Dr. Biter wants money

Dr. Biter has resurfaced and he's asking for money:

Dr. Biter has resigned from Scripps Encinitas with full OB, gynecological & surgical privileges! At this time, he still has the ability to do full inpatient & outpatient gynecological care & see patients for prenatal visits with a plan for individualized care...

Sure he got his privileges back ... as a condition of his immediate resignation. Who benefited from this? Dr. Biter, of course, by avoiding a Board of Medicine investigation into the events leading up to the suspension of privileges including the 6 pending malpractice suits.

The great man has a message for his supporters:

I am happy to say that I still am able to do 100% of my gynecological practice (see below for a complete list). As far as my OB practice goes, my staff & I are currently arranging the schedule only for pregnant women at this time. In many OB practices, a doctor sees a patient at some visits and a stranger delivers. You know that I do not practice that way. Everything that I have done has kept you, my patients, as first priority. This has cost me hospital privileges that I rightfully won back, a lot of money, and even more nights of lost sleep. I don't know what to say to reassure you other than that. My commitment to you has never been up in the air. My refusal to allow your birth to be a political or financial deal has put me into this unwanted situation, but you and your baby are worth it. Ours is a huge trust of faith....keep the faith. Birth matters.

In other words, Dr. Biter has not been able to get privileges at any hospital. Possibly, Dr. Biter can no longer practice obstetrics at all, because his malpractice carrier refuses to cover him (OB and GYN coverage are separate) or is demanding an exorbitant fee since he has 6 pending lawsuits.

Dr. Biter details the services he will provide:

Full prenatal care with individualized delivery plans available

Gynecological Services:

1. Annual Pap Smear

2. Sexually Transmitted Disease Screening and Treatment

3. Breast Health

4. Treatment of Abnormal Pap Smears Including: Leep, Colposcopy, and Biopsies

5. Minimally Invasive Hysterectomies

6. Hysteroscopies to Evaluate Uterine Lining or Polyps

7. Adolescent Health

8. Ultrasounds for Pain, Abnormal Bleeding, and/or Ovarian Screening

9. Prenatal Ultrasounds for Home Birthers

10. Rectal Prolapse Reconstruction

11. Pelvic Prolapse Reconstruction

12. Vaginal Support Reconstruction

13. 3D/4D Ultrasounds

14. Surgical and Non-surgical Treatment of Abnormal Bleeding

15. Surgical and Non-surgical Treatment of Urinary Incontinence

Gynecological surgeries will be performed by Dr. Biter at Carlsbad Surgery Center located at ...

Simply put, Dr. Biter offers prenatal visits, but cannot deliver your baby. He also offers routine GYN care and minor surgeries that can be performed at a surgi-center, but no major surgery.

But Dr. Biter wants your money. He wants it so badly that he hasn't even bothered to set up a tax free foundation before asking for it. He wants it so badly that you must send it directly to his bank account.

Help us keep the dream of Babies by the Sea Birthing Center and its mission alive and well. Here is how you can help:

1. Use the DONATE NOW PayPal link on this website to make donations to the Birthing Center Fund. At the present time this fund is not tax deductible. Dr. Biter is not managing this account. Any monies spent must be approved by an independent Board of Directors. A 2.9% charge will be taken out of the donation if credit cards or debit cards are used on PayPal.

2. If you prefer to send checks please make payable to Robert Biter, MD and send to ...

3. Deposits can also be made at any Chase Bank location. The account number is ...

No one should be fooled; the chances that this birth center will open are slim since Dr. Biter must obtain obstetric privileges at a hospital and he must obtain obstetric malpractice insurance. If you donate money, Dr. Biter will be free to keep it whether he ever opens the birth center or not.

Dr. Biter, you should be ashamed. You have made fools of these women by encouraging them to protest on your behalf while withholding information about your malpractice history. Now you are trying to get these women to donate their money to YOU (you haven't set up a tax free foundation) and there is a very real chance that you will never practice obstetrics in California again.

Man dies of uterine cancer; who's to blame?

May you never be an interesting case.

That's a cautionary proverb familiar to medical professionals. While it's bad to get sick, it's much worse to get sick with something uncommon or unusual. The more fascinating a case is for doctors, the more difficult it is for patients. Difficult to diagnose, difficult to treat, and often difficult to survive.

Kenneth Liew was doubly unfortunate. He was an interesting medical case and an interesting legal case. Now he's dead and a jury is currently deliberating who, if anyone, is at fault.

Kenneth Liew was really, really unlucky. He was unlucky because he had serious kidney disease that necessitated debilitating dialysis treatments three times each week. He was unlucky because it took 10 years for a matching kidney to be found to give him in transplant. He was unlucky because after he received his kidney and after it was working well, an autopsy revealed that the kidney came from a woman who, though she died of a stroke, had unknowingly had uterine cancer as well. He was unlucky because there is not a single case like his in the whole world, so no one knew the odds that the cancer would be transmitted. He was unlucky because he died of cancer only seven months after receiving the transplant.

Despite being exhorted by her dying husband to forgive the doctor, Mr. Liew's widow ignored his wishes and sued just about everyone she could think of including the doctor and New York University Medical Center where the transplant occurred. Eight years after Mr. Liew died, the jury has finally received the case.

First and foremost, this case has been a nightmare for Mr. Liew and his family. But secondarily, this case also represents a doctor's worst nightmare. The doctor, transplant surgeon Thomas Diflo, lost a patient through a freak accident that no one could have known about or predicted and now he's being blamed. I would feel sympathy for the doctor no matter what, but I am especially saddened because the doctor was one of my classmates in medical school.

