Childbirth in England - It's Shocking!

I have little Anglo-envy: the rain is dreadful, the beer is flat, and the pound is whooping my dollar's ass. But in the case of maternity care, I can understand my American friend Jo's sentiment, "Thank God I'm not trying to do this in the States!" She's married to a Brit and they're expecting their first baby at any moment. I've crossed the pond for the event, and in the two weeks I've been on call, I've had a taste of the English way of birth.

Of course, the prenatal care, the birth care, and the postpartum care -- including daily home visits to help with breastfeeding if needed -- are all covered by the taxpayer-funded National Health Service. Another stark difference: midwives run the prenatal clinics and labor wards here. Most women never even see an obstetrician; if they do it's because there's a complication or health concern. So when Jo first became pregnant and confirmed it with her general practitioner, he said, "Brilliant! Congrats! Call the midwives!" When Jo went for her first visit to the midwives, and they assessed her as a healthy woman having a normal pregnancy, one of the first questions they asked was, "So, where would you prefer to have your baby -- at home or in hospital?"

Home birth is no big deal in the UK. In fact, the NHS just launched new guidelines that encourage women to choose their place of birth, and they want to guarantee all eligible women a home birth by 2009 (it currently depends on the availability of the overworked community midwives). One might say this is purely a cost-saving measure, but there's also a call to train some 6,000 more midwives so that every woman -- no matter where she births -- can be guaranteed a dedicated, "named" midwife to support her during labor. That kind of one-on-one care doesn't come cheap, but it makes public health sense because it results in more normal births, as does giving birth outside the hospital.

In the States, home birth is radical; in some places it's seen as criminal. In some states, it is criminal for the midwife attending (see my previous blog about this). If Jo wanted a home birth in North Carolina, where she grew up, she'd have to find an illegal midwife by word of mouth, pay her a couple thousand dollars out of pocket, and hope that she weren't criminally charged or arrested during her pregnancy. (A group of forward-thinking doctors are trying to change that, but the American College of Obstetricians and Gynecologists "strongly opposes" home birth and actively lobbies against legislation licensing home-birth midwives. At last year's ACOG conference, attendees were given bumper stickers that said, "Home Deliveries are for Pizza.") Meanwhile, the NHS-issued handout Jo was given by the hospital says, "There is no evidence to support the common assertion that home birth is a less safe option for women experiencing uncomplicated pregnancies and not anticipated to need medical assistance at birth," and, "Planned home birth is associated with good outcomes for both mothers and babies."

Here's another shocker about childbirth in England: the TENS machine. I mean, it's literally shocking. TENS stands for Transcutaneous Electrical Nerve Stimulation. The gadget is about the size of an iPod, runs on Double A batteries, and creates a pleasing subdermal vibration that rivals skilled petting. I know because I tried it out the other night. I wasn't in any pain like that of labor, but I did have a stiff neck, so we stuck the electrodes on my shoulders and turned up the volume. Ooooh! Oh! Eeeee! Mmmmmmm... English women swear by it for early contractions. Brits also use birthing tubs more than we do (though not at the same time as the electricity, please note), and they're offered "gas and air" during labor, a 50/50 mixture of oxygen and nitrous oxide, or what Americans call "laughing gas" -- the stuff of dentists and whippits.

Women aren't offered these starters in the States. With pain, we seem to be all or nothing: if you're in the typical hospital, as most women are, you either withstand contractions in whatever position you're "allowed," which is increasingly limited to lying in bed, you get zonked with systemic opiates, or you forfeit your motor control and pushing control and get the epidural. The NHS now rates water (a.k.a. the "aquadural") as the most effective, least risky option for pain relief, but how many U.S. hospitals offer a shower, let alone a water birth?

Not that the UK system is perfect. Like in the U.S., the cesarean rate has been rising apace and there's pressure to chemically induce labor. There are also, admittedly, minor NHS indignities, like the reusable urine cup Jo was given in early pregnancy and instructed to bring full to each prenatal visit. On the other hand, her medical records also remain in her possession, and she can review them at her leisure, which she loves. Here in the UK, there's an emphasis on women's choice, and an increasing awareness of the need to support normal birth. It's not just the driver's side that's switched; women are in the driver's seat.

