labor and delivery

RECENT POSTS

OB Talks About Home Birth, Midwives And Re-Engineering U.S. Maternity Care

Dr. Neel Shah (Courtesy)

Dr. Neel Shah (Courtesy)

Just mention the phrase “home birth,” and controversy will surely follow.

One example: a recent opinion piece in the New England Journal of Medicine by Dr. Neel Shah, an obstetrician at Beth Israel Deaconess Medical Center in Boston. In the piece, Shah suggests that for many pregnant women, giving birth in the U.K. — with its streamlined system of midwives and greater acceptance of births in the home — may be better than the high-intervention childbirth system that dominate U.S. labor wards.

Shah wrote the piece in response to the release of new guidelines from the U.K.’s National Institute for Health and Care Excellence (NICE), recommending healthy women with low-risk pregnancies opt for home or midwife-led births. Shah’s conclusion? “The majority of women with straightforward pregnancies may truly be better off in the United Kingdom.” In other words, the intense treatment U.S. obstetricians are trained to provide is unnecessary in many cases.

Dr. Shah continued the conversation on Radio Boston earlier this week. Highlights from the segment include his analysis of why the U.S. and U.K. have such different approaches to childbirth and discussion of the possible movement towards a model more like the U.K. Listen to the segment or read an excerpt below:

Host Meghna Chakrabarti: You also point out in your piece — and we spoke with people in preparing for this conversation — that these are relatively new recommendations, and the vast majority of women in the U.K. as of today still have their babies in hospitals there.

Dr. Neel Shah: They do. So about 90 percent of babies in the UK are born in hospitals, although I’ll say that the model even for babies born in hospitals is that midwives provide the first level of care and the obstetricians are there for complexity, even if you’re in the hospital. But here it’s more like 99 out of 100, so there’s still a big difference.

MC: But how do we change that, though? If in the U.K., from what you’re describing, it seems that obstetricians are viewed upon as highly trained specialists who should be called on in the event of specialty care when it’s needed, and midwives provide more of the primary care. It feels like we don’t have that framework here in the United States. When a woman gets pregnant, her first thought is “I need to go see an obstetrician to provide what’s essentially primary care during a pregnancy.”

NS: That’s exactly right. I think there’s a few different things that we could do to move forward. There are a lot of strategies and, like I said in the piece, I think there are lessons in the U.K., but I think our model will obviously need to look different from the U.K. One of the things I think we should start to think about is health care systems in 2015 in the United States are starting to take responsibility for populations and trying to think about not just the surgery but your health care overall. And 25 percent of all hospitalizations are childbirth related; it’s the number one reason to come into the hospital. So it seems like this should be a big piece of the pie, and I think as big health systems start to take ownership over the health of people that they serve there’s an opportunity to reinvent and re-engineer the way we approach it.

MC: Let’s take a couple more calls. Emily is calling from Westford; you’re on the air, Emily.

Emily: Hi. Thank you for taking my call, and I’m thrilled that Dr. Shah is young and freshly out of medical school and doing what he’s doing. My experience was very different. I was 30 and 34 when I had my two children, and I worked with midwives both times in the Boston area. The first was Beth Israel’s Ambulatory Care Unit, and the two midwives there were ex-nuns, and they were both at the birth, and the obstetrician actually took pictures; he had nothing to do with the birth, which was great. And then the next one, four years later, was in Beverly, at the North Shore Birth Center, which was a house setting across the driveway from the hospital. So both of them were under the umbrellas of the hospital. Now I have to say this was in 1979 and 1983, but I was starting at an OB/GYN practice, and a friend of mine said, “You know, the OBs look for the abnormal. When you go to a midwife, they’re looking for the normal.” And I felt that was so true because all my appointments with my husband with me were an hour and a half at the midwife. Continue reading

Why A U.S. Obstetrician Says Some Women May Be Better Off Having Baby In U.K.

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.”

Dr. Neel Shah (Courtesy)

Dr. Neel Shah (Courtesy)

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