Mrs. Liew is sure that somebody is to blame for something and that she deserves $3 million dollars in compensation, but it is not clear who is to blame or what they are to blame for:

·         Did anyone know of the donor's uterine cancer? Both sides agree that no one knew or could have known that the donor had uterine cancer.
·         Was the patient informed that the donor had cancer? Both sides agree that the transplant surgeon informed the donor approximately 2 months after the he received the kidney.
·         Should the kidney have been removed immediately thereafter? Both sides acknowledge that there was no way to predict the chances of Mr. Liew developing metastatic uterine cancer. There had literally never been a similar case in the history of medicine. Therefore, the doctor left the decision up to the patient, advising him that based upon what is known about transplants and cancer and based upon the fact that uterine cancer does not metastasize to the kidney, the chance that Mr. Liew would develop metastatic uterine cancer was low. Mr. Liew's widow argues that the doctor should have advised that the kidney be removed immediately.
·         Would removal of the kidney have made any difference? It's unlikely. Whatever was transmitted to Mr. Liew from the donor kidney had already been transmitted.
·         What caused Mr. Liew's death? That's not clear. Mr. Liew died of cancer, but the metastatic cancer was so poorly differentiated that no one can tell what type of organ it came from originally. It could have been uterine cancer transmitted by the kidney, but it also could have been cancer that developed spontaneously in Mr. Liew.
So if no one could have known about the uterine cancer in advance, if removing the kidney would not have made a difference and if it is not completely clear what kind of cancer killed Mr. Liew, why are Dr. Diflo and NYU being sued? They are being sued because something bad happened and someone must be blamed. It wasn't anyone's fault; no one did anything wrong, but you can't get any compensation for bad luck. Therefore someone, anyone, must be blamed and must be made to pay.

The jury has the case now, and within a few days we will find out if they agree.

Is there any reason to delay cord clamping?

A new study being widely reported in the mainstream media has recommended delayed cord clamping. However, the authors acknowledge that there is no scientific evidence that delayed cord clamping provides any benefits for term infants; their recommendation is based on pure speculation.

The paper entitled Mankind's first natural stem cell transplant appears in the Stem Cell Review Series of the Journal of Cellular and Molecular Medicine. The authors of the paper include the founder and chairman of Saneron CCEL Therapeutics, Inc. a company that harvests stem cells from umbilical cord blood to use in developing new treatments for neurodegenerative and other diseases. It appears that the primary purpose of the paper is to demonstrate that cord blood collection for banking or research does not require immediate clamping of the umbilical cord.

The authors acknowledge that there is no demonstrated benefit to delayed cord clamping in term infants. While some studies show a reduced incidence of anemia in the first 6 months of life, this is only clinically important in developing countries where anemia is common in infants and children. The authors focus instead on potential benefits of transferring additional stem cells from the umbilical cord blood to the baby's bloodstream.

The authors make much of the fact that delayed cord clamping leads to the baby's "first stem cell transplant."

... autologous transplantation of stem cells naturally occurs in nature at birth in mammals via the umbilical cord. A delay in the cord blood clamping may increase the stem cell supply to the baby, thereby allowing an innate stem cell therapy that can promote acute benefits in the case of neonatal disease, as well as long-term benefits against age-related diseases....

Yet the authors don't provide any reason why a term baby has any need of or derives any benefit from a stem cell transplant. There is no scientific evidence that early cord clamping leads to a deficit of stem cells in the neonate or that delayed cord clamping has any impact on any neonatal system dependent on stem cells. The purported benefits are all entirely theoretical.

As any doctor knows, the history of medicine is littered with ideas that seemed to be great in theory, but surprisingly turned out to be dangerous in fact. Consider the use of 100% oxygen in the first incubators of the 1930's. Reasoning that if some oxygen is good, more must be better, premature infants having difficulty breathing were treated with pure oxygen. It may have been better from a respiratory point of view, but it unexpectedly rendered many of the infants blind. That's because the sensitive tissues of the retina develop best in a low oxygen environment, but no one knew this until they learned of the damage that resulted from exposure to 100% oxygen.

The reasoning behind delayed cord clamping is the same: adequate red blood cells are good, more must be better; adequate umbilical stem cells are good, more must be better. But we really don't know whether either of those claims are true. As the authors acknowledge:

One important point to consider is the long-term effects of delayed cord clamping. The present authors are unaware of any studies in either animals or human beings that followed the organism to adulthood. In human beings the longest studies go to 6–7 months and some benefits can still be observed with respect to iron status and motor disability. It is crucial to perform long-term follow-up studies to determine whether the reported benefits of delayed cord clamping are long term, or whether additional benefits may become apparent.

It never even occurs to the authors to investigate whether there might be harms from delayed cord clamping. After all, some umbilical cord blood is good, more must be better, right? Wrong. Without studying the matter we have no idea of the long term benefits or risks. It is irresponsible to recommend delayed clamping as the standard until we have scientific evidence that it provides benefits without leading to unexpected harms.

Why do natural childbirth advocates participate in their own humiliation?

Over the last few years, the public has been treated to the spectacle of prominent politicians facing serious allegations staging photo ops with a supportive wife at their side, such as the one of the former New Jersey governor and his wife above. And at many such photo ops, the wife is acting as enabler. She stands at the politician's side implying that she believes his denial (of an affair or a visit to a prostitute or similar behavior) even though she knows or ought to know that he is not telling the whole truth.

Perhaps she truly doesn't know; or maybe she knows but believes she is saving the marriage; or maybe she knows but is as invested in saving the political career as he is. In any case, she is an enabler in her own humiliation, standing before the public and pretending that the fact that she was betrayed is untrue or irrelevant, as if her feelings don't matter, as if her job is to support her husband right or wrong.

Evidently that phenomenon is not restricted to marriages. NCB advocates seems to have no trouble standing by the side of the various "Dr. Wonderfuls" supporting them as if their deeds don't matter, and as if it the job of the "little woman" to always support the man.

Witness Rixa Freeze's outrageous claim after learning that Dr. Stuart Fischbein had been convicted of sexual exploitation of a patient (in the comments section of Another Dr. Wonderful needs your help!):

Regarding the controversy about the consensual sex issue: I see it as irrelevant to the issue at hand. Dr. F's regrettable mistake in the past is being used as classic ad hominem and red herring arguments. It's a way of distracting people away from the real issue at hand (women's right to choose VBAC or vaginal breech birth, and physician's right to support them in those choices) by attacking Dr. F's character.

The conviction of sexual exploitation of a patient is irrelevant when determining whether other women should support this doctor? Only if you believe that turning a blind eye is an appropriate stance.

Barb Herrera, Navelgazing Midwife, has just written an astounding post that sets a new standard in enabling a "Dr. Wonderful". You can read the piece here. Barb acknowledges that Dr. Biter is currently facing 6 malpractice lawsuits; she confirms that Dr. Biter was reinstated only so that he could resign and avoid the consequences of a suspension; she glosses over the fact that Dr. Biter, her friend and colleague, never bothered to tell her about those lawsuits or the truth about the reasons for his suspension; she proudly declares that Dr. Biter is giving his approval to what she writes on his behalf. And then ... she ignores that information in order to continue to support the man that just abetted her public humiliation.

