Friday, July 31, 2009

Thoughts from Domestic Felicity

I read a blog entry today by Anna, a woman who didn't expect to appreciate natural birth so much as she did. I thought it was insightful how she likened the birth of a child to a wedding. Sure, the wedding day isn't as important as the marriage itself, but you still want to plan for it to be the happiest, best experience it can be. Similarly, a child's birth isn't as important as his life, but it doesn't mean that the family shouldn't plan to make that first experience a good one!

"It was lovely to have the help and encouragement of midwives and a doula, which made me feel more confident, but when it comes to the bottom line, I think I could have made it on my own as well. I didn't need drugs or a team of doctors supervising. There's something very empowering in the thought that God made your body with the ability to bring a baby into this world, from start (conception, which happens on its own) to finish (birth). And it was beautiful."

The Physicians' Declaration of Independence

From the Association of American Physicians and Surgeons, a Physicians' Declaration of Independence. You can find the document here:
Their motto is Omnia pro aegroto, which means "all for the patient." As it should be.

When in the Course of human events, it becomes necessary for one Profession to dissolve the Financial Arrangements which have connected them with Medicare, Medicaid, assorted Health Maintenance Organizations, and diverse Third Party Payers and to assume among the other
Professions of the Earth, the separate and equal station to which the Laws of Nature and of Nature's God entitle them, a decent respect to the opinions of Mankind requires that they should declare the causes which impel them to the separation.

We hold these truths to be self-evident: that the Physician's primary responsibility is toward the Patient; that to assure the sanctity of this relationship, payment for service should be decided between Physician and Patient, and that, as in all transactions in a free society, this payment be mutually agreeable. Only such a Financial Arrangement will guarantee the highest level of Commitment and Service of the Physician to the Patient, restrain Outside Influence on Decision-Making, and assure that all information be kept strictly confidential. When a Third Party dictates payment for the Physician's service, it exercises effective control over the Decision-Making of the Physician, which may not always be in the best interest of the Patient. The Third Party then intrudes heavily into the sacred Patient-Physician relationship and demands to inspect the Medical Record in a self-serving attempt to satisfy itself that its money is being spent in accordance with its own pre-ordained accounting principles.

The Financial Arrangements between Physicians and the Third Parties have become so destructive to the Patient-Physician relationship, and to the Medical Profession as a whole, that it is the Right, and Obligation, of the Members of the Profession to abolish them. Prudence will dictate that arrangements long established should not be changed for light and transient causes; and accordingly all experience has shown, that Physicians are more disposed to suffer, while evils are sufferable, than to right themselves by abolishing the forms to which they are accustomed. But when a long train of abuses and usurpations evinces a design to reduce them under absolute Despotism, it is their Right; it is their Duty, to throw off such arrangements, and to provide new Guards for their future security.

Such has been the patient sufferance of this Profession; and such is now the necessity that constrains them to alter their former Financial Arrangements. The history of the present system is a history of repeated injuries and usurpations, all having in direct effect the establishment of an absolute Tyranny over the Medical Profession. To prove this, let Facts be submitted to a candid world.

- The Tyranny began during the Second World War, when Companies, suffering under Wage and Price Controls, were forced to lure workers by offering Health Insurance Benefits. This benefit, in lieu of cash, received favorable tax treatment and was allowed to continue after the War, even with the removal of the Wage and Price Controls. This system created a strong incentive to use Medical Care and set the stage for massive Cost Inflation.

- Slowly, insurance changed into payment for all Medical Expenses, minus a small and shrinking Deductible, which led to further Inflation, and a call to control costs.

- The Government decreed that Employers must offer Employees the option of a Health Maintenance Organiz-ation. Thus were born the HMOs: Private Insurance Entities designed to ration Medical Care for their Members. These Organizations received Tax-favored treatment that allowed them to survive in spite of their horrendously flawed concept.

- The Government, in 1965, in its Infinite Wisdom and going far beyond its Powers as set out in the Constitution, decreed that the Poor and the Elderly should receive Health Benefits funded by the Taxpayer. Thus came into existence Medicaid and Medicare. Medicaid, from the Conception, paid Physicians such a lowly wage that few participated, thereby creating a Two-Tiered System. Medicare payments to Physicians were initially fair and reasonable, and many Physicians participated in Medicare. Both Systems flooded the Medical Marketplace with Money, which fueled Inflation even more.

- Alarmed by the Medical Cost Inflation that it had engendered, the Government set out to restrain costs, principally by limiting fees to Physicians. These Price Controls had the effect of increasing Medical Inflation, as Volume of Services went up, and Quality went down.

