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To hear more from Dr. Shah, check out our recent conversation we had with him about an article he published in The New England Journal of Medicine, titled A NICE Delivery — The Cross-Atlantic Divide over Treatment Intensity in Childbirth that talks about how the US and UK maternal health systems differ and how we can learn from their best practices.
The study was in response to an evidence-based review published by the United Kingdom’s National Institute for Health and Care Excellence (NICE) that concluded that healthy women with straightforward pregnancies are safer giving birth at home or in a midwife-led unit than in a hospital under an obstetrician’s supervision.
Neel Shah, MD, MPP, obstetrician-gynecologist at Beth Israel Deaconess Medical Center and Assistant Professor at Harvard Medical School recently published an article in The New England Journal of Medicine, titled
A NICE Delivery — The Cross-Atlantic Divide over Treatment Intensity in Childbirth. It was in response to an evidence-based review published by the United Kingdom’s National Institute for Health and Care Excellence (NICE) that concluded that healthy women with straightforward pregnancies are safer giving birth at home or in a midwife-led unit than in a hospital under an obstetrician’s supervision. American doctors, hospitals and medical organizations advocate a different point of view and Shah was prepared to rebut the UK findings. What happened next, took Dr. Shah by surprise.
Every Mother Counts (EMC): Dr. Shah, we’ve been talking about maternal health outcomes in the US lately and your article discusses many of the issues we’ve been covering.
Dr. Shah: I’m just saying what many other thoughtful people have been saying for a long time. I’m getting a lot of attention because it seems anti-establishment to question the safety of hospitals in the New England Journal of Medicine. Originally, I planned on rebutting the British guidelines but as I dug into it, I found that many of my arguments were based on flaws in the American system, not the British one.
EMC: The questions you post in your article are good ones: Are midwives safer than doctors? How can homes be safer than hospitals and what implications does this study have for the US?
It’s a super knotty issue and it shouldn’t be about the superiority of midwives over doctors or homes over hospitals. The debate we should be having is over “treatment intensity” in childbirth and when enough is enough. The concern is that patients can be harmed by doing too much and by doing too little — in the US I worry that we cause avoidable harm by always erring on the side of too much. There are striking differences between the UK and US. The biggest being that the UK offers women alternatives. The US has only one model for maternal healthcare and it’s super high cost. 99% of babies are born in hospital settings that look like intensive care units, surrounded by surgeons. The healthiest patients in the hospital are in labor and delivery and yet, we deliver care in the most intense treatment environment. It doesn’t take a rocket scientist to figure out why we overdo it. Delivering babies this way requires tremendous resources, which makes access to care in the US a huge issue. About 50% of counties in the United States don’t have an obstetrician or midwife. In parts of Oklahoma, South Dakota, and other rural areas, women routinely drive for hours to reach a maternity unit. Then, when they finally arrive, they often get overly intensive treatment. It’s like combining the first world and the third world into the perfect storm.
EMC: How is that different from the UK maternal health care system?
In the UK, women have four options — hospital, hospital-adjacent birth centers run by midwives, freestanding birth centers and home and all are equally legitimate options for low-risk women. They also have coordinated protocols so if things aren’t going well at home, the mother is transferred to the hospital in a smooth, integrated system. If you try to do a home birth in the US, you have a hard time finding someone fully qualified to do it. Then, if things go wrong, you have to call 911 and an ambulance comes crashing into your driveway at the 11th hour. We don’t have a coordinated health care system.
EMC: Currently, most American women don’t realize they should have options.
During my research, I realized the reason why women are willing to tolerate the way we do childbirth here in the US — with hours, if not days under florescent lighting, tethered to a hospital bed with wires and alarms, is because they think it’s safer. The argument they’re making in the UK is if you’re in an ICU surrounded by surgeons, you’re more likely to be intervened upon and this poses a different type of safety concern. There are two kinds of harm in medicine. Harm from not doing enough is the kind we worry about most. But there’s equal likelihood of inflicting harm from doing too much and we don’t talk much about that. Everyone who delivers babies sees that kind of harm all the time. Particularly for low risk patients, I think we would be wise to consider whether alternate models of delivering care may make us better off.
EMC: Is your article impacting the way your colleagues view labor and delivery?
It’s hard to change the world with one journal article, but it made some people think. It validated what groups like the American College of Nurse Midwives have said for a long time. Childbirth isn’t an intellectual issue for most people though. It’s deeply personal and emotional. The reaction to my piece has been interesting. Some people violently disagreed with me. Some accused me of trying to turn back the clock on women’s healthcare. But others agreed with me that I didn’t expect — hospitals and doctors included. My hope is that it added to a conversation we need to have about improving maternal health in America.
Read the fact about home birth
Photo: Marshall Clarke