Several days ago, Barb wrote a long post in support of Dr. Biter which alleged a giant hospital conspiracy to get rid of Dr. Biter because he is "unconventional" and "non-conforming" in his support of natural childbirth. Barb had absolutely no idea whether her claims were true; she provided no facts to support her claims and obviously she was unaware of the actual facts of the case. In light of the information she has learned in the last few days, Barb now writes ... EXACTLY THE SAME THING.

Oh, wait, not exactly the same thing. Yes she repeats the unsubstantiated claims of an elaborate conspiracy to remove Dr. Biter, but now she includes the deal apparently struck by Dr. Biter so that he could avoid further investigation and blames ... THE HOSPITAL. Barb twists herself into a pretzel to generate this mind boggling conclusion:

... If Dr. Biter did something egregious... something dangerous... why didn't Scripps Encinitas revoke his privileges and throw him to the dogs (the Medical Board)? In fact, it's been brought up that Scripps Encinitas is named in four of the six Biter lawsuits out there (and remember, a suit does not infer guilt!) and if Scripps Encinitas' lawyers felt that Dr. Biter was negligent, isn't it negligent of them to "let him go?" It is because of this that I believe he did nothing illegal or outright dangerous, but that they had a philosophical (and financial?!) issue with his being there...

So let me see if I get this straight: the hospital is "negligent" if it let Dr. Biter weasel out of a more thorough investigation of his competence to practice obstetrics. But the hospital couldn't be "negligent" so that must mean that Dr. Biter is competent and his suspension was a giant conspiracy to punish his practice style.

Barb starts with a fixed conclusion and fabricates backward from there. The fixed conclusion is that her Dr. Wonderful is worthy of her adulation, and anything else is unthinkable. Dr. Biter couldn't have struck a deal to escape further investigation because ... well because he just couldn't have done so. Yes, he let her speak on his behalf without warning her that there were critical facts that she didn't know, but that's okay. The facts are irrelevant when the great man needs support.

Barb ends with another dollop of the gushing adulation that she's been displaying all along:

He's thanking me for my support, letting me know I am saying the right things, defending him appropriately and reminding me of the variation in the standards of care between providers while remaining within ACOG Guidelines. Dr. Biter is hardly alone, this Doctor-as-Renegade persona.

If that's not enabling, I don't know what is.

Do Dr. Biter's charities actually exist?

Dr. Robert Biter, an obstetrician at Scripps-Encinitas, recently resigned within hours of having his OB privileges restored, thereby avoiding a Board of Medicine investigation into his practice. Dr. Biter has been less than forthcoming about the circumstances surrounding his suspension (he failed to inform his supporters about the 6 pending lawsuits that have been filed against him in the past 5 years). In investigating Dr. Biter's background, I have come across repeated mentions of the charities that he has started.

Dr. Biter's boutique, Babies by the Sea, proudly claim to donate revenue to two charitable organizations:

Babies by the Sea Boutique will donate a portion of net revenue to non-profit organizations developed by Dr. Robert Biter called Her Hearts Wish and Seaside Giving. Her Heart's Wish is a national organization dedicated to granting the wishes of women facing terminal illness. Seaside Giving provides medical care to pregnant women who cannot afford medical services.

Over the years, Dr. Biter repeatedly mentioned his involvement in Her Heart's Wish such as in this 2005 profile of Dr. Biter by San Diego Magazine:

Six years ago, Biter was completing his residency at Penn State Hershey Medical Center when he met Beth, a young mother dying of ovarian cancer. After coming to terms with her condition, Beth expressed two final wishes: to bake cookies with her children one last time and take a weekend trip with her husband. Biter mobilized other residents and nurses to make Beth’s wishes a reality just days before her death. But before she died, Beth revealed another wish: for other terminally ill women to enjoy the same opportunity to fulfill one last desire of the heart.

In 1999, Biter founded Her Heart’s Wish, a charitable organization that has granted hundreds of wishes in nearly all 50 states...

As far as I can determine, neither of Dr. Biter's charities currently exist.

Her Heart's Wish was a Pennsylvania non-profit organization that granted wishes to dying women. It was established in 1999 and is officially located in Hershey, PA. It maintained a website and was mentioned in a variety of print and web publications. Dr. Biter may have been a founder, but according to the patient Beth's husband, HE founded the organization:

Shortly after Beth’s passing, Jim rolled up his sleeves and spent the next two years creating an organization that would grant last wishes to other women. Navigating his way through the difficult legal and tax aspects involved in establishing a non-profit organization, he never gave up. Finally, in 2001, he launched Her Heart’s Wish, which in the following years has grown from a regional to a national wish-giving organization for women over 18.

The website went off line in late 2008 and the charity appears to exist no longer. Nonetheless, Dr. Biter continues to solicit donations for Her Heart's Wish now located at a residential address in Encinitas, CA.

How about Seaside Giving? As far as I can determine from public records, there is no charitable organization registered in California under the name Seaside Giving and there has never been such an organization. There is no website, no list of beneficiaries, indeed no mention of it anywhere except on Dr. Biter's own website.

It appears that Dr. Biter is soliciting funds for two charities that don't exist. Of course,I'm not expert in researching charitable organizations, and it is possible that I overlooked sources of information. So I would welcome everyone's help in finding information that would demonstrate that Dr. Biter's charities are real, and are dispersing funds to needy individuals.

Dr. Biter reinstated, resigns and thereby avoids investigation by medical board

Dr. Robert Biter, known to his supporters as "Dr. Wonderful," has voluntarily resigned his privileges at Scripps Encinitas Hospital two weeks after the hospital initially suspended him.

According to the San Diego Union-Tribune:

Less than a day after officials at Scripps Memorial Hospital Encinitas reinstated baby delivering privileges to Dr. Robert Biter, the natural birthing method advocate voluntarily resigned from the staff late Friday afternoon, hospital officials said.

The turn of events capped off a standoff between Biter and the hospital’s medical staff that had lasted for two weeks and had generated daily protests by his supporters in front of the Encinitas medical center.

Scripps officials suspended Biter’s obstetrics privileges on May 7 without offering a public explanation for the action. They left his gynecological privileges in place.

The doctor also declined to say why he was disciplined.

It may seem confusing, but it actually makes perfect sense.

