Obstetricians are the go-to care providers when giving birth in the U.S., but not all OBs are created equal. How do your obstetrician’s background and training impact the care you get, and is that aligned with the care you deserve? Dr. Stuart Fischbein shares his insights, the hard lessons he’s gained over his career, as well as why he still does breech deliveries, VBACs, and homebirths.
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- Approaches to Limit Intervention During Labor and Birth, American College of Obstetricians and Gynecologists (ACOG) Committee Opinion
- Midwife-led versus other models of care for childbearing women, Cochrane systematic review
- The Midwives Model of Care, Midwives Alliance of North America (MANA)
- The Obstetric and Gynecologic Hospitalist, American College of Obstetricians and Gynecologists (ACOG) Committee Opinion
- Birth by the Numbers website
- Mother-Friendly Childbirth Initiative, Improving Birth Coalition
- Maternal Mortality and Maternity Care in the United States Compared to 10 Other Developed Countries, The Commonwealth Fund
- “Home Birth” with an Obstetrician: A Series of 135 Out of Hospital Births, Dr. Stu’s research
- Breech birth at home: outcomes of 60 breech and 109 cephalic planned home and birth center birth, Dr. Stu’s research
- Case Report: A maneuver for head entanglement in term breech/vertex twin labor, Dr. Stu’s research
Related Birthful episodes:
- What You Need to Know About Birth Models (Birth What?)
- Why Choosing the Right Care Provider is Crucial for Your Pregnancy
- How to Avoid a “Cascade of Interventions”
- Cesarean Risk: What’s Your Place of Birth Got to Do With It?
- Why an OB/GYN Chose to Have a Homebirth
What You Need to Know About Obstetricians (OBs)
Adriana Lozada: Hello, Mighty Parent or Parent-to-Be! I’m Adriana Lozada and I want to welcome you to Birthful as we continue with our care provider series.
So far in this series we’ve talked in broad strokes about the different types of care providers, about the importance of choosing the right care provider, and how to know if your and your care provider are a good fit, because you need to be able to establish a relationship built on trust— where you are heard, where your wishes are respected, and where you participate in shared decision-making.
Now, go ahead and get comfy, because, in the next few episodes, we’re going to be taking a closer look at the different types of care providers starting today with obstetricians, or “OBs” for short.
And I want to give you a heads up that today’s conversation with obstetrician Dr. Stu Fischbein may get a bit controversial at times, and MAY even be uncomfortable for you if you are under the care of an obstetrician… but especially for that reason, you really need to hear it!
Dr. Stu has been practicing obstetrics since 1986 and has had a front-row seat to how training for obstetricians has changed during that time. Stu still actively cares for pregnant people in community birth settings and is one of those rare OBs that still practices and teaches the skills of breech birth. He also somehow finds the time to podcast; he is the co-host of the podcast Birthing Instincts.
Ok, so by now, you probably know how much I love putting things into context, so there are a few things you need to know before our talk.
The first is that in the U.S., 98% of births happen in hospitals, and 90% of those births are cared for by OBs. You may then assume this means that an OB is the best care provider for the job, but more and more we are seeing that this may not be the case if you are in good health and have an uncomplicated pregnancy. Even though OBs are the go-to care providers for birth in the U.S., it may surprise you to hear that they are NOT really trained in normal physiological pregnancy and birth, but rather in managing the process with interventions. And that is great if you actually need the interventions. Don’t get me wrong— I am so grateful that we have access to cesareans and magnesium drips, and the people who know how to use them. But if you have an uncomplicated pregnancy, you most likely do not need any of the interventions, but rather a person well versed in physiological birth, who is really comfortable taking a lifeguard approach, to paraphrase Robin Elise Weiss.
Now the history of how we got to such a medicalized state of birth dates back to the 1800s, it is quite complex, often steeped in sexism and racism, and in too many cases with economic interests put ahead of the patient’s best interests.
So the second set of facts that you need to know is that even though the U.S. spends more money on perinatal care than other highly-resourced countries, we have some of the worst perinatal outcomes in the world. And these outcomes are significantly worse if you are a person of color. What’s even more staggering is that many (if not most) of those negative outcomes are preventable.
Fortunately, awareness about this perinatal healthcare crisis and the over-medicalization of birth has been rising, with an ongoing push for change at a governmental and consumer level. Even the American College of Obstetricians and Gynecologists has published a committee opinion titled Approaches to Limit interventions During Labor and Birth that, of course, I’ve linked in the show notes. In this committee opinion, ACOG recognizes that “Many common obstetric practices are of limited or uncertain benefit for low-risk women in spontaneous labor.”
While looking at different models, what keeps coming up, again and again, is the importance of increasing access to the midwifery model of care for healthy and uncomplicated births, with midwives and OBs working collaboratively to escalate care to a more managed approach with OBs when it’s necessary. As a point of reference, in the U.K., more than half of all babies are delivered by midwives, and in France and Scandinavian countries, it’s more like three-quarters of all babies. As you might already know where I’m going with this, they all have better outcomes than we do.
So you may be thinking, “Okay, great context, but what does that have to do with my particular care provider?”
Well, since chances are that your care provider is an OB, and until the current model changes, most OBs continue to be trained to intervene, you need to basically figure out how “intervention happy” (if you will) your provider is, because to re-quote ACOG’s committee opinion “Many common obstetric practices are of limited or uncertain benefit for low-risk women in spontaneous labor.”
Basically, the point of this episode is to give you some behind-the-scenes of obstetrics so that you can know what to expect and take the reins of your experience.
