After reviewing all the available evidence, the organization (which is the equivalent of the U.S. National Institutes of Health) decided that healthy women with uncomplicated pregnancies are safer giving birth at home or in a midwife-led birthing center or hospital unit than in a hospital maternity ward under the supervision of an obstetrician.
Women should be able to choose which birthing option they want, the guidelines stressed.
The NICE report caused a bit of a stir — and consternation — among the medical community here in the United States, where almost 99 out of 100 babies are delivered in hospital maternity wards.
“The idea that any pregnant patient might be safer giving birth outside the hospital seemed heretical, at least to an American obstetrician like me,” writes Dr. Neel Shah, who teaches gynecology and reproductive biology at Harvard Medical School, in a recent article for the website The Conversation.
Yet something is clearly amiss with the current U.S. system of labor and delivery. Pregnant women in the United States have a one in three chance of delivering their baby via cesarean section. The current rate in the U.K. is one in four. Both countries’ rates are much higher than what the World Health Organization considers to be the optimal rate: 10 percent to 15 percent of all births.
Unnecessary C-sections put both the mother’s and the baby’s health at risk. Women who have C-sections may develop life-threatening complications, including infections, uncontrolled bleeding, blood clots and bowel obstructions. Babies born via a C-section are at increased risk of developing respiratory and other lung problems, including asthma. A study published last year found an association between C-section births and an increased risk of immunological disorders in children, such as juvenile rheumatoid arthritis and inflammatory bowel disorder.
The C-section rate has begun to dip in the U.S. in recent years, but it is still considered alarmingly high.
Following the evidence
“Knowing that no study or guidelines is foolproof, I began my task by looking for holes to form a rebuttal,” Shah says. “I soon realized that this rebuttal largely hinged on flaws in the American system, not the British one. While we take excellent care of sick patients, we do less well for healthy patients with routine pregnancies — largely in the form of turning to medical interventions more than strictly necessary.”
Shah’s NEJM piece was published last week. In it, he describes several of the key cultural and structural differences for why he has decided that most women would be better off giving birth in the U.K. under the new NICE guidelines than in the U.S.
“At its core, this debate is not about the superiority of midwives over doctors or hospitals over home,” Shah writes. “It is about treatment intensity and when enough is enough.
“Nearly all Americans are currently born in settings that are essentially intensive care units (ICUs),” he adds. ” … Surely every birth does not require an ICU. At present, five of the 10 most common medical interventions performed in the United States are related to childbirth, and cesarean sections are the most commonly performed major surgery worldwide.”
A coordinated system of care
One of the most important reasons why home birth is such a reasonable and desirable alternative for British mothers — including for first-time mothers for whom the risk of unexpected complications arising during labor and delivery is highest — has to do with the structure of the U.K.’s health care system, says Shah.
As he points out, 45 percent of first-time mothers in the U.K. who intend to give birth at home end up being transferred to a hospital obstetrical unit during labor. That’s a percentage that many U.S. pundits might jump on to claim that the American system is superior. But it’s actually “a sign of a working system rather than a failing one,” writes Shah.
“Access to care [in the U.K.] is a given,” he explains. “British women who give birth outside the hospital receive focused, one-on-one attention from a qualified midwife. When more intense care is needed, there are clear protocols and mechanisms to facilitate transfer to a hospital.”
Knowing that they can be quickly and safely transferred to a hospital if they or their babies should need more care widens the birthing options for British women, whether they are having a baby for the first time or have given birth before (and thus are at much lower risk of needing a transfer).
“Giving birth in the comfort and privacy of home not only seems reasonable — it seems preferable,” writes Shah.
Such a system, however, is not available to most American women, as Shah explains:
In the United States, access to obstetrical care that is coordinated among homes, birthing centers, and hospitals is both unreliable and uncommon. Nearly half of all U.S. counties have no practicing obstetricians or midwives, so women are often forced to drive to distant facilities offering needlessly complex care. … Unlike our British counterparts … U.S. obstetricians lack clear protocols for determining when and how to transfer patients to risk-appropriate facilities. Moreover, U.S. facilities often lack formal referral relationships and may face financial disincentives to transfer patients.
A lesson to be learned
“As a U.S.-trained obstetrician, I have little doubt that the United States offers outstanding care for medically complicated pregnancies,” Shah concludes. “But there are lessons to be learned from the British system. The majority of women with straightforward pregnancies may truly be better off in the United Kingdom.”