- With each new round of Controls, Regulations and Paperwork multiplied many fold. This caused Physicians great Anguish, and took more time away from the Patients, with attendant loss of Quality and increase in Medical Inflation.

- Government policies continued to favor the HMO, in the hope they would tame Inflation. These Organizations skimmed Money off the Premiums as Profit, but which they called "Savings." They spent less on Medical Care by denying or limiting access to Specialists, Procedures, Hospitals, and High Technology. Since this strategy mostly delayed care, it was ultimately more expensive. Thus did the Premiums again start to rise.

- The HMOs paid the Physician by Capitation; Physicians could stay profitable by having large numbers of Capitated Patients, which they would see rarely, if at all! There were other Financial Incentives to Physicians to limit their Patients' access to Tertiary Care. These incentives set Patient against Physician, thus destroying this Sacred Trust.

- Remuneration for Physician services by the Government and the HMOs has dwindled to the point of Unprofitability and has compelled the Bankruptcy of increasing numbers of Practices, and the search for Other Sources of Income by Physicians. No other Profession in the United States is denied the ability to raise fees to cover increasing costs of doing Business.

- The Government, becoming increasingly desperate that all its strategies to control costs had failed (because they themselves were the cause of Cost Inflation!) resorted to Criminal Prosecutions of Individual Physicians and Hospitals for alleged Fraud. The Regulations being so Arcane and Vague, a simple Billing Error could be interpreted as Fraud. Most of those so pursued, being financially unable to defend themselves, simply capitulated and paid Huge Sums to the Government. Some were imprisoned.

- The Government passed a Massive Bill called HIPAA, which forced Doctors and Hospitals to spend billions to comply, with absolutely no positive impact on Patient Care.

- The Government passed a law called SGR which automatically lowers Physician Payment when total spending and volume increase, virtually assuring a downward spiral in Payments.

- The Government and HMOs now conspire to limit fees to Physicians by a diabolical machine known as "Payment for Performance," based on "Practice Guidelines." In addition to insulting our Ethic, this system will close the circle between the Central Payment for Care and the Central Prescription of Care. Thus do we completely lose our Professional Autonomy.

In every stage of these Oppressions We have Petitioned for Redress in the most humble terms: Our repeated Petitions have been answered only by repeated injury. A System whose character is thus marked by every act which may define a Tyrant, is unfit to be the ruler of a Free Profession.We, therefore, the undersigned Physicians of the United States of America, appealing to the Supreme Judge of the world for the rectitude of our intentions, do, in the Name of our Patients solemnly publish and declare, that we will withdraw our participation in all above-described Third Party Payment Systems. Henceforth and Forever, we shall agree to provide our services directly to our Patients, and be compensated directly by them, in accordance with the ancient customs of our Profession. As has always been true of our Profession, our charges will be adjusted to reflect the Patients' ability to render payment. Nothing prevents any patient from purchasing and using Insurance. The Patients' medical interactions with us will remain completely confidential. We pledge the highest level of Service and Dedication to their Well-Being.

And for the support of this Declaration, with a firm reliance on the protection of divine Providence, we mutually pledge to each other our Lives, our Fortunes and our sacred Honor.

Richard Amerling, M.D.,
New York, NY, April 2009

Association of American Physicians and Surgeons, Inc.
A Voice for Private Physicians Since 1943

Sunday, July 26, 2009

Penny Simkin on the Role of Doulas

Watch the video:

Penny Simkin, the co-founder of Doulas of North America (now DONA International), talks about using doulas for birth care and how the doula movement came about.
Midwifery Today Conference in Eugene, Oregon.
March 2009.

an excerpt:

"I'm Penny Simkin and I've been involved in childbirth work for 41 years. I have many interests in birth. But the one you're interested in right now is my interest in doulas. I am a doula. I accompany women in labor. I'm a childbirth educator. I'm the author of several books. I do train doulas. And I'm also a birth counselor. I try to assist people who are feeling a lot of anxiety about the upcoming birth or who have had a very disappointing birth experience. I try to help them to come to terms with that kind of thing.

One of the most recent additions to the maternity care team is the doula. A doula is a woman, usually a woman - not always, who is trained and experienced in childbirth. And she gets to know the couple before they have their baby. And she's with them from the time they need her in labor through the birth. Providing not only her continuous care, but also emotional support, reassurance, encouragement, hands-on comfort measures, some guidance on when to try this or that, and also helping her to get information that she might need. If a doctor or midwife is concerned about something and wants to change the plan, the doulas helps her understand what her choices are.