I also want to underline that not all obstetricians practice a medicalized model of care, just like not all midwives practice a low-intervention model of care. In fact, if you heard my previous episode with Nana Eyeson-Akiwowo, you know that her OB was the perfect fit for what she needed. And, oh my god, this is even true for laborists! I have a fantastic episode with Dr. Nicole Rankins precisely on How to Avoid a “Cascade of Interventions,” and Dr. Rankins is both a laborist and a big proponent of supporting physiological birth.
Even though in this episode we will be talking in generalities, you need to turn on your critical filters and match our conversation to YOUR particular care provider.
Ultimately, the goal will be to find a care provider that will work with you and your wishes, allowing for your birth to unfold while being ready to intervene if needed or as you desire, but not by default.
Dr. Stu has some great suggestions of questions you can ask your care providers, ways to prepare during pregnancy, and other actions you can take as labor starts.
You’re listening to Birthful, here to inform your intuition.
Adriana: Dr. Stu, welcome! It’s so great to have you here.
Dr. Stu Fischbein: Thanks, Adriana. I’m happy to be here. And looking forward to talking to you.
Adriana: So tell me a bit… You were trained in the medical model of obstetrics, but decided to support the midwifery model of care. Why don’t we clarify that for listeners? What are the differences between the two models, and what led you in that direction?
Dr. Stu: Well, quite simply the difference between the two models is how they look at human pregnancy and labor. The medical model looks at human pregnancy and labor, essentially as a disease requiring treatment, observation— like something’s going to be going wrong at any moment. And only modern medicine can help deliver babies safely— that’s sort of the way it’s really looked at and y’know, it sounds simplistic, but that is true. That’s why… that it’s hospital-based. That’s why every woman’s given an IV. That’s why women are generally not allowed to eat. That’s why women are continuously monitored. That’s why there’s a team of obstetricians and nurses and neonatal personnel and anesthesiologists and everybody on standby, because they’re waiting for something to go wrong, so they can intervene.
The midwifery model looks at pregnancy and labor as wellness, and something that is a normal function of the female body and only requires intervention when something goes wrong. So midwives are experts at normal birthing, while doctors are experts at abnormal birthing. The problem, of course, is that about 85% of women in this country are normal laboring and birthing women, and the people that are taking care of them actually have very little training in taking care of normal birthing.
So it’s sort of a paradox, because we should be allowing women to be cared for by the practitioner of their choice. We should be supporting the model that treats pregnancy as a normal human function, rather than a malfunction. And the medical model that’s clinging to its principles, much to the detriment, in my opinion, of many in this country, who deserve better.
Adriana: Somebody once told me that having an OB— it kind of put things into perspective for me— having an OB, y’know, in charge of a low-risk pregnancy and delivery was akin to having a trained psychologist come and babysit your child. Like, it was overkill because chances are, unless there’s something actually wrong, you don’t need that much level of training. OBs are, first and foremost, surgeons.
Dr. Stu: Well, yeah, and that’s a really good analogy. I heard it slightly differently, but that’s perfectly why we’re overqualified for 85% of what we’re doing, and we’re not even trained in it, to do it. So, yes! And the thing that really irks me and the thing that’s really… I would call it a pet peeve of mine… is the people that are training our next generation of obstetricians— the academicians, the maternal-fetal medicine specialists, the people working in academia and hospitals— are not training them to be obstetricians. They’re training them to be, like you said, generalists or surgeons. And there’s very little in between, because, Adriana, when you think about it, what makes the obstetrician unique?
And in my opinion, what makes an obstetrician unique is that they can do things that a family practitioner or a midwife or general surgeon cannot do— and they’re not training those skills anymore. And I’m talking about things like forceps delivery, breech delivery, breech extraction of a second twin, external version, that sort of thing, and having skills that separate you out from a generalist.
And if you’re not teaching obstetricians to do those things anymore, what good is the specialty of obstetrics? I mean, we… If a woman has a bladder problem, she can see a GYN-urologist. If a woman has a high-risk pregnancy, she can see a maternal-fetal medicine specialist. If a woman needs a cesarean section, she could have a general surgery and even a family practitioner can do that sort of thing. If a woman has a hormone problem, she can see a reproductive endocrinologist. So what is the purpose of a general OB/GYN— which we’re training and putting out in large numbers— when all they’re really doing is general office OB/GYN and c-sections? Midwives can catch normal babies. We don’t need doctors for that.
So what I would argue is that obstetricians are becoming obsolete and are eliminating themselves from the marketplace over time, unless they start to retrain their students in the skills that make us unique, like breech delivery and forceps delivery and twin vaginal delivery and those sorts of things.
Adriana: Why do you think all the training of those skills has gone away?
Dr. Stu: Now there’s three reasons— and none of them are good. I basically call them 1) expediency, 2) economics, and 3) medical legal concerns. And by expediency, I mean it’s a lot easier for a lot of doctors to just do cesarean sections than it is to deal with hospital policies that may require them to spend 12 hours in a hospital with a VBAC or a breech when they get the same pay and can be back in the office or be home for dinner by doing a cesarean section that takes 45 minutes.
The incentives are all backwards! Economically, although doctors may not make more money by doing a cesarean section, they certainly can save some of their time— but hospitals certainly make more money on a cesarean section than they do on a vaginal birth. And if a hospital’s prime motive is to stay open and its fiduciary duty is to maximize its income, then there’s actually no incentive for a hospital to lower c-section rate.
