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Despite the fact that we all go through it, birth remains a fraught topic. Everyone, it seems, has an opinion on the ideal place, position and method of childbirth, and those views can be unshakable.
Into this prickly arena steps Dr. Neel Shah, an obstetrician at Beth Israel Deaconess Medical Center in Boston and assistant professor at Harvard Medical School. In a smart, nuanced and provocative opinion piece in the current New England Journal of Medicine on the cultural and systemic differences between giving birth in the United Kingdom compared to the United States, Shah suggests what might seem like heresy to some in his field: "The majority of women with straightforward pregnancies," he writes, "may be better off in the United Kingdom."
Why write about this now? The U.K.'s National Institute for Health and Care Excellence (NICE) recently issued new guidelines saying that healthy women with uncomplicated, low-risk pregnancies are "safer giving birth at home or in a midwife-led unit than in a hospital under the supervision of an obstetrician." When the recommendations came out, Shah notes, "eyebrows went up. The New York Times editorial board (and others) wondered 'Are midwives safer than doctors.' How can hospitals be safer than homes?"
Before you, too, reject Shah's conclusion out of hand, consider the careful thinking behind it and the larger context, which is that one in three births are now carried out by cesarean section — major abdominal surgery — and that C-sections are the most commonly performed surgery on the planet. But Shah's argument focuses more on the vastly different medical cultures involved: "At its core," he writes, "this debate is not about the superiority of midwives over doctors or hospitals over homes. It is about treatment intensity and when enough is enough. Nearly all Americans are currently born in settings that are essentially intensive care units: labor floors have multi-paneled telemetry monitors, medications that require minute-by-minute titration, and some of the highest staffing ratios in the hospital. Most labor floors are more intensive than other ICUs in that they contain their own operating rooms. Surely, every birth does not require an ICU."
I asked Shah to lay out the key points of his piece. Here they are, edited:
RZ: Why do you conclude that it may be safer for women to give birth in the U.K. rather than the U.S.?
NS: I think the biggest takeaway from this piece is that there are harms from doing too much just like there are harms from doing not enough and that's a big paradigm shift in U.S. health care. Childbirth is one of the biggest illustrations of that: We err on the side of overdoing it and for the healthy majority, we end up causing a lot of harm from overdoing it in the interest of making it safe for the high-risk minority.
People think that C-sections are like a rip cord — they are if you are truly at risk. But if you are low-risk, C-sections have a lot of bad consequences. Major complications such as hemorrhage, severe infection and organ injury are three times as likely to occur with cesarean deliveries as they are with vaginal deliveries. But even more fundamentally: you could go home with a 12-centimeter incision with a newborn or you could go home without a 12-centimeter incision and a newborn....moms are resilient so they just deal with it but that has a major impact.
What are some of the systemic differences delivering a baby at home in the U.K. and the U.S.?
Here's the difference: In the U.S. if you're trying to have a baby at home and you're looking for some help, you'd have a hard time finding someone more than a lay midwife to come to your house. If something becomes complicated with your delivery — which happens, unexpected things happen — it would be hard to get a qualified, skilled birth attendant to deliver the baby at home. So instead, they'd want to bring you to another facility and what often happens is it's the 11th hour when the complication is flagged and recognized, and an ambulance comes crashing into your driveway in an emergency kind of way, and they ask you 'Where do you want to go?' and the ambulance will bring you to the hospital and the the hospital will say 'Who are you?' and it's something that causes tension in the relationship between the patient and the doctor.
In the U.K., the National Health Service sends a qualified midwife to your home, a credentialed person, and they give you one on one care. That's huge and there are clear protocols for when something bad happens, so it doesn't get managed at the 11th hour. In the U.K. there's an up front triaging system for figuring out if you are high risk or low risk, and if you need to be transferred to the hospital there's a much clearer system, a plan for when you'd go and where you would go, and what would happen. Having a plan for where to go is a big part of the story. We don't have a coordinated system of care here. Fifty percent of U.S. counties don't have a single midwife or OB to take care of women — we think everyone has to give birth at a big expensive hospital.
As a result of their system, the midwives and physicians are used to working much more closely together in the U.K. Even at a unit in the hospital run by doctors, the midwives have a bigger role, and they take care of low risk patients and the docs do the cesarean deliveries. They are used to working together. Here doctors and midwives don't always work well together.
Why are the cultures so radically different?
It's really the difference in comfort with physician-led birth compared to midwife-led birth. Obstetricians, who are trained to use scalpels and are surrounded by operating rooms, are much more likely than midwives to pick up those scalpels and use them. OBs are hard wired to operate, we're surgeons. You can either either try to rewire the OB, or avoid the OB unless you really need one. The U.K. seems to have decided that rewiring the OB is too hard, but that's what we're trying to do in the U.S. with interventions like quality measurement and payment reform.
How might the new guidelines change childbirth practices in the U.K. and will it spill over into the U.S.?
You have four choices in the U.K.: You can have a baby at home, at a midwife-led birth center, at a midwife-led birth center as part of a hospital, or in a hospital labor unit run by an OB. Nine out of 10 women currently give birth in a hospital but British officials think that number will drop. Since the guidelines just came out it will take some time to know if this is the case.
I don't expect many U.S. obstetricians to embrace birth outside the hospital — particularly given the systematic gaps in access to safe, coordinated care we talked about. But my reading of the U.K. doctors is that there's no revolution going on. Even now, for first-time mothers in particular [in the U.K.], the risk of delivering a baby with a serious medical problem is two to three times as high at home as it is in a hospital. As a result, 45 percent of British first-time mothers who intend to give birth at home ultimately get transferred to a hospital obstetrical unit during the course of labor. Still, NICE presents home birth as a reasonable, preference-sensitive option and emphasizes the risks of over-intervention in hospitals. By contrast, ACOG (the influential U.S. association of obstetricians and gynecologists) strongly emphasizes the risks of under-intervention and states unequivocally that "hospitals and birthing centers are the safest setting for birth."
When I learned that nearly half of first-time mothers wanting a home birth in the U.K. get transferred to a hospital, I thought of it as a failure. But because of the established protocols and coordinated care, I think it's a sign of success, that they transfer successfully with good outcomes.
What's the overall message here about childbirth and safety?
For the last 20 years in health care, we've made patients safer by doing more things. This issue of treatment intensity is different, it's trying to figure out how to do fewer things. Most pregnant women are young, healthy people and yet we've come to a point where one in three women have major abdominal surgery to give birth. Between 1970 and 2010, the C-section rate has gone up 500 percent and it's the most common surgery performed on human beings. It's hard to believe that's all truly necessary. And the consequences are pretty severe — 20,000 avoidable complications to young healthy people every year, at a cost of $5 billion.
I think the most important thing pregnant women in the U.S. should realize is that there's this expectation that doing more is better than doing less, but childbirth is a case where sometimes doing less is the best thing.
As a U.S. obstetrician, I went from thinking the U.K is nuts to thinking how can we make it safe and convenient to have babies in low intensity settings, including at home. It has totally turned around for me.
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