Comments

[Novapye]

I am a student midwife in England and I agree that the system we have here is much better than the US. However, it is far from perfect and despite the government promising women the right to choose where they have their baby and who is in attendance the local PCT's who employ midwives cannot afford pay for the additional midwives needed to ensure this service becomes a reality. Your article also mentions that the government are training 6,000 more midwives to cover demand this service will have on midwives. Unfortunately midwives are being trained and due to the higher education system in the UK, they are getting into debt (to cover living expenses whilst completing their training) only to find no one will employ them once qualified. No one is hiring. There are thousands of newly trained midwives without jobs.

[Russ1960]

As a man in the US, who has participated (watched?) the birth of two sons, I'll not claim any expertise. However, we need to remember that pregnancy, child birth and the accompanying activities ARE NOT DISEASES! They are normal, everyday occurances that normally should not need any medical intervention at all. Birds do it, bees do it...

[partlysbabe]

I can soo relate to this after having children in both countries, I had my first 2 children in the UK under the care of a midwife and the last 3 were born in the US and I can say that I have definitely come to the conclusion that the UK has an all round better system,
All my births have got longer not shorter and also each consecutive baby has come earlier and earlier, even to the last one when I was induced due to a high blood pressure reading, (actually 2 of them, but only 40 minutes apart and the second one was when I first arrived in the L&D for high blood pressure of course its going to be high, after which I was informed that I was going to deliver that day!!)
I I would consider the difference in care to be the reason this has happened not saying that the US Level of care is in any way more indequate but its just different! and needs to be redefined!....I am currently planning on starting school soon and becoming a midwife!

Partlysbabe

P.S. I am in the process of reading PUSHED and its great!!.. Funnily enough I started reading it before I found this blog! what a coinkidink ?

[BritPatJax]

jljeppson (See profile | I'm a fan of jljeppson)
Out of 171 countries the United Nations has identified the U.S. as ranking the 41st when it comes to maternal death rates. BOSNIA ranks better than we do. Ireland, ranked number 1, has a maternal death rate of 1/almost 48,000 women. Our rate is 1/4800 women. Quite a bit of a difference there, and a clear indicator that our choices for health care are not as good as they are touted to be, nor are our dr's the miracle workers and saviors they are proclaimed to be. Check out all the other countries ranked better than us and you'll see that while they have ob/gyn's and are grateful for their care of pregnancy and labor and delivery complications, they do not rely on them for normal pregnancies. Seems to me like this is a clear indicator for a need for a change in the US's approach to childbirth.

Brit Reply: You do have to remember of course the difference in lifestyles between women here and in Europe. Europeans walk much much more and are generally living a more active life and don't sit at work and in their cars half as much. In the UK thousands of women never own a car for all their lives. Natural childbirth is a result of that. Like shelling peas for a fit active woman? For most that I knew anyway? Family, friends?

[jljeppson]

I completely agree with your comment about the difference in lifestyles. One of my other posts mentions I believe that proper education about nutrition and exercise would make a huge difference in the maternal/newborn outcomes in the US. We've never had more resources available to us, and yet we've never been unhealthier as a country as a whole. True education is going to need to start at birth; not education for the parents, but education for the children. The way our next generation is raised will determine the outcome of birth's in the US. Homebirth and midwifery is just the first step in a long journay back to the health a nation as rich as our's should be enjoying.

[ConcernedAboutRFuture]

THANK YOU Jennifer.... I just needed to read something like this to validate the fact that I wasn't just another hysterical mother when I wanted to take control of the situation during the birth of my son.

[Midhusband]

We are fortunate that there remain objective and courageous physicians, with the fortitude to do the right thing, in contrast to Amy.

Simply put, Amy’s claims on outcomes are unsubstantiated and she has been corrected on many occasions (yet these lessons seem to go into short term memory). Furthermore, when the trade union of industrial medicine prevents qualified midwives from attending women who would choose to birth at home, they are effectively outlawing it.