And the third thing, I think, is the medical legal concern— that, in my own opinion, is blown way out of proportion, because I do believe that if you have a good relationship with your client, and spend time with them and get to know them (which of course is also being destroyed by the medical model, of the shift to medicine mentality)…
But if you have a good relationship, you’re not very likely to get sued. I think that the fear of liability is often used as a hammer to get people— both professional medical people and clients— to do what you want them to do. So hospitals, they put risk management far above patient care on their criteria.
They don’t ever say that. And they’ll never, y’know,… You look at the mission statement, it isn’t there, but ultimately, in the bowels of the hospital boardrooms, it’s risk management that runs the show, and not patient satisfaction or patient care, and it’s sort of tragic. And I know that it is sort of negative, but it is a reality.
And I look, I spent 28 years working at a hospital. Now, working at home, there’s a clear difference as to the quality of care that patients get. So why things won’t change in the hospital setting are really those three reasons: economics, expediency, and the fear of medical legal concerns.
Even if it’s not as real as they think it is, it doesn’t really matter. It’s what the administrators and people that run hospitals now, they make the decision… The ideal situation, Adriana, would be to get normal birth out of the hospital, and use the hospital like you would for any other issue. For digestion and breathing we don’t go to the hospital, but when we have asthma or we have colitis, we go to the hospital. Y’know, people will say, “Well, what if something goes wrong?” Well, the problem is things are far more likely to go wrong when you’re in the hospital than when you’re out of the hospital, if you select, y’know, your clients properly, if you know what you’re doing, and you’re well-trained. And that’s why I’m saying midwives are very well-trained in normal and therefore they can easily recognize abnormal. Whereas doctors are not really comfortable in that role.
Adriana: Right. And they are trained to intervene, so they wanna do something about it.
Dr. Stu: Yeah, I mean, in the training model by which doctors are trained, or even in the private practice model, doctors don’t deal with normal laboring women, and they’re called to the labor room by the nurse when something needs to be done.
So it becomes ingrained in their system that when they enter the labor room, it’s time to do something. It could be “Start Pitocin.” It could be “Rupture membranes.” It could be “Start pushing,” before the woman is ready to start pushing. It could be whatever it is, “But since you called me there, now I must do something.” Mentality is pervasive. Wouldn’t it be nice for a doctor to walk in a room when they got called in from home and realized that there’s nothing they need to be doing right now and say, y’know, “Gee, Susie, you’re doing really, really well. I’m gonna go in the lounge and you keep doing what you’re doing, and I’ll be back in a bit.”
Adriana: It would be fantastic. And it goes back to understanding birth as a physiological process, where being scared, being— y’know, having adrenaline come into it— feeling anxious, those are a detriment to the process. So the quote-unquote “intervention” that would be best is to bring calm. That could be the thing you do: bring calm or bring reassurance.
Dr. Stu: And that comes from being a confident practitioner, but also comes from having a good relationship long before that day. And the problem with the medical model— we have another, well, there’s multiples— but another problem is the fact that the primary caregiver to a woman in labor in a hospital setting is someone she’s never met. And that would be the nurse that changes shifts every 12 hours. And so, again, there’s no real comfort zone there. Plus the whole idea of any mammal leaving its place of safety and comfort and getting in a car and driving to another place— which is a place of anxiety and stress— and thinking that that mammal’s going to labor well there, while she’s restricted in movement and not allowed to eat and constantly interrupted, and all the things that go on at a hospital… is silly.
And yet it is the… It’s the pervasive way of thinking, which becomes, then, the standard of care, by the true definition of “standard care,” which is what most most physicians in a community would consider to be normal. And therefore the standard of care is anti-mammalian, because that’s not how mammals give birth. They don’t give birth in a setting where they’re interrupted, anxious, immobilized, starved. It doesn’t work well. You wouldn’t do— I know this sounds controversial, but it’s not— you wouldn’t do to your dog in labor what we do to a human.
Adriana: Yeah. And I’ve had on this show several different practitioners, including Diane Weissinger and Karen Strange, talking about those different aspects— it all comes back to the same center of birth of the physiological process. And I really like your analogy about breathing and asthma.
Dr. Stu: About which one?
Adriana: Breathing and having asthma.
Dr. Stu: Oh, asthma, right.
Adriana: If you’re breathing, you’re not like, “Oh, I have to breathe. Let me go to the hospital.” But we do say, “Oh, I have to birth. Let me go to the hospital.”
Dr. Stu: Right?
Adriana: So tell me a little bit about, with all your knowledge and have… You’ve gone from having a practice in a hospital to now, sort of a homebirth or birthing center practice. What are the differences that you’ve seen in terms of outcomes and satisfaction with practicing a midwifery model of care?
Dr. Stu: The satisfaction level for both the clients and for myself has skyrocketed. I’m absolutely certain of that. I just think it’s a much better model for caring for women who are not in need of hospital-based care. And I don’t even like to use the term “high-risk,” Adriana, because it’s a term that by very… it’s very… by calling anything “high-risk,” it’s a self-fulfilling prophecy and you basically, by labeling someone “high-risk,” you instill anxiety and fear into them, which is already setting them up to fail. Just because a woman is tiny or a woman is over 35 or you think she has a big— I always wonder why do the doctor say to a woman, when in her third trimester, why do they say things like “No, your hips are really small” “I think you have a big baby,” or “That baby’s head, that’s really big on ultrasound,” why do they say that? Y’know? And I know why they say it… they’re projecting their own anxiety onto the woman, so they can alleviate themselves of their own. It’s very psychological. I mean, we ought to get a psychiatrist on our discussion to talk about all these things, because there’s so much projection, y’know, fear involved in what goes on.