Apparently, there was never any chance of Dr. Biter continuing to practice at Scripps Encinitas. The hospital is bound by confidentiality agreements and cannot reveal the allegations, but it is likely that the 6 pending lawsuits filed within the last 5 years had something to do with it. That is an extraordinary number of lawsuits for an entire 40 year career, let alone the first decade of practice.

But Dr. Biter was able to negotiate something other than the worst possible outcome for himself. By law, the hospital was required to notify the Board of Medicine within 15 days if his privileges were suspended or revoked, automatically triggering an investigation by the board that could lead to the loss of Dr. Biter's license. However, he managed to avoid that investigation by promising to voluntarily resign if his privileges were reinstated.

It's a win for the hospital, because they have successfully severed their relationship with Dr. Biter. Obviously it does not protect the hospital from the lawsuits that have already been filed, but it ensures that the hospital will face no further liability. It is a win for Dr. Biter, because he has avoided the most serious possible consequence of the allegations, an investigation that could lead to the permanent loss of his license to practice medicine.

It is emphatically not a win for the women of California. Because of the deal struck between Dr. Biter and the hospital, all the allegations remain confidential. A hospital has severed its relationship with a doctor because it considers him a serious liability, but it has released him to set up shop elsewhere and continue doing whatever got him into trouble in the first place.

Dr. Wonderful???

The supporters of Dr. Robert Biter, the San Diego obstetrician whose privileges have been suspended by Scripps Encinitas can't seem to figure out why this has happened. They ought to check the public records of the San Diego Superior Court website. Evidently Dr. Biter has been sued 6 times in the past 5 years! That must be some sort of record, especially when you consider that he has only been in practice since 2001.

For perspective, consider that almost all obstetrician are sued once in their career and many are sued twice, but being sued three times or more is far less common. Scripps Encinitas has been named as a co-defendant in 4 of 6 lawsuits including 2 lawsuits filed within the past 5 months. It's hardly surprising that the hospital has taken the opportunity to review Dr. Biter's status as an obstetrician at their hospital.

Correction: a previous version of this post reported 7 lawsuits. There appear to be only 6 lawsuits with one listed twice in the public record.

Natural childbirth and the cult of the male obstetrician

Can you still be Dr. Wonderful if you are engaged in inappropriate physical contact with patients? Evidently you can. Dr. Stuart Fischbein is still receiving the support of natural childbirth advocates even after being convicted of sexual exploitation of a patient. Now another "Dr. Wonderful" is facing disciplinary action and natural childbirth advocates have rushed to his defense without knowing the accusations.

Dr. Robert Biter, the "Dr. Wonderful" who worked with Barb Herrera (Navelgazing Midwife) has had his obstetric privileges at Scripps Encinitas suspended. Natural childbirth advocates have held marches, begun a letter writing campaign, and have blogged in support of Dr. Biter, all without having any idea of the charges against him.

Now Barb Herrera comes to his aid, and with friends like that, you don't need enemies. Barb, a personal friend of Dr. Biter's, believes she knows what is going on. You can read her post So, What's the Deal with Dr. Wonderful? for yourselves, but the message I took away from it is that Dr. Biter has been accused of:

1. Failing to be available when his patients need him.

2. Repeatedly violating hospital policies and placing the hospital and its staff at risk of malpractice claims. Barb has written elsewhere that Dr. Biter confided to her that he expected to lose his privileges. That suggests that he was warned and placed on probation, but ignored the warnings.

3. Most disturbing, Dr. Biter has been accused of inappropriate physical contact with patients.

Now you or I might consider inappropriate physical contact utterly incompatible with being "Dr. Wonderful." Natural childbirth advocates don't see things the same way. Their heroes can do no wrong. Barb actually goes so far as to justify Dr. Biter's alleged behavior with classic sexist excuses:

A common [comment] was that he was too chummy, too huggy. His physical kindness is a hallmark in Dr. Biter’s care and is welcomed by those that adore him. I’d almost forgotten the snarky things people had to say about how he hugged them too much until a Biter Rally attendant ran into a couple of RNs that alluded to the reason behind his expulsion was because he was too "friendly" with his patients and their families. When she mentioned it on-line, the topic quickly blossomed into "I noticed his affection for his clients in the photos you took," and "At first I was taken aback by how he touched the women in the pictures." Upon examination, we were able to see the sexism in the equation, that if he were a female OB, it wouldn’t seem out-of-place at all. I countered that I don’t often see female OBs hugging their patients, either. But, I suggested we exchange his male OB-ness for a midwife and the "ah-ha!"s had the picture. It isn’t inappropriate for a care provider to hug a client, it’s just crazy bizarre to see an OB doing it!

In the photo spreads I’ve done, I noticed that I took the pictures because Dr. Biter was doing something so unusual, so beautifully different than every other obstetrician –and many of the midwives- I’ve worked with in my life. I went over the photos again and smiled at the love that man has for life. I look and remember every moment of the births with him. Dr. Biter is so present with his clients. No matter how tired he is, no matter how much he still has to get done, he is there with whomever is in front of him. And women/clients/families feel that kind of adoration. It is returned to him a million-fold.

That's a fairly good compendium of sexist excuses for inappropriate physical contact: She misunderstood. No one would have minded if he were a woman (well, duh!). No one would have minded if he were a midwife. The second and third reasons are really just variations of the first: "Don't worry your pretty little head about it, young lady. It's your fault because you misunderstood."

Why do natural childbirth advocates put certain male obstetricians on a pedestal? The heroes of the natural childbirth movement are all men, but that's probably because there were very few female obstetricians until recently. How can we explain the current tendency of NCB advocates to idolize male obstetricians who share their philosophy? I don't know the answer, but I do know that female obstetricians and midwives are not recipients of the gushing adoration and the willingness to forgive all that are directed toward certain male obstetricians.

I commented on Barb's blog, and of course she refused to post it. [addendum: my commented was posted on 5/19.] I commented on Rixa's blog about her support of Dr. Biter in the absence of any information on the specific allegations. She removed my comment despite the fact that another commenter (an NCB advocate) agrees. That tells me two things: They found my criticism personally embarrassing so they removed it. In addition, they feel compelled to protect Dr. Biter by keeping the truth, or even speculation about the truth, from women.