The Certified Professional Midwife credential was established in 1991. The number of CPMs has doubled in 6 years and today there are ~1300 CPMs serving women and families all over the US. They are the only professional explicitly trained in the home setting. Eventually, all states will integrate CPMs into their healthcare portfolio as it is simply the right thing to do.

Outcomes for the baby born at home are equivalent to hospital for low risk women. Interventions are dramatically reduced and injury to the mother is reduced. For many women, this option is safer, but Amy is not interested promoting safety for women who do not choose to birth the way she thinks best.

Her objective is to maintain the strangle hold that industrial medicine enjoys over women’s liberty even at the expense of safety.

Russ

[cognate]

Birthing is far from the only event when a doctor's services are usually not needed. But the doctors' lobby (American Medical Assn) has long seen to it that Americans are legally required to avail themselves exclusively of doctors and doctor approved practices. It's a racket.

However increasing the power of the government is not the way to bring prices down. Universal government-run health care means effective rationing will instantly have to be instituted. There is no way to avoid that.

What would work is competition unfettered by government-mandated standards and monopolies.

Ron Paul, an obstetrician, understands this.

[jljeppson]

Out of 171 countries the United Nations has identified the U.S. as ranking the 41st when it comes to maternal death rates. BOSNIA ranks better than we do. Ireland, ranked number 1, has a maternal death rate of 1/almost 48,000 women. Our rate is 1/4800 women. Quite a bit of a difference there, and a clear indicator that our choices for health care are not as good as they are touted to be, nor are our dr's the miracle workers and saviors they are proclaimed to be. Check out all the other countries ranked better than us and you'll see that while they have ob/gyn's and are grateful for their care of pregnancy and labor and delivery complications, they do not rely on them for normal pregnancies. Seems to me like this is a clear indicator for a need for a change in the US's approach to childbirth.

[AmyTuteurMD]

"Out of 171 countries the United Nations has identified the U.S. as ranking the 41st when it comes to maternal death rates."

First, race is a risk factor for maternal mortality, with women of African descent having higher maternal mortality than other women. In the US, for example, the rate of maternal mortality for African Americans is 4 times higher than for white women. The countries that have lower maternal mortality than the US are whiter than the US. Maternal mortality for white American women is comparable to that of any other first world country.

Second, the most common causes of maternal mortality are pregnancy complications like pre-eclampsia. These women are not candidates for homebirth, so their deaths tell us nothing about the safety of homebirth.

Third, almost all the countries that rank BELOW the US have higher rates of midwifery and higher rates of homebirth.

Could maternal mortality in the US be improved? Almost certainly. Could maternal mortality be improved by homebirth? Definitely not. Does maternal mortality tell us anything about the safety of homebirth or direct entry midwives? Of course not.

[mae692]

Regarding the women of African descent (I assume we're talking about African-Americans here) how does income level/class factor in? Is the rate higher for middle-class, insured, prenatal care receiving black women vs uninsured, low-income, show up at hosptial in labor white women.

Also is the infant mortality lower in places where the income gap is narrower?

I don't have a problem with homebirth but I agree with you that potential high risk mothers/babies should be identified and directed to hospitals as quickly as possible.

[futuremother]

One of my first introductions to birth as a teenage girl was staying at a friend's house, who's mother was almost due to give birth. She went into labor and, while her husband was out warming up the car to head the hospital, a leg popped out. Breech! I knew enough to know the baby wasn't supposed to come out feet first. There was no option, but for me to deliver the baby. It wasn't an easy birth - the baby's head got stuck, and the mom had to try several positions - squatting, standing, etc, before he finally came out. He's a healthy boy today, but that experience gave me a healthy fear of birth - I know it's not all warm fuzzies - but I've also learned that the hospital doesn't contain any magic, either.

I believe that Dr. Tuteur is promoting exactly the attitude that gets so many doctors in trouble... Much of the physician liability problem is caused by comments like this - basically doctors assuring people that the safest place on earth to have a baby is in the hospital with an doctor. Sometimes that's the case. But people get the impression that they are "safe" there and if anything happens the doc has some magic there to "fix" it.
They think that by coming to the hospital and being a good patient, they are guaranteed a healthy baby. Not so.

There are no guarantees in life. If doctors were a little more honest about their limitations, they might not have so many disillusioned parents suing them.

The words of a well-know perinatologist:
"If you're going to play God, you're going to get blamed for natural disasters."

[jljeppson]

For Caucasians here, the death rate is 9.3/100,000. Ireland's is around 2.5/100,000. "Among the ten top-ranked European and other industrialized countries..., fewer than one in 16,400 will die from complications of pregnancy and childbirth". Compare that to our 1/10,000 and that's an appreciable difference.

Secondly, the study states that these numbers are due to "good-quality health and family planning services that minimize their lifetime risk". Their women are educated about pregnancy and l&d well BEFORE they get pregnant, not after. Our education is usually a sublevel health class in high school and/or classes provided by the local hospital which tells them the hospitals rules and regulations disguised as childbirth classes. Our education processes are sorely lacking when it comes to l&d, as well as when it comes to nutrition and exercise, 2 of the main things that would make huge differences in the outcomes of pregnancies in the US.

Thirdly, if the fact that many of the countries that rank above us are whiter than the US than it should be pointed out that the countries that rank lower than us are not "as white" as the US and if it is a big factor in maternal outcomes for the US it should be included as a big reason for outcomes in those countries as well. Personally, I believe it has far more to do with education, overall health (starving does tend to make pregnancy, labor, and delivery harder on the body), and sanitation than it does race.

[jljeppson]

Continued from my last post.

I didn't mention homebirth or midwifery in my previous post but since you have brought it up let's talk about those countries that rank lower than the US that have higher rates of midwifery and higher rates of homebirth. Let's be specific and choose Afghanistan. It's maternal mortality is the second worst in the world with 1,900 deaths per 100,000. Currently "there is a movement afoot to dramatically increase the number of TRAINED MIDWIVES available to serve women throughout their pregnancies." Under the Taliban new midwives were not allowed training and didn't have equipment available that midwives in industrialized countries do. Now that training is again allowed and supplies, including those for basic cleaning and sterilization, are becoming available numbers are expected to drop dramatically. Note that the WHO isn't looking for more dr's, but more trained midwives with an emphasis on trained.

An untrained midwife can certainly be a danger, but midwifery proponents in the US are not saying that just any person should be able to declare themselves a midwife. They are saying that trained and qualified individuals should be able to provide services to those people that desire them without fear of prosecution. Let me repeat, trained midwives should be available for THOSE PEOPLE THAT DESIRE THEM. None of us are saying that it should be mandatory for everyone. But we do say that it should be available for those that desire it.

[AmyTuteurMD]

"in some places it's seen as criminal"

That's disingenuous. Having a homebirth is not a criminal offense anywhere as you well know. It is criminal for an undereducated, undertrained person (direct entry midwife) to represent herself as qualified to attend homebirths.

"a group of forward thinking doctors"

I don't think that one doctor qualifies as "a group". As far as their website indicates, there is only one doctor involved and he is using the site to advertise his practice.

"In fact, the NHS just launched new guidelines that encourage women to choose their place of birth, and they want to guarantee all eligible women a home birth by 2009"

Yes, and the National Institute for Health and Clinical Excellence, a health watchdog agency in the UK, recently undertook a comprehensive review of the homebirth literature and concluded that:

Most homebirth studies are poorly done.
Most homebirth studies are biased toward homebirth.
Nonetheless, homebirth appears to have an excess rate of neonatal mortality ABOVE the rate of neonatal mortality in the hospital.

There has been controversy in the UK over the fact that the government is promoting a less expensive birth alternative that is known to be less safe.