I don’t see it so much at home, because the homebirth clients we have are well-educated. They’ve researched the thing. A lot of ’em are doing it because they had a… didn’t have a good experience in the hospital with the first one, where someone in their family didn’t, or they have a long history of homebirthing. But the difference is night and day, because at home they feel safe— they can move about, they’re allowed to eat, they’re not strapped down with monitors. They’re in a familiar environment and they’re not interrupted constantly.
Y’know, the hospitals have policies and protocols that are put in place for no scientific reason. They’re put in place because of risk management. The idea that a woman needs her blood pressure taken every half hour or every hour in labor is silly. It’s ridiculous. That continuous fetal monitoring thing is known. It’s already been shown to do nothing but raise the cesarean section rate. Everybody knows that, yet hospitals won’t get rid of that.
Finally, they’re beginning to do things like allowing women to eat. I love the word “allow,” by the way— it seems like the hospital is magnanimous by “allowing.”
Adriana: Right. It goes back to that whole psychological thing we were talking about: “I’m gonna let you go two weeks past your due date.” “I’m gonna let you”… like I could force your body to do something!
Dr. Stu: Yeah. It’s a bit of language that again, doctors are taught this in residency, and in our culture and it takes an awakening to really realize that the words that we use: calling women “clients” or calling them “patients.” “Clients” is a term that midwives use, that it’s taken me a long time to become aware of the fact that by labeling someone a “patient,” you’re basically calling them… “Patients” are reserved for the people who are sick. That’s what a patient is. So, while a pregnant woman is not sick, but if you call her a patient all the time, it just sort of sets the tone.
Adriana: The reality is most people are gonna give birth at a hospital with an OB. It’s gonna take a long time for that to change. It’s a drastic cultural change, but for the people who are having a hospital birth with an OB, what can they do to ask more from their OB to receive better care?
Dr. Stu: Well, the number one thing, I think, a woman who’s giving birth at a hospital— especially if it’s her first baby— can do to improve outcomes and improve her situation is to hire a doula. I think that it’s very clear that a woman with a doula is more likely to have the birth that she wants, including the route that she wants (vaginal), than if she doesn’t have a doula, especially in your first pregnancy.
Secondly, you can’t be afraid to ask your doctor questions. And you can’t ask him a silly— I mean, it’s a silly question to ask him what’s his c-section rate, right? Because if it’s really high, he’s not gonna be telling you about it anyway. So that’s really not the right question, but the question you should ask is sort of, y’know, “How would you feel about me not being monitored? How would you feel about me walking around? Will I be able to eat in my labor? How do you deal with the baby when it comes out? If it’s fine, can the baby be put right on my chest and leave the cord alone?”
What are the policies and procedures at your hospital that you have to come to, and find out whether that… whether that’s compatible, you can look at the c-section rate at the individual hospitals, because those are posted online, but hospital rates are really only dependent on the individual doctor rate.
One of the things that came out recently, which I thought was really interesting, is they looked at the laborist model, and they looked at the laborist model in a single institution. And the whole idea of a laborist is that they have a doctor working, like, a 12 hour shift, that’s doing all the deliveries.
And so they feel like it takes away the time pressure— other doctors in private practice who want to get to the office or want to get home, to push the envelope or do a c-section. If there’s somebody just sitting there in the hospital all the time, they felt like it was going to take away that, and it would probably lower the c.
Of course, they did all this without any research whatsoever. They just… somebody thinks some of an idea and they implement it and they don’t research it first. And what they found in this paper was that the c-section rate was completely dependent on the individual laborist, not on the model. Had nothing to do with the model! Had to deal with the skill of the laborist and the comfort of the laborist.
So ultimately the model isn’t going to change anything. It’s the skills of the doctor. And if you’re in a hospital with a laborist model that’s gonna be taking care of you, remember you’re going to be taken care of by somebody you’ve probably never met, and you have no idea about their skills.
So I would personally avoid a hospital with a laborist model. I would try to find a hospital that allows midwives to deal with normal labor stuff, and you’re more likely to have a better outcome.
Adriana: And it’s really interesting that result about the laborist model being dependent on the comfort level of the person who’s taking care of the birth, which is similar to the outcomes that you find with the quote-unquote “big baby,” that the biggest indicator of a cesarean for a big baby is having the care provider think that it’s a big baby that gives you a higher risk or higher incidence of a c-section than the actual weight of the baby.
Dr. Stu: Well, y’know, much to their credit— although it carries no weight— ACOG has come out, the American College of OB/GYN has come out with certain statements about allowing women to labor longer and not doing c-sections for suspected macrosomia or borderline amniotic fluid. But the truth is that their papers that don’t fit with the model by which doctors and hospitals want to practice are completely ignored, and papers that come out that fit the model by which they wanna practice are adopted quickly.
When they come out with an anti-breech paper or an anti-homebirth paper, so those are accepted quickly— but when they come out with a “allow women to labor longer” or, “breech delivery is actually something that should be retaught and retrained,” those things, y’know, take forever to be incorporated, if they are at all.
So there’s a cognitive dissonance, of science, selection that goes on, and things that support the model by which people want to practice are promoted. And if it puts them in a position of feeling uncomfortable with the way they practice, then that report is ignored or ridiculed— that’s classic cognitive dissonance.
And that’s what’s going on. They have to know that in 1970 in America, the c-section rate was 5.5%. Now it’s 32%, and we have nothing to show for that as far as better outcomes to speak of. And in fact, we probably have worse outcomes. And in the long term, we might find that all those cesarean section babies, there’s greater risks of other things going on.
But putting that aside, we have a 500% increase in the c-section rate, with nothing to show for it. And this is the model by… which is considered still the standard and is the model of excellence, by which home birth midwives and doctors like me are compared against, y’know, and we come out with our 6-7-8% c-section rate, and that doesn’t make any difference! We’re… What we’re doing is “dangerous.” And what they’re doing is “standard” and “the best care.” And it… there has to be a cognitive dissonance, because even when I say it like that, it sounds ridiculous.
Adriana: And I think that circles back to something else I wanted to talk about, which was the whole idea of “Informed consent in birth is a human right.” And I know you’re a huge advocate for that!
Dr. Stu: I mean, when we have informed consent, it’s a nice theory— but every day, in every hospital, and every doctor’s office, we all violate the tenets of informed consent. And technically we all violate our medical ethical obligation to give information to women and then support their reasonable choices because we all skew our information and we all… we don’t give informed consent.
We don’t support women’s reasonable choices. I mean, we know that VBAC is a reasonable choice, right, Adriana? I mean, it’s in this country, the NIH, ACOG, everybody else supports the option of VBAC. Yet there are many, many hospitals and many physicians who tell patients that if they’re gonna have a VBAC, they “can’t do it at our institution because it’s really dangerous and the baby could die,” right?
So that’s a violation of medical ethics, And they vilify those of us that support VBAC! So we know by everything in the literature that it is a reasonable choice. And evidence-based ethics says that if it’s a reasonable choice, we have physicians to support that choice. Now support could be, “I will help you with your VBAC,” or “I would love to help you with your VBAC, but I can’t because my institution won’t allow it, but if you go to the doctor down in that other county or that other city, then you can have your VBAC,” that would be reasonable and ethical. But to tell a woman that if she tries a VBAC, she’s being an idiot, is not ethical.
Adriana: Well, right. And, we’ve talked about how important wording and language is when talking to especially— and, y’know, any clients, but especially a pregnant person, who is by definition in a more vulnerable, heightened state— and they rightfully so will hear something like, “Oh, your baby’s big,” what you were mentioning before, and be anxious about it. And then that will have their body respond and affect the physiological process.
Dr. Stu: Yeah, I don’t think the physicians are taught that the effects of anxiety that you’d mentioned earlier— the effects of fear and anxiety on mammalian birth— is detrimental to labor. I mean, it puts out adrenaline, it stops the contraction. It stops labor, it delays the onset of labor. I don’t even know that the average physician knows that stuff! But the idea that normal birth should be something that we fear, and that we need to turn into a procedure, is pervasive. So, y’know, I find it really hard to blame the young physicians coming out, because as you said, they’re indoctrinated and we’ve had three generations of American women indoctrinated into believing that their body doesn’t know how to do this.
Adriana: So here’s what I’m trying to wrap my brain around, ’cause the purpose of this episode was to try to give ways to make their experience better—
Dr. Stu: Alright, well then let’s concentrate on that, because I’ve already sort of just made it that much more difficult! But, yeah!
Adriana: Let’s go back to helping!
Dr. Stu: Alright, so a doula is very helpful. Picking an institution that may allow you to have a birth plan and . to enforce your own choices— the problem is many people live in a community where there’s only one hospital and there’s very little choice and there’s really not much they can do. And for those people, I would tell you that if you have a homebirth midwife in your community, at least check it out, at least have an interview with her, and see whether that is something that you can consider.
If you’re going to the hospital, you want to go to the hospital as late as possible. Go to the hospital when you’re eight or nine centimeters dilated, and then you’re less likely to get intervened upon, because the problem, of course, if you go to the hospital too early then, because of the change in venue and because of the anxiety provoked there, your labor will likely space out a little bit… but now you’re in the hospital, and since you’re in the hospital, we might as well get things moving. And so they either rupture your membranes or they start Pitocin. And then of course that hurts, and you epidural and they get the whole cascade going. And that happens because you get there too early. So don’t get to the hospital too early!
By the way, another good point would be if you find that physician, ask them what the physician recommends if you’re at home and your water breaks, because if the physician says “You need to come to the hospital right away,” I’d run away from that physician. I would like to find a physician who says, “Well, I’m gonna ask you a couple questions, and if the fluid is clear and the baby’s moving and everything’s quiet, you should stay home.”
That’s a physician that I might feel more comfortable with, than one who tells you, “You immediately need to go to the hospital,” because now you go to the hospital and then what happens? Well, you sit there… and of course, hospitals don’t like it when you sit there. And so they start doing stuff, and you don’t want to be doing stuff.
There is no such thing as an “18 hour” or “24 hour” rule. You really think that bacteria know that it’s 24 hours or that an infection is likely to occur? An infection is very unlikely to occur in women who ruptures her membrane, who isn’t contracting and isn’t being examined, and especially if her group B strep status is negative. Does that make sense?
Adriana: Makes absolute sense to me! As a birth doula, I know very much what you’re talking about, but then we have all these media depictions of birth where the first thing that happens is water breaks and people run to the hospital and it’s ingrained, like, in the back of the mind. I, like, always tell people, like, your water doesn’t have to break, even, like, you can be in labor and it can be the last thing that happens!
Dr. Stu: Yep.
Adriana: So, I guess, if we’re gonna come full-circle, it goes back always to people informing themselves, so they can understand what’s important to them.