I got very interested in this whole concept from two sources, really. Way back in the early 1980s, we had some studies by Marshall Klaus and John Kennel and others in Guatemala that showed that the presence of a kind woman with women in labor made a difference in their outcomes. And I thought "Well, that's interesting." But I didn't do much about it. But then I did a study myself on women's long term memories of their birth experiences and what contributed to their satisfaction. And I found that women who were cared for well were the ones most likely to feel satisfied with their births. And women who felt that they were neglected or not respected or not listened to or left alone, they were the ones that were likely to feel very unsatisfied with their births. And this was over 20 years, when they were looking back 20 years to their birth experiences, that was what stood out. And I thought, "Gosh, we can't control a lot about labor - when it starts, how long it's going to be, whether its complicated- but we can control how we care for her."

Sunday, July 19, 2009

Reducing Infant Mortality

The folks at are raising money to fund this film about the state of childbirth in America. Watch the commercial and feel free to donate money towards the cause on their website.

"Listen to obstetricians, doulas, neonatologists, midwives, psychologists, pediatricians, and other physicians explain how our health care system is failing babies and mothers and what we can do about it."

Wednesday, July 15, 2009


Just a quick update to say that this morning I saw a baby born after a 27-hour labor. It was the 6th childbirth I've seen and, as I've come to expect, totally different from any of the others so far. There will be some thoughts and "lessons learned" to share soon, but for now I'm just posting a status update. I'm tired, but staying in the game. :)

I'm super appreciative of Kristen Downer, too, and the opportunity she has given me to learn from her wisdom and years of experience. She is a great doula and it has been a treat to see her in action.

Monday, July 13, 2009

Laboring Without the Labor Bed: It's a Good Thing

This press release from the University of Toronto details a pilot study that removed the standard hospital bed as a focal point of labor. In the redesigned "ambient" room, instead of the typical hospital room, women didn't spend as much time in the bed. And the result was that they labored better and had a better perception of their labor experience.

Here's the story:

A University of Toronto pilot study that re-conceptualized the hospital labour room by removing the standard, clinical bed and adding relaxation-promoting equipment had a 28 per cent drop in infusions of artificial oxytocin, a powerful drug used to advance slow labours. The study, called PLACE (Pregnant and Labouring in an Ambient Clinical Environment) was published in the current edition of the journal Birth.

In addition, more than 65 percent of the labouring women in the ambient room, compared to 13 per cent in the standard labour room, reported they spent less than half their hospital labour in the standard labour bed.

Led by Dr. Ellen Hodnett, Bloomberg Faculty of Nursing professor and Heather M. Reisman Chair in Perinatal Nursing Research at the University of Toronto, PLACE included 62 women at two Toronto teaching hospitals.

Hodnett devised a set of simple, but radical modifications to the standard hospital labour room, with the intention of surrounding the women and their caregivers with specific types of auditory, visual and tactile stimuli.

"The removal of the standard hospital bed sent a message that this was not the only place a woman could labour," says Hodnett. A portable, double-sized mattress with several large, comfortable cushions was set up in the corner of the ambient room. Fluorescent lighting was dimmed, and DVDs of ocean beaches, waterfalls and other soothing vistas were projected onto a wall. A wide variety of music was also made available.

"The intent was to allow the women the ability to move about freely during their labour, to permit close contact with their support people, and to promote feelings of calm and confidence," says Hodnett.

Reaction to the ambient room was overwhelmingly positive, as respondents were pleased to have options for mobility and for helping to cope with their labour. They also indicated they received greater one-on-one attention and support from their nurses.

"This study raises questions about the assumptions underlying the design of the typical hospital labour room," says Hodnett. "The birth environment seems to affect the behaviour of everyone in it – the laboring women as well as those who provide care for her.
Hodnett hopes to further this study with a larger, randomized controlled trial.

View Dr. Hodnett's study here:

Read Dr. Hodnett's bio here:

Thursday, July 9, 2009

Florida hospital creates suite for natural birth

I'm not sure how natural the births that happen in this hospital are, but here's a news report about their attempt to appeal to clients who want less intervention and more of a homey ambience...

Saturday, July 4, 2009

Womb Serviced

The four-week class with Kristen and Paige has finished. We spent the last evening talking about baby care and watched a really good video about breastfeeding. It featured Dr. Jack Newman, who wrote one of the books on my DONA required reading list, so I'm looking forward to reading that.

the DVD:
the book:

How hilarious is this photo?