[TucsonEd]

Of course Amy the doctor would poooh-paw this story. My son is 32 years old and I had the worst care possible, yes in America. My doctor refused to believe I had a problem and was late in diagnoising my Toxemia. When I went into labor, he refused to believe I was in labor so I went to the ER anyway where they confirmed that I was in labor. The hospital got me mixed up with two other women who had the same last name and one of them got two Epideral blocks while I got none. I had to have a C-section and I refused to stay in the hospital the full week I was supposed to cause I was afraid they were going to kill me or my baby. Those who tout we have the finest medical care in the world need to try to have a baby here. oh btw yes I did have medical insurance.

[ConcernedAboutRFuture]

Amy, Amy, Amy.... where do I begin.

I had a son almost 2 years ago... via a midwife but in a hospital. She was wonderful during the birth. A few hours after his birth, he began breathing heavily...at least that's what the nurse said. After X-RAYING him, they found FLUID in his lungs. Me, a first time mother, concerned, scared, and wiped out by particulary painful labor....and CHING!! CHING!! Off to ICU he went, ripped out of my arms, and taken away... radiated, medicated, put in a box under the heat lamp...not in his mother's arms to feel her warmth and to bond with. They gave him antibiotics...yes, my healthy boy, antibiotics. Then they radiated him again, then more antibiotics at a whopping what $300 per shot AT LEAST.

Two days later, I began asking questions, only to be ignored by arrogant doctors who wouldn't even speak to me. I told them to stop giving him antibiotics. They did. Then another arrogant doctor came in at 2 a.m. when I wasn't vigilantly watching him, and REINSTATED the meds without even telling me. When I found out, I was furious. No one would listen to me or my husband even though we pleaded with them; we felt completely helpless. We told yet another doctor that we did not want to radiate our baby with anymore Xrays... he told us, and I'm quoting verbatim "don't worry, the Xray machine gives off as much radiation as a building" ??? And he walked off. I lost it, completely.

I began writing down names, times and reasons for what they were doing. People started looking worried in ICU, whisperig, doctors started being available to see us... and my baby was in my room that afternoon! He was perfectly fine from the beginning...but they shot him up with antibiotics... and radiated him... at a cost of $10,000 EXTRA... that's right... 10K in 3 days...that's in addition to the 25K it cost to have him.

TO BE CONTINUED

[ConcernedAboutRFuture]

I told them that if they touched my baby one more time, or gave him any more meds... my lawyer would be there before they can pop open a pill case.

Does this sound like they had my baby's best interest in mind or mine Amy? It was the almighty buck talking... like it does with most MD's...and probably you too.

When I got home, I did some research and found out that is was perfectly NORMAL for infants to have fluid in their lungs the first few days as it dissipates... and any obstetrician knows this....but these SOB's took it for every penny it was worth, at the risk of my child's health.

This event was so traumatizing to me that I don't think I could have any more children... at least not in this state.

I urge ANYONE who is going to give birth, to read A LOT and TAKE CONTROL of the situation... before these thieves with MD behind their names take you and your insurance company for everything they can.... because it isn't your baby they're worried about. You sign a waiver the second you get into the maternity ward.

So you can stick it Amy... and "teut" your crap somewhere else... where you can rob people. I've learned my lesson... and should I be giving birth again... it'll be with my lawyer at my side thanks to greedy hags like you.

[Katherine63]

Amy, you're on record elsewhere as supporting the ability of nurse midwives in the US as being qualified to attend home births.

If home birth itself is as unsafe as you claim, then why do you support allowing nurse midwives in the US to provide this service?

And if home birth itself is so unsafe, then what do you propose we do about all of the nurse midwives in the US who are delivering babies at home? I would suggest that if they're providing such a substandard level of care, then they need to be held accountable.

[AmyTuteurMD]

"you're on record elsewhere as supporting the ability of nurse midwives in the US as being qualified to attend home births"

No, I am on record as saying that certified midwives are well educated, well trained practitioners with excellent outcomes (in hospitals). Most CNMs refuse to attend homebirths because they feel they are too dangerous. If serious complications arise during a homebirth, the equipment and personnel to treat them are unavailable at home and there is a high risk that the baby will die.