Dr. Stu: That’s another good point, is that a well-informed woman is much calmer and much more likely to have a successful birth. And I think the midwifery model is geared toward that, because the prenatal visits in the midwifery model are, y’know, often 30 to 60 minutes long.
And in the medical model, it’s essentially… You’re lucky, if you get six minutes for a prenatal visit! You can’t possibly educate somebody and talk about wellness, talk about nutrition, talk about stress reduction, and sleep and all the things that help keep a woman healthy in a six or seven minute office visit with a busy physician who unfortunately for… And not of his own making, but the system is such that the reimbursement model and the overhead for running a doctor’s office is so high, and the reimbursement is so low, that doctors— in order to do obstetrics— have to do volume. And when you do volume, you can’t do it as well as when you don’t do volume. And midwives generally don’t do volume; they’ll take three or four (homebirth midwives I’m talking about), maybe five births a month. And you can spend much more time with these people. And then they understand the things that we talked about, like, y’know, your labor may go this way, or it may go that way. Or you may rupture your membranes, you may not rupture your membranes. You may see blood, you may not see blood. These sorts of things! And then you’re well-prepared and then you’re not nervous. And it gets back to the whole mammalian thing: when you’re nervous, it doesn’t work well and you end up getting intervened upon. It’s a self-fulfilling prophecy, the medical model.
And I didn’t know that! And you asked me very early on, by the way, how I ended up doing what I’m doing, and it was not intentional, of course not! I came out of med— a residency training program— thinking that I knew everything and that, y’know, I was hot shit. And I was really good at what I did, but I was very much in the medical model.
And so I started backing midwives. I was approached early in my career to be a backup doctor. And I started hanging with midwives and going to some of their meetings. And it was… it wasn’t altruistic. It was a selfish thing. I wanted to build my practice. And I figured that this was just another way to build my practice.
I also did free clinics, things like that, because in those days it was different than now, where people come out of residency now and they want to get a salary, they wanna work a shift. When I came out you hustled, you hung your shingle, you built your practice. And so I worked with a lot of midwives.
I started going to midwife meetings and peer reviews and gatherings. And I began to see things in a different way. And then when I wanted to continue practicing the way I was taught to practice, like breech and VBAC, and the hospitals I’d been working at began banning those things. And I worked with midwives in a collaborative practice and we had really good outcomes. And then the hospital— and the anesthesia department and the pediatric department and the OB department— didn’t like the fact that we were using midwives, for very selfish reasons on their part. They began to ban the midwives from working there. And then they stopped me from doing breech delivery and then they banned VBAC. And it really, as an individual, it’s very difficult to fight a large institution. You almost always lose. And it takes a lot of… it takes a big toll on you both financially, emotionally.
Adriana: So, how did you make it work? I’m more thinking of— I’m not gonna ask specifics of your financials— but how can other physicians make it work as well?
Dr. Stu: Well, the only way that another physician can make it work is if they really desire to learn these skills and if they feel comfortable with birth. And in today’s world, most residents coming out are not feeling comfortable with birth. And so doing what I’m doing— where you don’t have an anesthesiologist and you don’t have a NICU team standing by— is very uncomfortable for most physicians, most obstetricians. I mean, I’ve tried to recruit a couple of local guys here and, y’know, they’re very, very reluctant to let go of, well, what they consider to be the safety of having these other people standing by, because that’s how they train. It’s all they know.
And again, it requires certain skills that I have, that midwives don’t have, like forceps. And I can go past 42 weeks, which they can’t do here in California. I can do it at 36 weeks, which they can’t do here in California. I— y’know, again, why these laws get passed— is all again about turf and territory and the false argument of “safety.”
I mean, if doctors would only turn their inspection of what’s safe on themselves, we might have improvement in the hospital-based model. I would like to reach out to young doctors and have them come to the midwifery meetings and seminars, but it’s very hard to reach them. It’s very hard to get them to do it.
And you need somebody who’s gonna look at what’s going on right now and say “This isn’t right.” And it’s very hard to do that when you’re a student or a resident.
Adriana: And I feel that we’ve been saying that “This isn’t quite right” for a while now, and things are starting to change— but so slowly, and it’s like that “two steps forward, one step back” cha-cha. I know I’m not… I’m asking a lot of you by saying, like, “What is the answer? How can we do this?”
Dr. Stu: It’s hard, because the evidence is out there supporting what we’re doing, and at least it’s a reasonable option, right? There may be articles that say homebirth is unsafe and there are articles that say hospital birth has higher c-section rates and maternal mortality, and there are articles on both sides.
There’s enough evidence out there to say that ultimately whatever decision the hospital wants to make, or the doctor wants to make, the decision doesn’t belong to them. The decision belongs to the pregnant woman, who’s well-informed, and our obligation is to inform them well and then support their decision. And if we could all skip back to the basic ethical thing and not be so worried about economics and expediency and medical legal concerns, our whole country would be better off.
I mean, pregnancy affects every family. Everybody in the country knows somebody who’s pregnant. And yet, as you said earlier, it’s so distorted— the world that they see about pregnancy is so distorted. Y’know, it’s sensationalism. Sensationalism sells, and unfortunately birth has been— like everything else— has been sensationalized. And it really doesn’t have to be. It really doesn’t have to be. People need to educate themselves!
And y’know, when you’re 80 years old, you may not even remember your wedding, but you’re gonna remember the birth of your children. And a lot of people don’t have very good memories of that.