The problem, though, is much bigger than this episode. NCB advocates need to ask themselves why they have made a cult of the male obstetrician, why they can forgive him anything, and why they respond with sexist putdowns to women who have observed or experienced inappropriate physical contact from certain male obstetricians.

addendum: According to the San Diego Union-Tribune, Dr. Biter has been served with 4 malpractice lawsuits just in the last 13 months. A search of the San Diego County Court webiste shows that there are another 3 lawsuits suits that have been filed between 2005-2008. Scripps Encinitas was named as co-defendant in 4 of the 7 suits including 2 suits filed in the past 5 months.

How vaccine rejectionists hurt the rest of us

Vaccine rejectionism is based on a profound lack of knowledge about immunology, statistics and science. Virtually every single empirical claim of vaccine rejectionism is factually false, but parents who lack even the most basic understanding of immunology are often incapable of evaluating those empirical claims. Indeed, those parents most likely to proclaim themselves "educated" on the topic are generally the most ignorant.

A new paper on a recent measles outbreak, Measles Outbreak in a Highly Vaccinated Population, San Diego, 2008: Role of the Intentionally Undervaccinated, provides insight into the erroneous beliefs eagerly adopted by gullible and credulous parents.

... They reported substantial skepticism of the government, pharmaceutical industry, and medical community. They believed vaccination was unnecessary, because most vaccine preventable diseases had already been reduced to very low risk by improvements in water, sanitation, and hygiene and were best prevented by "natural lifestyles," including prolonged breastfeeding and organic foods. In contrast to the immunity produced by disease, they felt that vaccines could damage the immune system while producing a number of other immediate and long-term adverse health conditions, particularly those involving the child's neurologic system.

The paper highlights yet another false empirical claim of vaccine rejectionism. To the extent that they consider the impact of their actions on others, vaccine rejectionists falsely believe that no others can or will be harmed by their refusal to vaccinate their children. In the San Diego measles outbreak, fully 25% of the children who became ill were too young to be fully vaccinated. In addition, 48 children too young to be fully vaccinated had to be quarantined because of known exposure to an affected child. Although only a small number of children was ultimately affected (12 cases of measles), the total cost of the outbreak was over $175,000 of which $125,000 was born by the taxpayers.

It is instructive to explore the way in which the disease spread:

On January 13, 2008, the 7-year-old male index patient returned from Switzerland, asymptomatic but incubating measles. He transmitted infection to his 9-year-old unvaccinated sister and 3-year-old unvaccinated brother. On January 24, 2008, after 2 days of fever and conjunctivitis, the index patient attended charter school A. Forty-one of the 377 students (11%) at charter school A were unvaccinated for measles because of personal beliefs, and 2 children became infected. The next day ... the index patient was taken to pediatric clinic A ... No respiratory precautions were taken, 6 children were exposed, 5 were unvaccinated, and 4 were infected (3 infants too young for vaccination and a 2-year-old whose parents had intentionally delayed measles vaccination)...

...The index patient's sister infected 2 schoolmates and exposed an unknown number of children at a dance studio. One infected classmate of the index patient infected his own younger brother and exposed 10 children at a pediatric clinic, 18 children and adults at a clinical laboratory, and an unknown number at 2 grocery stores and a circus. Another infected classmate of the index patient exposed an unknown number at an indoor amusement facility. Four secondary patients from clinic A returned to the same clinic while symptomatic on 4 separate days ... thus exposing 37 children. Of these same 4 patients, 1 exposed an additional 95 children in a preschool on 2 consecutive days, 6 patients at an outpatient laboratory, and 47 children at a swimming-instruction facility; the second patient exposed children in the same swimming class; the third patient exposed 55 students in a school and 10 persons at an outpatient laboratory; and the fourth patient potentially exposed 166 passengers on an airplane flight to Hawaii.

Ultimately 73 children, including intentionally unvaccinated children and children too young to be vaccinated, were quarantined for 21 days each because of significant exposure to measles.

The San Diego outbreak was a small exposure in a city with high vaccination rates. Therefore, the outbreak was easily contained. But there would have been no outbreak at all if it weren't for the vaccine rejectionists. The outbreak was brought into the community by an intentionally unvaccinated child and initially spread by other intentionally unvaccinated children. Even though the outbreak was easily contained, one quarter of children who became ill were too young to be vaccinated, and the taxpayers spent $125,000 containing an outbreak that was entirely avoidable.

Vaccine rejectionists don't hurt just their own children, they hurt everyone else's children and they cost the taxpayers large sums of money to contain the results of their gullibility. San Diego ought to present a bill for $125,000 to the parents of the intentionally unvaccinated child who introduced measles into the city. Perhaps compelling vaccine rejectionists to put their money where their mouth is might make them think twice about exposing the rest of us to preventable diseases.

Waterbirth fatalities

Waterbirth has become a central component of "natural" childbirth dogma, despite the fact that for primates giving birth underwater is entirely unnatural. You don't need a medical degree to appreciate the idiocy of birth in water. The most critical task for the newborn is to take its first breath. Inhaling a mouthful of fecally contaminated water instead of air is profoundly dangerous. Not surprisingly, as the popularity of waterbirth has grown, the number of neonatal deaths directly attributable to it has grown as well.

A new paper in the American Journal of Forensic Medical Pathology discusses the tragic case of a term newborn who died of Pseudomonas pneumonia and sepsis as a result of waterbirth. The authors review the existing literature on fatalities associated with waterbirth and the underlying processes leading to neonatal death.

The case report:

A normally formed 42-week gestation male infant was born underwater in a birthing tank to a 29-year-old primigravida mother. The Apgar scores were 9 and 10 at 1 and 5 minutes, respectively. The infant was covered with thick meconium and demonstrated intercostal recession with peripheral cyanosis. He was transferred to hospital where his respiratory status worsened and a chest x-ray demonstrated generalized opacity. Presumed sepsis was treated with broad-spectrum antibiotics. There was no evidence of hyponatremia. Despite maximal therapy he developed respiratory failure with disseminated intravascular coagulation and died at 4 days of age.

... Death was due to extensive P. aeruginosa pneumonia and sepsis associated with meconium aspiration and water birth.

The authors reviewed the literature:

Underwater birth has been promoted as a means of improving the quality of delivery... While the benefits of immersion are said to include increased comfort and relaxation for mother and infant, with greater maternal autonomy, fewer injuries to the birth canal, reduced need for analgesia, with decreased instrumentation and operative intervention, this has been disputed with no clear advantages or disadvantages over conventional births being demonstrated. In addition, other reports of underwater births have documented significant morbidity and even death. Problems have included infections, near drowning/drowning, hyponatremia/water intoxication, seizures, infections, respiratory distress, fevers, hypoxic brain damage, and cord rupture with hemorrhage.

