jeudi 18 juin 2015

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

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

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. Neel Shah (Courtesy)

Dr. Neel Shah (Courtesy)

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% 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.

MC: Emily, thank you so much for your call. Dr. Shah, I wonder what do you see as the obstacles to creating more of the kind of model that Emily was talking about, maybe midwifery-led, but hospital-linked or hospital-based or across the street, some sort of relationship so there is that continuity of care we were talking about earlier.

NS: I think the biggest obstacle is money, but I think actually understanding what that means in detail provides an opportunity for solutions. What I mean by that is that labor floors typically for a hospital are loss leaders. The cardiac ICU is a cash cow; the labor floor is a loss leader. It’s very resource-intensive, but they lose money.

MC: Really? Because I saw a report in the New York Times that the cumulative cost for 4 million annual births in the United States is 50 billion dollars.

NS: We spend a lot of money on it, don’t get me wrong. The cost-to-reimbursement ratio compared to other parts of the hospital like cancer care or cardiac care, because at the end of the day we’re taking care of healthy people. And we end up staffing healthy people with one-to-one nurse the whole time. It ends up being quite expensive, and so I think in the traditional model of paying hospitals, childbirth ends up being an afterthought. I think we’re at the precipice of a pretty radical shift in the way we pay for care in this country, and I think that’s actually going to help a lot. That’s one thing.

MC: You’re shining a light on what I think is the giant elephant in the room. When we talk about comparing the United States and the UK. There is a system of national health care in the UK, no such thing here.

NS: No such thing here, but we’re getting incrementally towards a system where we can make sure that we’re rewarding hospitals and doctors for providing value and not just volume. Right now there are incredible throughput pressures on labor floors, and childbirth is a great way of expediting labor. And I think if we had ways of alleviating some of that throughput pressure we would see less C-sections.

MC: Can we decipher what you just said? Throughput pressure means getting people through they system as fast as possible. Expediting labor means getting that baby out. So if a woman’s taking a long time to give birth, there’s a lot of pressure to speed it up.

NS: In low-risk women, this is in the data. In low-risk women, the number one reason to do a c-section on someone who’s started in labor is something we call failure to progress. It’s a very subjective call, and one way of interpreting that is, “You’re taking too long. I don’t think that even OBs are consciously doing that, but if you’re busting at the seams, you’ve got no labor rooms left, that’s often what these areas look like, there are pressures.

MC: And so how do we overcome those pressures though? I know it’s a huge and complicated system.

NS: This is what’s going to make it different in 2015. We’ve tried payment reform in health care a lot. You mentioned that I started this nonprofit, Costs of Care, that has looked at this, and that’s part of it, but what’s really different in 2015 compared to say 1994 when we tried to reform health care, is that in 1994 you were getting AOL CDs mailed to you, and in 2015 the internet looks different. And I think because of some the work Martha Bebinger is doing and other folks, the demographic that is online looking for transparent quality and price information is our demographic. It’s young, healthy women. And increasingly – there’s billions of dollars in the Silicon Valley to make a Yelp for health care. And I think that’s going to be the game changer.

MC: Let’s take another call. Dave is on the air from Bridgewater.

Dave: Hi; thank you for taking my call.

MC: What’s your story?

Dave: My wife gave birth to our first child, a son, in December, at Beth Israel. We were very happy with the care there, and there were some minor complications. It was a long labor, and when he actually came out we had about 12 people in the room, including the NICU team because he came out sunny-side up and there were some other concerns. And I just want to say, these conversations about medical waste, and whether it’s in the context of frivolous testing or unnecessary hospitalizations, it’s always interesting in the hypothetical, but when you’re in the moment and it’s your wife and your child, I want to be there where all the professionals are. I don’t want to be at home when there’s an emergency during birth.

MC: Thank you so much for your call and your perspective, because I think that returns us back to what the central tension is here: that we are, especially in a place like greater Boston, fortunate to have 21st-century medical care available. And it’s hard to have this conversation in the United States about are there other options without thinking that any difference is actually a diminishment in access to that care.

NS: I think that is definitely a challenge and, Dave, thank you for your comments, and I really sympathize with that. I’m glad you got good care at Beth Israel Deaconess, and it’s likely that maybe you needed 12 people in the room, and I’m glad that you got it. Part of our challenge, too, is that we don’t always know when an emergency is going to happen. You can start with a low-risk woman and then something unanticipated can happen, and that might have happened with Dave’s wife. That’s part of what we have to consider. What I’ve found with this is that the debate and reaction to the New England Journal piece feels a lot like the treatment intensity at the end of life debate. They’re almost identical in terms of the concerns and the worries about trying to decrease unnecessary care and try to understand the harms. The only difference is that we’ve thrown reproductive politics into the mix.

MC: You make an interesting point in the piece, which I think is once again a good motivation to think about reframing, because you point out that 45 percent of British first-time mothers who intend to give birth at home, so they start laboring at home, they ultimately get transferred to a hospital. Some people look at that as a failure of home births, but you had a different interpretation.

NS: Yeah. I read that and I was like, “What are they doing?” Because I was imagining 45 percent of women in the U.S. like with the ambulance crashing into your driveway, and then when I read the guidance and understood better how things work there, I realized that’s actually the signal of a very well-working, highly-coordinated health care system. It’s only for first-time moms that it happens that frequently, and so maybe if you’ve had babies before that actually makes you an even better candidate for this. First-time moms who really value wanting to have a baby at home, they’re careful.

MC: And then it’s easy for them to go to the hospital.

NS: Right. They expect you; the hospital’s close by. That’s another difference, honestly. One of the challenges that we have here in the U.S. is that we have just a bigger country.

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