Adriana: It just makes a difference on how you go forth into parenting, on how confident you are about bringing up your child, I mean, and I think it does affect more things!
Dr. Stu: Of course it does, Adriana. The medical model does not take into account the psychology of a woman. It does not. Y’know, their model is, “Well, we got a healthy mom and a healthy baby.” If I hear that one more time, I’m gonna slap somebody, alright? There’s much more to it. There’s much more to it than that. If anyone has ever gone to an ICAN meeting— International Cesarean Awareness Network— you know what I’m talking about. And you have women there that are scarred, probably for life, because they felt that they were cheated. They felt they weren’t given an opportunity. They were induced for no reason. They were allowed to labor long enough. You know, they ended up with a cesarean that was probably unnecessary. I mean, here’s a glaring statistic, alright: if we just round things around, there’s 4 million births a year in the United States and we have one-third of those women getting a cesarean section, okay? That’s about 1.4 million cesarean sections. If the World Health Organization says that the c-section rate should be about 10 to 15%— and I think that that’s probably reasonable, so let’s just say 15%— that means that of the 32% of women that are getting sectioned, 17% (or over half of them!) are being sectioned unnecessarily.
So we’re talking about 7- or 800,000 unnecessary surgeries being done every year, and no one raises a peep about that! You know, if there are 800,000 unnecessary gallbladder surgeries or knee surgeries or hip replacements, people’d be pissed about it… it’s crickets. It’s crickets.
Adriana: Yeah. And it’s— I mean, that would launch us into another hour of talking of, y’know, birth as a human rights issue and why don’t we care, or people are not, y’know, outraged and everybody up in arms about 800,000 unnecessary surgeries!
Dr. Stu: Yeah, I think, I think women should understand that their body was designed to do this. It is very unlikely that you’ll grow a baby inside of you that will not get out. If you make it the term, you’re otherwise healthy— we’re not talking about women who develop severe problems like severe preeclampsia or gestational diabetes or preterm labor— we’re talking about normal women that make it to term, the 85 to 90% of women. Your body is designed to do this.
If you’re confident and comfortable with that information, likelihood that things are going to work out fine. And when you allow labor to go naturally, you rarely, rarely, rarely see the sudden deterioration that you see on television or in the movies. Babies at home! People always wonder, “Well, what happens if something goes wrong at home?” but when you’re not meddling at home and you’re not on Pitocin and epidural and immobilized and such, babies won’t suddenly deteriorate.
It’s extremely rare. And babies will give you information. And the mothers will give you information in labor— by the words they’re saying, the sounds they’re making, the heart rates, the things that we can listen to that tell you that things are okay. And if they’re not, then you need interventions, but you don’t need interventions to get you a good outcome. A matter of fact, it’s an oxymoron.
And that’s what I would tell pregnant women, is to “Trust your body is designed to do this.” It’s a normal function that does not require thinking. As a matter of fact, thinking gets in the way— it’s a primitive brain function. It’s a primitive brain function, like breathing or digesting, as we talked about earlier. When you start thinking too much, labor becomes dysfunctional.
Adriana: Yeah, you gotta get primal! But before you get primal, know you have options, inform yourself and trust the process— ’cause you don’t wonder if you, like, “Are you breathing right? Are you pooping right?”
Dr. Stu: Yeah, it’s hard. It’s hard to get primal in an institution which is constantly interrupting you. It’s asking you to sign consent forms about surgery and death, and what they call “advanced directives,” what should happen to you if this… That, I mean, nobody wants to come in in labor, and then they’re asking you questions about, like, “How many stairs do you have in your house?” By the way, the questionnaire that you’re asked when you come into a hospital generally for labor is the same questionnaire if you were coming in to have your appendix out. There’s no difference.
Dr. Stu: Yeah. They ask you, y’know, “When did you last eat?” What did you know… “How many stairs do you have in your house?” y’know, “What jewelry do you have on?” What, I mean, what difference does that make? You’re coming in for a normal function. Why do you care how many stairs I have in my house?
Adriana: Well, they’re thinking ahead for possible, y’know, surgery— it’s like a surgery questionnaire, right?
Dr. Stu: That’s exactly right. That’s what it is. And by the way, with electronic medical records, they can’t get to the next page until they ask you these questions. So they have to ask you all these questions and you’re… and it’s not like you’re coming there, sitting in a chair. You’re contracting every three minutes and they’re asking you these silly questions!
There’s a disconnect between what you’re there for and what and their policies. So don’t show up until late. That’s what I’m telling you. And if they say you have to fill out this questionnaire, just say, “I’m not doing it. I’m not doing it. Take care of me.” By law, the hospital can’t make you sign any documents. They can’t make you answer any questions. They have to take care of you, alright? Now, if it’s convenient for you to cooperate, fine. But if you’re in the throes of labor, tell them to, like, leave you alone! “Just leave me alone, we’ll deal with that afterwards.” Don’t be a pushover. You get to control the situation. Contrary to what you’re taught— be a shepherd, not a sheep.
Adriana: Yeah, at the end, we can’t change the system that quick, as quick as we’d like… but then people have to take it into their own hands.
Dr. Stu: Yeah. I mean, the system is changing. It’s just that it probably won’t change fast enough for people like you and me in our lifetime to see a significant change. And what ultimately I would love to see is an alternative to the hospital for normal birthing, whether it be birthing centers or something of that nature.
