In December 2014, the UK’s National Institute for Health and Care Excellence (NICE) updated their guidelines for the care of healthy women and their babies during childbirth.
NICE reviewed all the available evidence for birth outcomes for mothers and babies in different settings, and came to the conclusion that women with uncomplicated pregnancies (low risk) have better birth outcomes in environments that are not associated with obstetric care. In other words, the less healthy women have to do with physician led care, the better their birth outcome will be.
NICE emphasises women should be offered the choice to birth where they feel most comfortable, whether that is at home, in a birth centre or the hospital. But it goes on to clearly state that birth within an obstetric unit has higher rates of intervention than other settings. The message is crystal clear: for the majority of healthy, low risk women, birth is safer when we don’t mess around with it. Interfering with what is normal causes more intervention, usually in a cascade fashion.
Hospital Birth Is The Norm
For most women, you can’t avoid the statistics about birth. It seems every other day a new report is being published decrying the high c-section rates in developed countries like Britain, Australia and America. We are so conditioned to accept that birth in hospital is the norm, and anything that contradicts this seems to fly in the face of what is considered safe. Just because something is uncommon, it doesn't mean that it's dangerous. Our own stories of having to be saved from birth cement the pervasive belief that procreation is indeed a dangerous undertaking.
Considering c-sections are the most commonly performed surgery on the planet, you could be forgiven in thinking there is a problem with birth. Yet when a leading body comes out and says that uncomplicated vaginal birth is achievable if we switch to more midwifery support, it barely raises our pulse. But it should.
Re-Thinking And Changing The System
The importance and value that should be attached to NICE’s guidelines is the fact that the UK have looked at the problems facing childbearing women — and got it right for a change. Instead of continuing with the ‘one size fits all’ approach for birth, which is creating more problems than it should, the UK maternity system is encouraging women to seek their own choices, reducing the financial cost of birth, and lowering the overall rates of interventions to mothers. It is supporting women in owning their birth choices.
This could effectively lead to a maternity system that has corrected its trajectory down the slippery slope, reducing maternity options to hospital or nothing, much like the US — and Australia is following closely behind.
In America, 99% of all babies are born in hospital, with 90% of women having a physician in attendance during labour. High rates of interventions for decades has entrenched the medicalisation of birth. Caregivers and women themselves have little chance to see normal physiological birth. Maternity costs are high with poor outcomes. They have some of the highest newborn and maternal death rates in the developed world.
The US system has trapped itself in a ‘one size fits all' approach, with all women being treated the same regardless of their pregnancy risk. Without a universal health care system, American women are further reduced in choices by what they can afford for their maternity care, not what is the best option for them.
The Cost Of Medicalised Birth
The cost of medicalised birth is high. American pregnant women have a 33% chance of having their baby via c-section. While undoubtedly a life saving operation when medically required, the World Health Organisation (WHO) recommends rates should be no more than 10-15%, else the benefits are outweighed by the risks. Mothers and babies are being exposed to the risk of death or injury unnecessarily, because after that 10-15% (which is based on extensive research), they found that no additional lives were being saved. Isn’t saving lives what medical assistance is supposed to prevent during labour and birth? One US obstetrician has come out and argued that the opposite is now true.
In an article for the New England Journal of Medicine, Dr Neel Shah pointed out the stark difference in medical culture between the UK and the US: “nearly all Americans are currently born in settings that are essentially intensive care units (ICUs)”, highlighting that perhaps the proximity to medical interventions encourages the use of them more than is strictly necessary.
“The safety argument against physician-led hospital birth is simple and compelling: obstetricians, who are trained to use scalpels and are surrounded by operating rooms, are much more likely than midwives to pick up those scalpels and use them.”
Home Birth vs. Hospital Birth
This leads us to the inevitable argument: is home birth safer than hospital birth? Dr Shah says the debate should not be about which care provider and setting is better, rather how the maternity system automatically treats birth as a catastrophe waiting to happen and over-intervenes. While the NICE guidelines emphasises the risk of doing too much in hospital, on the other side of the Atlantic, the American College of Obstetricians and Gynecologists (ACOG) underscores the risks of not doing enough.
In the UK, women planning to birth at home are provided with one to one focused midwifery care during pregnancy, with coordinated follow up care if additional care is required. The health system is structured in a way that all women are guaranteed access to care, and those who do need to transfer from home to hospital know it will happen safely and quickly. Transfers happen collaboratively as doctors and midwives are more used to working in partnership. In the US, such collaboration is nearly impossible to access, as is the case in Australia. These things contribute to making homebirth unsafe and impractical — not women wanting homebirth or those trained to support them. The US and Australia has much to answer for, by not supporting women with their right to choose and failing to make an effort putting effective systems into place.
Normal Birth Needs ‘Normalising’
Ultimately, women will choose the environment that is promoted as the safest for the birth of their baby. Generations of women have been led to believe that hospital provides this safety, but the evidence is stacking against this long held belief.
There are many organisations and groups now focusing on supporting women’s rights in birth, supporting women who have suffered birth trauma due to obstetric violence, and working toward normalising birth for future generations. Women are beginning to demand autonomy over their right to bear children how and where they want to.
American women don’t have the luxury of birth choice that British women do, through no fault of their own. While women in the UK can reduce their risk of intervention by staying away from hospital if they choose, pregnant women in the US (and countries following the US maternity model) are essentially be held hostage in a one size fits all model of care. The challenge is for women to have their voices heard in a birth culture that is dominated by doctors who don’t know how to do better even when they know better.
For information about birth advocacy groups in your area: