Note: there is follow-up to this post with a response from Dr. Paul Burcher. You can read it here.
Obstetrician Paul Burcher has a column called The Ethical ObGyn at ObGyn.net in which he instructs his fellow OBs, “Don’t Dread the Birth Plan.” The best thing I can say about it is that not everything he says in this column is offensive.
He starts off citing Frank Chervenak and Laurence McCullough’s concept of “preventive ethics.” For those of you not familiar with Chervenak, he is an OB, an expert in ultrasonography, and an anti-homebirth crusader. He is perhaps most famous among homebirth supporters for a clinical opinion he published in AJOG in which he discussed midwife-supported homebirth in terms of “recrudescence” (which basically means resurgence or revival, except it tends to refer to something really bad, like guerilla warfare). Chervenak also presented an anti-homebirth screed in the IOM Birth Settings Workshop in the Spring of 2013 in which he used vital records (birth certificate) data to make the case that homebirth led to a an enormous increase in stillbirth. The statistician representing the National Center for Vital Statistics, Marian MacDorman, responded after his presentation that vital records were not a reliable source for making such claims, but he went on to publish the data anyway. He also wrote the following in response to the ACOG Committee Opinion against homebirth (which he did not feel went far enough):
Obstetricians have an ethical obligation to disclose the increased risks of perinatal and neonatal mortality and morbidity from planned home birth in the context of American healthcare and should recommend against it. Obstetricians should recommend hospital-based delivery and respond to refusal of these recommendations with respectful persuasion.
Note that he is not suggesting that there be a full explanation of the benefit-risk analysis, a shared decision making process, or a consideration of the woman’s values. There should just be information (that has been questioned by numerous experts) that neonatal mortality increases (and as I have posted before, even with the increase cited by Chervenak, the absolute risk of such a grim outcome is very, very small). In other words, women should make the choice that he deems to be ethical. At the time he wrote this recommendation, the hospital where he practices had one of the highest cesarean rates in New York.
But back to Burcher. Burcher makes a private assessment of birth plans, dividing maternal requests into “of course,” “probably,” and “nonstarter.” He suggests beginning by placating women with the “of course” items, such as not shaving because the hospital never does that anyway (do any hospitals still do routine shaves? Even 20 years ago in the middle-of-nowhere hospital where I delivered, it never came up).
Regarding the “nonstarters,” his approach is reasonably respectful. he suggests asking the woman about why she made the request and seeing if it can be fully or partially accommodated in some other way. For instance, if a woman planning a VBAC wants to avoid continuous electronic fetal monitoring, but it is not the monitoring she objects to, but rather the restriction of movement, telemetric monitoring could work. While I still think that women should have the ultimate choice about what is done to their bodies, I also understand that outside forces on physicians could jeopardize their careers if they agreed to processes that went against hospital or practice guidelines. However, that does not mean that a woman cannot refuse against medical advice (AMA), and if she does, her wishes should be respected. He does not address this very important ethical issue.
This biggest issue I have with Burcher are the “maybes.” First of all, if it’s a maybe, it seems like what it should really be is “yes.” If it is possible, and the woman wants it, what is the debate? Of course, he is referring to the possibility of complications that would tip a “maybe” to a “nonstarter”–however, he indicates that this is already the case with the “of courses”:
I always tell my patients that my comfort zones may be different than the limits that my partners may have, so I cannot guarantee that the decisions made during prenatal care will all be carried out during labor. As circumstances change, so may our determinations of what is safe and appropriate.
This strikes me as bait and switch. I read stories from so many women saying that their provider said s/he would support a VBAC, only to insert so many caveats along the way (you must go into spontaneous labor by x date, you must consent to y while in labor, you must deliver in z way) that their support for VBAC revealed itself to be a sham. So what he is saying is that he cannot guarantee that he will attend the birth, and if one of his partners is there, what has already been determined by him to be perfectly acceptable might be outside the other practitioner’s “comfort zone,” and therefore the agreed-upon birth plan would be meaningless. I don’t understand why the doctor’s comfort zone is under consideration, as he is not birthing the baby. How does the new doctor get the woman to change her informed consent? By telling her that Dr. Burcher misinformed her?
The woman must have the autonomy to make the final decisions regarding her own care even if the doctor would personally make a different choice. That is ethical, and that is the point that Dr. Burcher (and many of his colleagues) seems to miss.