Natural childbirth advocates have a terrible habit of inventing scientific "facts" and waterbirth is a classic example. According to NCB advocates, newborns will not attempt to breathe while immersed in warm water and will wait to take a first breath until they are in direct contact with air. That theory has no basis in neonatal physiology.

It has been postulated that newborns will not breath or swallow while immersed in warm water, and that respiration will only be initiated on exposure to cold air. This has been used to support assertions that drowning and aspiration of water cannot occur with underwater delivery. However, animal studies have demonstrated that this reflex can be over-ridden, and given that respiratory movements occur in utero, it is difficult to see why this process would not continue in a neonate delivered into water. The documentation of cases of near drowning and respiratory distress with apparent aspiration of fluid would also be supportive of the occurrence of breathing under water. In addition, the finding of hyponatremia in certain of these infants would be in keeping with inhalation of fresh water, as lowered sodium levels have resulted from fresh water drowning.

It is ironic that NCB advocates, the self appointed guardians of "physiologic birth" would embrace a practice that is profoundly non-physiologic. Not surprisingly, the consequences can be devastating. Neonates can and do inhale copious amounts of fecally contaminated water during waterbirth. Indeed, they have been found to inhale such large quantities of water that the water dilutes the concentration of sodium in the bloodstream to fatally low levels (hyponatremia). Even small amounts of inhaled water can introduce significant amounts of bacteria into the neonatal lungs leading to pneumonia and other infections as the authors explain:

Sepsis has also arisen from underwater deliveries, ranging from umbilical and ear infections to septicemia and pneumonia. The source of such infections has been contamination of birthing tubs, hoses, and taps with virulent organisms such as P. aeruginosa and Klebsiella pneumoniae. These bacteria have been found despite careful cleaning of systems between deliveries. Lethal Legionella infection has occurred in an underwater birth reported from Japan and other organisms such as amoeba and Mycobacterium avium have been found in spa baths...

The bottom line is that waterbirth kills babies.

As the death of a newborn from entirely preventable factors is of great concern, parents who elect to have an underwater delivery must be appraised of the risks that characterize an aquatic birth, and should have access to resuscitation equipment to enable rapid suctioning of the airway.

The avoidable tragedies of waterbirth cast a harsh light on the fundamental weakness of "natural" childbirth philosophy. "Natural" childbirth advocates pick and choose desired elements of "natural" birth without regard to whether those elements are truly natural. Despite the claims of NCB advocates that their philosophy is "evidence based," they routinely ignore scientific evidence and make recommendations without ever performing safety testing on those recommendations. Moreover, they are not above fabricating scientific "facts" to bolster claims that have no scientific support. Finally, and most egregiously, babies die as a result of their "advice" and they don't know and apparently don't care.

A psychoanalytic theory of mothering

In the ongoing battle known as the mommy wars, participants tend to treat different styles of mothering as interchangeable choices. The assumption is that a woman chooses to adopt attachment parenting, or chooses to value work outside the home. Hence the arguments often boil down to identifying which women are making the best "choice."

In a thought provoking chapter of a new book, Parenthood and Mental Health: A Bridge between Infant and Adult Psychiatry, (Tyano et al., 2010 John Wiley & Sons, Ltd), Joan Raphael-Leff, of the Faculty for Psychoanalytic Research, UCL/Anna Freud Centre in London, proposes that women approach mothering with specific psychological orientations. She divides these orientations into four different groups: facilitators, regulators, recipricators and conflicted. I'm intrigued with the idea that mothering style reflects specific psychological orientations and I find her descriptions spot on.

According to Raphael-Leff, the different orientations to mothering manifest themselves during pregnancy. She concentrates in particular on facilitators and regulators.

The facilitator:

… treats pregnancy as the culmination of her feminine experience. Throwing herself wholeheartedly into the process, she dons maternity clothes early, ‘communes’ with her baby, reveling in the special attention. She plans as natural a birth as possible, wishing to minimize the traumatic ‘caesura’ that will reunite her with her familiar baby.

The regulator views pregnancy as:

… an unavoidable means of getting a … baby. She resents being treated as an 'incubator', prey to comments by strangers. Childbirth is imagined as a dreaded, exhausting and painful event to be mitigated by medical intervention… Their elevated incidence of elected Caesarean sections indicates preference for predictability and a way of bypassing the potentially humiliating experience of vaginal birth.

Not surprisingly, a woman's psychoanalytic orientation has a profound impact on her mothering.

For facilitators:

Enveloped in the maternal body, the infant rediscovers mother’s voice, her wake/sleep rhythms, cadences of breathing and kinetic patterns of stillness and movement. Some experiences are new: the feel and fit of mother’s fleshy contours, the taste of breast milk and odours of her breath, armpit, vaginal excretions, her bodily warmth, unmuffled immediacy and differing smooth silkiness/rough edges of her caress . . .

Feeling mothering is her vocation, the Facilitator mother adapts herself to her baby, convinced that only she, the biological mother primed by pregnancy, can fathom her infant's needs. Hence as exclusive carer, she maintains close bodily contact, treating every gurgle as a communication that must be responded to.

Whereas regulators believe:

… mothering is a 'learned skill', acquirable by others. Since to her neonates do not discriminate between people, she introduces co-carers early on, establishing a routine which reduces unpredictability, provides continuity between nurturers, and differentiates between 'valid' crying and ignorable 'noise'. Hence, proximity is not an issue. The main goal is to ‘socialize’ the asocial, presocial or even antisocial infant and regulate his or her desires. To this end the baby must adapt to the household regime.

Inevitably, different orientations lead to different views of work outside the home.

… To maintain their self esteem, Regulators need to engage meaningfully with adults outside the home, whereas Facilitators dread separation from the baby. Wishing to provide full-time exclusive care, they return to work reluctantly of economic necessity or job stipulations. Conversely, Regulators resent economic dependence, and the slow 'mommy-track' which penalizes career advancement and salary growth.

Mothers of both psychoanalytic orientations experience distress when mothering does not go according to plan.

