Romans 12.2: “Do not be conformed to this world, but be transformed by the renewing of your minds, so that you may discern what is the will of God — what is good and acceptable and perfect.”
This past August, I was fortunate to spend a week shadowing a true luminary in our modern birth world. Stuart Fischbein, MD, FACOG has decades of experience as a an obstetrician in the Los Angeles area, produces “Dr. Stu’s Podcast,” travels the world to teach his trade, and most notably to me, supports and attends out of hospital (OOH) births — whenever it is a reasonable option — as well as vaginal breech birth, vaginal birth after cesarean (VBAC), and operative vaginal deliveries, such as vacuum and forceps assisted births for those rare circumstances in which they’re necessary. In an age when it is not uncommon to find obstetricians with an over 50% cesarean rate, at least in south Florida, it is refreshing to know that there is at least one American doctor who not only is keeping alive options for birthing families, but passionately advocating for their rights.
I was drawn to his practice from the first time I heard of him, a few years ago when he was interviewed in toLabor’s toRaise podcast (an excellent resource for doulas or anyone interested in becoming a doula). More recently I was reminded of him by Indie Birth Association, in which Dr. Fischbein teaches midwifery skills, after a journey of discovery and prayer that followed the fantastic, accidental “indie birth” of my youngest child. All the joy and healing I felt from that birth opened my heart and mind to a new calling — to widen my impact and move into a more clinical role. I spent months researching midwifery programs, intrigued and enamored with the midwifery model of care, but unsettled by the thought that I would, someday when a family’s situation became complicated, have to turn over my care of a client to a doctor. I never found peace with this fact, until I realized I could be that doctor! Why not? Besides, then I would enjoy the privilege of supporting all the midwives I love when their OOH birthing clients occasionally have a need for transfer of care.
So, I quietly enrolled in a local university’s post-baccalaureate pre-med program. Although I felt sure that this was the correct next step in my life, I was not yet brave enough to tell the world about this crazy scheme. I was only brave enough to tell my husband and Dr. Fischbein, who warmly welcomed me to shadow him. (By the way, this blog post is my first public announcement of my intentions).
With my excitement for birth work and my curiosity for medicine in tow, I flew out to meet my role model and didn’t waste a second of my time with him. Over the week I spent with him, I was permitted to view gynecological procedures, observe diagnoses under the microscope, watch ultrasound scans, attend a postpartum house call, attend a prenatal home visit, sit through a consultation with a breech family, hang out with his awesome midwifery student, Blyss, meet Elliot Berlin,* watch films from births he attended, witness much of the behind the scenes office work (pharmacy calls, texting lab results to clients, and emailing with listeners of the podcast as well as his co-author on a piece researching vaginal breech OOH births), and ask many questions about his work both at the office and while sitting in the famous LA traffic. By the end, I wanted to do all of it (except the LA traffic)!
I learned so much in this week! There is much more that I learned than I can reasonably share here, and primarily, I learned that I have much more to learn. However, I will share the following insights, and how they have affected me:
Back when Dr. Fischbein was in medical school, how many lectures do you think there were on lactation? If you guessed zero, you would be correct. This is helpful for me to know, as a breastfeeding mother trying to navigate a world that is trying to be breastfeeding friendly, but ultimately still has so many cultural and informational barriers to overcome. In fact, learning this has prodded me to work towards earning the IBCLC credential, as a stepping stone prior to med school application. I’ll post updates here on my progress (all I can share now is that I’m taking an anatomy class this semester to complete my academic requirements).
Next observation: today, the majority of OBGYNs who are emerging from residency opt to work in large practices that employ call schedules, which limit a mom’s chance of experiencing a strong sense of rapport with the provider who attends her birth, and minimizes continuity of care throughout her pregnancy, birth, and postpartum period. This is, of course, convenient for the doctor who just wants to start earning a paycheck without having to be an entrepreneur, and who wants to quickly repay med school debt, and who prefers the predictability of a schedule not defined by unpredictable pregnant people. These desires are compounded by the fact that the majority of today’s new OBGYNs are females, who tend in their residency and post-residency years to become mothers themselves. Frequently, the OBGYN/mother switches from OBGYN to mere gynecology after only a few years of the work. Keep in mind: obstetricians have a high burnout rate, are sued an average of three times in their careers, and, considering they were in medical school during their dating years, have a decent chance of being married to a mate who can provide financially for the post-residency family, should they choose to reduce their work responsibilities and work fewer hours. All of these new norms (and many others I haven’t even mentioned) define the maternity care system we have in our country today. Is it any wonder that, in such a situation, we have a shortage of doctors?
To discuss these matters openly goes against some of the feminist agenda, but I do have to admit, I would never be angry at a female doctor for wanting to honor the precious time of her children being infants, toddlers, and young children. In fact, I have blogged before about my own tug of war between work and motherhood, and how much peace I have found to allow myself to be patient with my career in this season of life. Going slow for this season does not make me less ambitious; it just means I understand how time-sensitive and important the needs are of children. Medicine is a calling, for sure, but it certainly does not need to negate the calling to mother. As far as how this adversely affects maternity care, I’m grateful to have this topic planted as a seed in my mind now, and definitely will be investigating the subject more.
In contrast to the newer OBGYNs, Dr, Fischbein uses a solo practitioner approach (although he shares some employees and office space with other OBGYNs). As a solo practitioner, he helms his own ship. This means he gets to choose to accept self-pay patients, and thereby skip the electronic medical record keeping system that is legally bound to insurance, and which has been shown to decrease face to face interaction between patients and their providers. Styling his practice after the midwifery model, Dr. Fischbein calls the pregnant women who enter his clinic “clients” instead of “patients,” because from his perspective, pregnancy is not pathology. In their appointments, Dr. Fischbein spends a solid hour, or more sometimes, getting to really know the families, build rapport, and importantly, cover all of the information needed for truly informed consent. As an example, he is quick to point out that naysayers of VBAC and vaginal breech birth overemphasize relative risk, while dismissing absolute risks. Effectively, they are creating the illusion that vaginal birth in theses scenarios is quite dangerous, when actually, it is safe enough to be considered a decent choice. Moreover, he says, those advocating a more medical management of birth also tend to dismiss the risks of the cesarean sections themselves, which can have particularly detrimental repercussions for women interested in subsequent pregnancies. As a result, women who may otherwise feel badgered or even bullied over their birth plans can, in Fischbein’s office, feel safe and respected.
However, I did become very aware of the fact that not every moment in Fischbein’s work is full of sunshine and roses. It was particularly sobering to me to witness Dr. Fischein determine a baby’s intrauterine growth restriction (IUGR) that potentially could have lead to fetal demise. With no fetal growth from the previous appointment, and a worsening environment for the baby noted on ultrasound, Dr. Fischbein made the judgment that this baby would be healthier outside the womb than inside. He told the parents they needed to go to the hospital to be induced if they still wanted a chance of VBAC.
Knowing very personally the joy that I got out of birthing my last child at home, after two hospital births, I had been so excited for the family to also have a healing home birth experience. I felt broken by their disappointment over their home no longer being a reasonable location for birth, and broken over how the mom must have felt to learn that her body had apparently failed her. Fortunately, Dr. Fischbein did come up with as many options for them as he could, under the circumstances, and they did still end up with a VBAC, and more importantly, a healthy (though tiny) baby. Nevertheless, it was important for me to see that I would not, as an obstetrician, be able to give every family the birth of their dreams. A more naive part of me imagined that, in a clinical role, rather than doula role, I would better be able to ensure women receive the experiences they are hoping for.
So by now you see a mom-of-three doula who was naive and too scared to even tell people her own plans for her life. Some doctor that girl would be, right? Thankfully, God’s not finished with me. The most frightening insight from my week with Dr. Fischbein was, perhaps surprisingly, the one which compels me most to persevere in this journey. This insight, which is not news for anyone involved in the care of pregnant women, is that there is a culture war in the maternity care system. To join the ranks of the few obstetricians who attend OOH births and support VBAC as well as breech and twin vaginal births, would undoubtedly put me in the minority. If I am to stand for ethics and support the choices of my clients whenever they are reasonable, I unfortunately may risk making enemies, battling hospitals, and being lonely. I am only irresistibly drawn to do this work anyway because I do, very much, want to “be the change” that I long to see in the childbearing landscape. After the wonderfully transforming care and experiences I’ve been given, I must pay it forward. When in my presence Dr. Fischbein listened to or read the disempowering, ethically questionable, and sometimes traumatic experiences that his clients and podcast followers were subjected to by their previous care providers, I felt entangled in their stories. What imprint their stories make in my life, and the lives of anyone in my future sphere of influence, is yet to be determined. I just hope that there will be some redeeming factor.
The good news is that there is enough inspiration and comfort to motivate me as I move forward. As I reflect on the work of Dr. Fischbein, I know that whatever I face, he and others have been through, too. I don’t have to fit the mold of the typical mom, typical pre-med student, or typical doctor. I know, from laboring with my own children, that love is more powerful and enabling than fear, and that patience is a virtue. Every contraction in birth and every challenge in school or life is an opportunity to respond with faith, courage, and perseverance to God’s calling in my life.
In summation, it was a good week. I learned a lot. Hopefully you learned a little just reading this, too, and, hopefully you believe it. I sadly was so “in the moment” the whole week that I never thought to ask if anyone could take a picture of me with “Dr. Stu.” for evidence. However, he did take pictures of me, my husband, and my baby with actor Stanley the Giraffe, who lives on the same ranch as the doctor’s horses. I’m posting one below, since it’s what I’ve got, and since it was a fun memory. Maybe missing a photo with him will be my excuse to return in the future. Mainly, though, I’d like to go back to learn more. Few doctors, as far as I can tell, are teaching the obstetrical skills that Dr. Fischbein has mastered, so I feel blessed that I could be privy to some of his knowledge. Better still, I feel blessed to have come to know someone whose work is carried out with conviction in a world where, at least on the labor and delivery wing, liberty and the pursuit of happiness are sort of forgotten sometimes. But not by all. Thank you, Dr. Stu.
*Dr. Elliot Berlin, DC is a prenatal chiropractor, podcast producer, and documentary maker. His sense of humor and access to pregnant celebrities makes his podcast, The Informed Pregnancy, a hit both for birth workers and everyday parents. His film productions include a youtube series, The Real Midwives of LA, and the documentary Trial of Labor.