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


  1. This comment has been removed by the author.

  2. So a massive problem I see with this, is the statement about putting physicians 'in the place of' the hospital. Unless there is equal collaboration and complete respect, it won't work - just another way for physicians to own and regulate midwifery? Right? Or am I reading this wrong...?

    I think midwives need to own birth centers and hire the right physician to be on call for the epidural/emergency cesarean issue.

  3. Christal:

    The statement "putting physicians in place of the hospital." Means that they now own a facility that competes with hospital. This is equivalent to a midwife that owns a birth center that competes with the hospital.

    The details of how this model will work is the subject for negotiations and discussions. The Controversies in Childbirth Conference will provide the arena for these discussions to take place.

    Keep in mind that I am not advocating for this model. I am simply putting putting it out there for discussion and debate.


  4. Thanks for clarification, Alan. I wasn't 'getting' what was meant.