasizes that birth is only safe with immediate physician and cesarean section capability, which free standing birth centers don't have.

(Click here to read, ACOG statement)

Remember, the above is a revised statement, originally, free standing birth centers were not endorsed by ACOG.. so why did ACOG add accredited free standing birth centers to the approved list?

The popular belief is that ACOG is a trade association and is responsive to its membership. Free standing birth centers work very closely with obstetricians, in some cases are owned by obstetricians, but generally have backup and collaboration agreements with ACOG members. Allegedly, these member obstetricians put pressure on the organization to protect their own income and caused ACOG to reverse themselves. The above paragraph sounds totally plausible and is most probably, what actually occurred.

Even with the above statement, obstetricians are not in favor out-of-hospital birth, whether it is an accredited birth center, or whether it is homebirth! This makes the out of hospital midwives, furious, regardless if they are a ACNM certified or CPM certified.

Could anything be done so that obstetricians become hearty supporters of out-of-hospital birth? I believe the answer is YES, however, I don't think the midwives will be supportive of the steps necessary to make the OB's supporters.

Tune in tomorrow to see what it will take and what the backlash will be.


Tuesday, October 27, 2009

I Am Punting This Blog Posting

For the past week I have been in Florida, traveling the entire state meeting with representatives of different disciplines, including; public health, healthy start, midwives, birth activists, and obstetricians.

I did not arrive back in Austin until almost 2 AM last night. Therefore, rather than put up a blog post that's gibberish, I will just tell you that over the next week or two. I'm going to be discussing some major issues that may become very controversial, and also that will be incorporated into the Controversies in Childbirth Conference.

Please, check this blog tomorrow, for some hugely interesting discussions.


Monday, October 26, 2009

Politicians Promise Pregnant Women, More Choices Despite Shrinking Resources

How do politicians stay in office? Simple, promise voters that they can have whatever they want. When pregnant women start demanding more birth choices, politicians offer more childbirth choices. What happens when women are promised their birth choices, and then the politicians and bureaucrats are unable to deliver?

In the United Kingdom in 2007, top officials promised that by the end of 2009 (two months from now). ALL pregnant women will be given the choice of: hospital birth, birth center birth, or homebirth. Who can argue with giving women choices?

Of course, as we all know, resources are getting scarce and money to pay for these choices might decrease as the economy slides. In the UK, a just-released report shows that only 5% of women are being offered all of the birth choices that the government promised . Remember, there are only two months left to fulfill the promise of 100% of pregnant women being offered all the birth choices.

(Click here to read UK Guardian article).

In the UK, giving women a choice between hospital, birth center, and homebirth is not unusual, as midwives deliver the majority of babies there The government firmly believes that giving women more maternity choices is in the best interest of the government and the people.

So how does this relate to the United States? I don't believe anyone would say that women should not have choices in maternity care. However, just like in the UK, saying it and offering it are two different things. With hospitals closing labor and delivery units, and obstetricians and midwives leaving practice , we must question if it is feasible to offer women more choices, while the number of providers shrinks?

The midwife advocates will say that the answer is more midwives. If midwives are in fact the answer, then we must ask the question: “For every obstetrician that stops delivering babies, how many hospital midwives will it take to replace the OB? How many birth center midwives will take to replace the OB? How many homebirth midwives will take to replace the OB?”

With two months to go ,the United Kingdom is falling short by 95% of its goal. What is the goal of the US, and what are our chances of achieving that goal?


Friday, October 23, 2009

Improving Birth, or Setting It Back 40 Years?

22 years ago, I was a clueless father-to-be. My at-the-time wife, and I were expecting a baby, (my first). Please remember that this is before internet, before everybody had a cell phone, and before they put wheels on suitcases. I had a decision to make: when it was time for the birth. Do I leave the labor room or do I stay for the birth of our daughter? At that time, men could have chosen either way, and it was socially acceptable. I chose to stay. I will always remember crying the first time I held my little girl. I would not have changed that experience for anything in the world. My daughter and I are very close, and I attribute that to the promise I made her right after she was born, which was: to “always love her and always be there for her, no matter what”. It is a promise I have always kept. Today, it is socially desired and accepted for men to be at the birth if they want to have any involvement in the life of their child. When I was running birth centers, and some of the dads were iffy about being at the birth, I would talk with them and convince them that it was the right thing to do. Recently, Michel Odent MD, a French obstetrician, who is revered as a god in the midwifery and natural birth movements and ignored by the mainstream medical establishment, stated that he thinks that men should be banned from the delivery room. This includes male obstetricians as well as fathers. He believes that only midwives and the mom should be in the room. (Click here to read article). As you know from having read last Friday's blog, Patrick Houser, the author of the Fathers To-Be Handbook is leading a workshop at the Controversies in Childbirth Conference ( on the importance of dads being involved in the pregnancy and the birth. Patrick believes that the dad, is the most important variable in giving the mother a good pregnancy, birth and breast-feeding experience. On the other hand, Dr. Odents ays: “If she can’t release oxytocin, she can’t have effective contractions, and everything becomes more difficult. Labor becomes longer, more painful and more difficult because the hormonal balance in the woman is disturbed by the environment that’s not appropriate because of the presence of the man.” It appears that Patrick Houser and Michelle Dunn cannot both be right on this issue. Therefore, the Controversies in Childbirth Conference, which is being held in Tampa, Florida, February 19-21, 2010 will extend an invitation to Dr. Odent to debate Patrick Houser on this issue. We will let you know if he accepts this invitation. I do have some questions that the birth media has not asked: A) If the mother does not want midwives, does that mean that the dads can be in the room? B) If there are only male obstetricians in the hospital, does that mean the woman is better off delivering along? IS it a choice between dad and midwife? C) If mlel obstetricians were banned from the delivery room because they interfere with the birth process, does that mean that. Michel Odent’s lifetime of work should be ignored, because HIS presence in the delivery room may have actually hurt women? D) What would be the implications for society be, as a result of banning men from the delivery room? As the conference coordinator for the Controversies in Childbirth Conference ( I must remain officially neutral on this issue. I've had a number of conversations about this issue in the last few days with both professionals and moms and dads AND, without exception they all asked the same question: "Is he crazy??" Hopefully, Dr. Odent will be able to defend his unusual position at the Controversies in Childbirth Conference. Have a great weekend. Alan