… [A] Facilitator mother experiences 'primary maternal preoccupation' … before and during the months following childbirth. Her identity becomes primarily that of a mother. Holding a distinct mothering philosophy, she strives towards her maternal ideal of devotion, suspending her subjectivity by adapting to the baby, intuitively facilitating, holding and dedicating herself in unconscious identification with both maternal ideal and vicariously gratified baby-self… Facilitating mothers feel devastated if unable to breastfeed. Desperation over minor lapses of maternal perfection induces irreparable guilt, remorse and anxious over-involvement. Self-reproach for 'ruining' the ideal may escalate to depression, hopelessness and, in extreme cases, even suicide.

In contrast, regulators may feel:

… 'primary maternal persecution'. In-depth exploration of their subjective experience boils down to feeling trapped. If the sense of exploitation persists, feeling undermined, and at the mercy of a potentially greedy/spiteful infant, hostility must be managed. Most Regulator mothers do this efficiently. More breastfeed today than in the past – health-education stresses both infantile immunity and maternal benefits … Intake is regulated by schedule, and feeding bottles are introduced early to ensure shared care. This allows the mother to replenish herself by spending time in an enriching social world, protecting her from risks of ruptured defences and/or surrendering to 'sentimentality'.

What I find most compelling in Raphael-Leff's analysis is the idea that different styles of mothering are not "choices" and do not reflect specific philosophies. Rather, different styles of mothering reflect the different psychological needs of the mother. If that is the case, the mommy wars are worse than pointless, because there is no "right" way to mother. There is only the ongoing effort by mothers to balance their psychological needs against the needs of their children.

Attachment parenting does not reflect the needs of the child; it reflects the needs of the mother. Natural childbirth, exclusive breastfeeding, the family bed are not objectively "better" for babies and are neither feminist nor rebellious. They are comforting and satisfying to women who have a particular psychological orientation to attachment.

Similarly, rejection of natural childbirth or exclusive breastfeeding is not "selfish" or unwomanly. It is the best way for women who have a deep and real need for regular involvement in the world of work and who would feel trapped by attachment parenting.

Taking a woman's psychological orientation into account is not a radical idea. We do not expect all marriages to be the same and we do not expect all friendships to be the same. We understand that these relationships only succeed when they meet the particular psychological needs of the participants.

There is no basis for believing that there is only one way to conduct the mother-child relationship. While it is critically important that the relationship meet the psychological needs of the developing child, a successful mother-child relationship should also meet the psychological needs of the mother. And since mothers differ in their psychological needs, we should anticipate and celebrate many permutations of successful mother-child relationships.

In case you thought I was exaggerating NCB self-righteousness

I've written a series of posts over the past several weeks that point out what is wrong with the factual and philosophical claims of the "natural" childbirth movement. Several commenters have suggested that I have exaggerated the dogmatism and self-righteousness of NCB activists.

Fortunately, the Unnecessarean has reprinted a post from NCB activist Rachel that helpfully demonstrates the ignorance, self-righteousness and pathetic immaturity of NCB activists. Just consider the following quotes.

There’s a disturbing trend in feminist discourse that goes something like this:

... * the advocacy groups go a bit too far in their encouragement of the better/healthier practices and women begin to feel that their choices are now being curtailed in the opposite direction
* a backlash ensues in which we seem to feel that we have to deny the often well-documented and undeniable benefits of this thing the advocacy groups are fighting for.

Hence you see feminists denying that breastmilk is nutritionally better than formula, or that births with fewer medical interventions are, generally speaking, safer for mothers and babies. And this puts us in a really strange and irrational position, because we're having to deny facts that are well-established through mountains of research.

No, Rachel, you seem to have missed the key point. There are NOT mountains of research that prove NCB claims. There is some research that is equivocal and contradicted by lots of other research. Indeed, what feminists are pointing out is that the very claim that breastfeeding and NCB are superior is NOT supported by the scientific evidence. Rather, those unsupported claims are being used to force women into a specific philosophic vision of motherhood.

I've been told that by merely noting that natural childbirth was an empowering experience for me I'm oppressing women for whom natural childbirth was not an option. And I’m sorry, but that's bullshit, and that silences me and delegitimizes my experience.

No, Rachel, it's not bullshit. The rest of us call it "being polite." Your claim makes about as much sense (and reflects the same level of immaturity) as whining that people shouldn't feel bad when you repeatedly announce that your children are the smartest and the best. The rest of us don't need to know that you think your children are better than ours, no matter how fervently you believe it. Similarly, the rest of us don't need to know that you think your birth experience was better than ours. To paraphrase the immortal words of Mad Magazine: "If we wanted your unsolicited opinion, we'd ask for it."

"While I was pregnant I did a ton of research ..."

No, you didn't Rachel. You read tons of propaganda and because you can't tell the difference between propaganda and research, you pretend that it is research. Did you read Williams Obstetrics? Did you read the top 100 or so scientific papers in obstetrics? If not, you haven't done research. Reading Henci Goer on childbirth is like reading Eric Carle on very hungry caterpillars. It's pleasant; it's fun; but it's not research.

My decision was based on the fact that, all other things being equal, natural childbirth is healthier for the mother and the baby than any of the other options. This is a non-normative, purely descriptive, well-documented fact.

Wrong again, Rachel. Why? Because "all other things" are not equal. Because emergencies in childbirth are common, not rare. Because childbirth is, in every time, place and culture a leading cause of death of young women and the leading cause of death of children.

And for me, personally, taking the natural route was also a defiant act of standing up to the bullying and the smirking and the micromanaging and the distrust of women's bodies that’s so prevalent in the medical industry. It was me saying “Fuck you and your patriarchal fucking attitude toward my body and my mental toughness and my instinctive knowledge of how to birth my own fucking baby.”

See, that's the immaturity I have been talking about. You think that risking your baby's life is an act of defiance. It's difficult to imagine anything more selfish, self-serving and childish than putting your baby's life on the line to make a point.

And I took on natural childbirth, which was tough and painful and stressful and one of the hardest things I've ever done, and I fucking kicked its ass, and it was an incredibly empowering experience.

Well, then you've got to get out more, Rachel, and rack up some actual achievements. You're proud of yourself because you did what any woman in the world could do if she felt like it? Are you proud of yourself because you did what your dog could do? Did you consider it an achievement for your dog when she gave birth without intervention? If it's not an achievement for your dog, why on earth is it an achievement for you?

