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. Continue reading