Direct entry midwives are a second class of practitioner with less education and less training than certified nurse midwives. In fact, direct entry midwives have less training than ANY midwives in the industrialize world.

Direct entry midwives practice at home by necessity. They are considered unqualified to practice anywhere else.

We already have midwives. Why should we license practitioners who have less education and training than any midwives in Europe or any other first world countries? The people who are direct entry midwives in the US do not meet either the educational or clinical qualifications to be a midwife in the Netherlands or the UK. Do American women deserve less than their Dutch or British counterparts?

[mae692]

What is a 'direct entry midwife'? Is that opposed to an RN/Nurse Practioner or is there some other training for a midwife? I have a friend that delivered at home, with a lay midwife, and her husband signed the delivery papers so the midwife would not get in trouble. Is that the kind of midwife you mean?

[mae692]

Over there they have 'socialized medicine' and over here we're arguing over whether children 'deserve' healthcare.

[dadw5boys]

I deliveried a baby in a rice paddy in Vietnam.
The lady had fallen during a motar attack from the V.C. and she started labor. I delivered the little girl and cut the cord with a a Pocket Knife I sterlized with a cig lighter.
I carried mom and baby to a local village where the older ladies tok care of her and the baby was still kicking 14 months later.

We have had 6 kids and I swear here in the states they make it like a big show I guess so they can justifed that big bill. We even had to argue to have our child left in the room with the wife. Too much a do about nothing.
My wife says American women are too damn pampered and silly about having kids. FEW American women today would have ever make it as Pioneers that for sure.

[Midhusband]

Thank you, Jennifer, for reminding us that it is possible to engineer a system of maternity care that is actually responsive to a mother's right of self-determination (and with great outcomes to boot!).

Please tell Jo that we will fix NC in the fullness of time. Every year there are between 300 and 400 planned home births in NC attended by Certified Professional Midwives. There are thousands of folks that comprise the community and we are working hard on reform. We are thankful for the leadership of NC Physicians for Midwives. Our arguments are straight forward and will carry the day just like they have in the many other states that have integrated CPMs into the maternity care portfolio.

Thank you, again, Jennifer, for all of your work.

Yours,

Russ

[BritPatJax]

I agree about the rain Jennifer but that flat beer stuff is old hat. I am approaching 65 years and spent 58 of them in England or at least Europe. Five in Germany. I had no idea that there were people who could not afford to have a family. I have met many here. Both with jobs that don't come with insurance and cant see a way out? Then we have Boorzt and Limbaugh and Hannity going on about how bad it is in England. I sometimes went 4 years without seeing a doctor in the UK and no doubt my taxes, especially gas tax, probably kept the ones who went once a week alive? Even here I have only had a check up once. For the first time in my life I got asked to 'bend over'? Nice one. I am glad that my daughters and my friends have the UK system to fall back on and they are sooooo not stressed as a result that they probably need their doctor less. I seem to be about ten years younger than most 65 year olds here, due to walking and climbing as I still do when possible. Don't let anyone tell you that Social Medicine does not work. Check ten European nations?

[NavyMom]

I'm intensely envious of the British Way of Birth. But the really important thing is that they have LOWER infant mortality than the US.

[olivine]

I am all for women being in control, but I have had five children-and if it wasn't for epidurals I think I would have left my husband and joined the convent. I actually have a theory that one reason Convents used to be FULL is that as young women watched (and heard) other women giving birth, they hightailed it to the nunnery.Has anyone noticed a correlation between use of the pill and a drop in vocations?

[Novapye]

Epidurals have there place and I believe it is every woman's right to have this choice, however, evidence shows that continuity of care, being mobile during delivery and adopting birth positions other than that of lithotomy (most commonly used in US) reduces the uptake of epidural use.

Having someone with you during labor and birth who believes in you and your bodies ability to birth your baby is empowering. This reduces anxiety and fear and allows your body to do what is natural. Endorphins are released (the bodies natural painkillers) so there is no need for intervention either from analgesics or from epidurals. Epidurals themselves increase the risk of further intervention and an operative delivery.