You "kicked its ass." I've got news for you Rachel. Labor is not a person; it is a bodily function that happens without your control. Do you routinely kick digestion's ass, too? How about urination? Are you proud of yourself when those things happen without intervention?

But my point is that silencing people when they talk about the flaws of our overly-medicalized, patriarchal approach to childbirth or about their personal experience of natural childbirth is not the answer.

Sorry, Rachel, but you cannot justify your desire to proclaim your superiority as striking a blow against the patriarchy. If the patriarchy is paying attention, it is laughing at your ignorance and immaturity. You are not promoting the cause of feminism. Indeed by insisting that there is one "right" way to be a mother and a woman, you are actively working against feminism, which exists to provide women opportunities to go far beyond any single view of motherhood or womanhood.

Rachel, you're just another insecure NCB activist, with limited education, and limited professional success. You're trying to feel better about yourself by pretending that reading propaganda is "research", performing bodily functions is an "achievement", and ignoring medical advice is "defiance." And you're being obnoxious in the process.

addendum: Apparently it isn't enough for Jill at the Unnecessarean to remove comments that she doesn't like. In a sign that she's really afraid, she's now trying to block my access to the website (which, of course, is easy to get around). The claims that she and her guests make are obviously so indefensible, even to Jill, that she wants to keep me from reading them and exposing them for the falsehoods that they are.

All that's wrong with midwifery in two sentences

The folks over at the Journal of Midwifery and Women's Health have a problem. They are obsessed with labeling birth. They are absolutely, positively certain that their view of birth is THE TRUTH, and want to give their view an adjective that proclaims to everyone (most especially themselves) that their view is the safest, best, healthiest way to have a baby. First they called it "natural" birth as if everyone who deviated from their prescription were somehow having artificial births or producing plastic babies.

In addition "natural" birth is a problematic description because the philosophy of "natural" childbirth bears absolutely no resemblance to childbirth in nature. Last I checked, childbirth in nature did not involve prenatal visits, blood pressure checks, periodic weighing. It also didn't involve intermittent fetal monitoring, kiddie pools and neonatal resuscitation.

So midwives invented a new description used only by them and their acolytes: "normal" birth. But as Holly Powell Kennedy recognizes in an editorial in this month's issue, calling their view of "normal" implies that anyone who doesn't do it their way is abnormal.

... It is a word that dichotomizes—if you are not "normal," then you must be abnormal, atypical, disordered, unhealthy, or irregular—and who wants those labels?

This issue doesn't present much of problem for most of us. Normal birth is pretty simple: the baby that was once inside is now outside, and most importantly, the baby is healthy. That's all there is to "normal" birth for most women. But that's unacceptable to midwives like Kennedy, who in the tradition of birth activists, is obsessed with the process and considers the outcome almost irrelevant.

I propose that "normal" is commonly used by midwives as a way to describe a process that counters the common and escalating interventions in many birth settings. A more fitting term might be "physiologic"— that which reflects the innate capacity of a woman’s body to reproduce without intervention—and which most women would be able to achieve when left alone to find their strength, and supported as needed in the process.

There you have it: everything that is wrong with contemporary midwifery wrapped up in two somewhat clumsy sentences. Why is this sentence appalling? Let me count the ways.

1. "commonly used by midwives"

The definition that counts is the one that midwives select. There are no objective criteria.

2. "counters"

The correct views of midwives are oppositional. Whatever is common in current obstetrical practice is to be opposed. Do common practices save lives? Who cares? It's about the process, not the outcome.

3. "innate capacity"

What is that supposed to mean? Every woman has the "innate capacity" to get pregnant, but that doesn't mean that she can. Every women has the "innate capacity" to carry a pregnancy to term but that doesn't prevent miscarriage. Every woman has the "innate capacity" to have a vaginal delivery, but that doesn't mean that the baby will fit or that the baby will live through the process.

4. "reproduce without intervention"

Ahh, there's that obsession with process again. And what's wrong with interventions anyway? It's as if Kennedy and other midwives oppose any interventions on the principle that they are inherently bad. No attempt is made to discern if the interventions are helpful or even if they are requested by a woman herself.

5. "most woman would be able to achieve"

Would the baby be alive at the end of this achievement? Would the mother be alive? Kennedy doesn't say. It's the process that counts, not the outcome.

6. "strength"

Oh, please, please stop the bullshit! Strength? Birth has precisely NOTHING to do with strength, either physical or spiritual. It depends on three things: the pelvis, the passenger (the baby) and the power (strength of uterine contractions). If the pelvis is too small, the baby won't fit, and all the "strength" in the world won't make a whit of difference. If the baby is too big, won't fit and all the "strength" in the world is useless. If the uterine contractions are not forceful enough, the baby won't come out and both mother and baby will die in the process, and, you guessed it, strength is irrelevant.

The stupidity doesn't end there.

I suggest that our culture has situated childbirth fully in risk ...

How sad for all those women and babies buried in graveyards around the world. They didn't die because of the risks of childbirth. They were tricked!

Fear of birth has become the foundation of childbearing in US culture. We do not usually fear things that are normal ...

Last I heard, most people fear death and there's nothing more normal than death. Childbirth is one of the top 10 causes of death of young women in EVERY time, place and culture, including our own. Out of the 18 years of childhood, the day with the highest risk of death is the day of birth. Stop pretending that women fear birth and acknowledge reality: women fear that they or their babies could die and that fear is completely justified.

We live in ... a culture that deifies technology and control, with no room for uncertainty of any kind or for less than perfect outcomes.

Yes, we live in a culture where we don't like to wonder whether our babies will live or die and we certainly don't like them to die or be rendered brain damaged. Evidently people like Kennedy, for whom the process is more important than the outcome, are willingly to risk "less than perfect outcomes" so they can brag out their "normal" births.

The problem here is not birth, it is midwives. This piece unwittingly reveals the profoundly unscientific, biased and self aggrandizing nature of contemporary midwifery. Midwifery is obsessed with labeling women, dividing them into those who give birth following the preapproved directives and those who do not. Midwifery is obsessed with insulting women who do not adhere to its principles. The language used, words like "natural" and "normal," is deliberately and profoundly judgmental. Midwifery is obsessed with process; the outcome is virtually irrelevant and never even mentioned in the editorial. Midwifery is based on opinion, not science; in the entire editorial scientific evidence is not mentioned even once.

Midwives have appointed themselves arbiters of birth. They define, they judge, they pontificate. They are mean and they are wrong.