Look what surgery centers did to the hospital. They forced hospitals with their gargantuan bureaucracy to become more efficient, to compete with these surgery centers where people are getting surgery, where if you have a nine o’clock surgery, it starts at nine o’clock. It doesn’t start at 10 minutes after 10, which is what happens all the time to doctors at hospitals. It was very inconvenient. It was very… It was the only show in town. And the thing that will change— make hospitals and everybody else change for the better— would be competition. The problem of course, is that most states are lobbied by these big industries to keep things the status quo. And they make it difficult.
That’s why in states like Oregon and California, they have crazy laws restricting what midwives can and cannot do. Why do they have that? They’ll use the guise of safety, but it isn’t about safety at all. If you wanna be safe in medicine, you need to revise what’s going on in the hospital. Hospitals are not safe. There. I said it, okay?
Dr. Stu: They’re not safe.
Everything has risk, right? Not necessarily lots of risk. Everything has risk. There’s risk to homebirth. There’s risk to midwives. There’s risk to doctors. There’s risk to hospitals. Each person has to weigh the risks to themselves. But the idea that VBAC is a procedure and VBAC requires a special skill, don’t fall for that. People will often lump, “Well, I don’t do breech, twins, or VBACs.” Well, breech and twins I can understand, you don’t have the skill, but VBAC a is the absence of doing anything. Don’t let someone fool you into thinking that a VBAC is actually a procedure! The VBAC is absence of procedure. It’s allowing a woman to deliver vaginally after a cesarean. And that means the best thing that you can do. And the one thing that… another thing that doctors don’t do well, and that’s the ability to do nothing. It’s a skill we don’t have. And that I had to learn. It’s very difficult for me sometimes to sit and do nothing, but I’ve gotten much better at it.
Adriana: Yeah, be more and do less.
Dr. Stu: What is it? Knit more and do less…? What?
Adriana: Be more and do less!
Dr. Stu: Yeah, one of the midwives told me that I should learn knitting, because that’s the best way to do that.
Adriana: Yes! Sit in the corner knitting!
Dr. Stu: Yes.
Adriana: Fabulous. Stu, thank you so much for this lovely talk and all that great information.
Dr. Stu: You’re welcome, Adriana. Thank you for what you’re doing!
That was Dr. Stu Fischbein, who has been practicing obstetrics since 1986. Dr. Stu still actively cares for pregnant people in community birth settings and he travels far and wide teaching hands-on seminars on breech birth. He also offers one-on-one consultations for anyone around the world, including annual all-access memberships via phone and email. You can find Dr. Stu on Instagram @birthinginstincts or listen to his podcast called Birthing Instincts.
And you can connect with us @birthfulpodcast on Instagram.
In fact, if you are not driving, please go ahead and take a screenshot of this episode right now and post it to Instagram with your biggest takeaway from the episode. Make sure to tag @birthfulpodcast so we can see it and amplify it.
You can find the in-depth show notes and transcript of this episode at birthful.com, where you can also learn more about my birth and postpartum preparation classes and download your free postpartum preparation plan.
Birthful is created and produced by me, Adriana Lozada, with production assistance from Aysia Platte.
Thank you so much very much for listening to and sharing Birthful. Be sure to follow us on Goodpods, Spotify, Apple Podcasts, Amazon Music, and everywhere you listen.
Come back for more ways to inform your intuition.
Lozada, Adriana, host. “What You Need to Know About Obstetricians (OBs).” Birthful, Birthful. October 5, 2022. Birthful.com.
About Dr. Stuart James Fischbein
Stuart James Fischbein, M.D. was Board Certified in 1989 and became a Fellow of the American College of Obstetricians and Gynecologists in 1990. He has been a practicing obstetrician in Southern California since completing his residency in 1986. While well-trained at Cedars-Sinai Medical Center in the standard medical model of obstetrics, he had the respect and vision to support the midwifery model of care and served as a backup consultant to many home and birthing center midwives for 25 years. In 1996 he founded The Woman’s Place for Health, Inc., a collaborative hospital-based practice of Certified Nurse-Midwives and Obstetricians in Ventura County, California.
In 2004, Dr. Fischbein co-authored the book Fearless Pregnancy, Wisdom & Reassurance from a Doctor, a Midwife and a Mom. For his efforts, he has been awarded the Doulas Association of Southern California (DASC) Physician of the year award three times and, in 2008, was the very first recipient of DASC’s lifetime achievement award in support of pregnant people. He has spoken internationally on breech and vaginal birth after cesarean, and has appeared in many documentaries, including: “More Business of Being Born”, “Happy Healthy Child”, “Reducing Infant Mortality”, “Heads Up: The Disappearing Art of Vaginal Breech Delivery” and multiple YouTube videos discussing birth choices and respect for patient autonomy and decision-making.
Dr. Fischbein currently practices community-based birthing and works directly with homebirth midwives to offer hope for those who prefer and respect a natural birthing environment and cannot find supportive practitioners for VBAC, twin and breech deliveries. He is an outspoken advocate of informed decision-making, the midwifery model of care, and human rights in childbirth, having received the 2016 “Most Audacious” award from HRIC and the Association for Wholistic & Newborn Health. Hear more of his thoughts and advocacy for evidenced-based, reasonable choices on his podcast.
Dr. Fischbein still actively cares for birthing people while teaching hands-on seminars on breech birth around the globe. He has the goals of improving collaboration amongst the differing professions in the birthing world and the re-teaching of the core skills, such as breech and twin vaginal birth, that make the specialty of obstetrics unique. He now offers annual all-access to him as a resource via phone and email, or for one-time inquiries and hour-long Zoom consults.
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