01 September 2017
The U.S. and the U.K. used to have the same rate of women dying in pregnancy and childbirth. Now, Britain’s is almost three times lower. Here’s what they’re doing right.
This story was co-published with NPR.
<p></p><p>At 11:58 p.m. this past June 25, Helen Taylor gave birth to her first baby, a boy, at West Suffolk Hospital in the east of England. At 11:59 p.m., with 15 seconds to spare before midnight, his sister was born. The obstetrician and her team were pleased; the cesarean section was going smoothly, fulfilling Helen’s wish that her twins share a birthday.</p><p></p><p>But 40 minutes later, Helen had lost over a third of her blood.</p><p></p><p>Enraptured by new motherhood, she barely noticed when the obstetrician’s head appeared around the surgical drape. “We need to give you a drug to help stop the bleeding, is that OK?” Helen nodded. Ten minutes passed before the question came again. Then again. The fourth time, Helen realized something was seriously wrong.</p><p></p><p>During pregnancy, the uterine blood vessels that nourish the fetus are wide open. Once the baby is delivered and the placenta removed, these vessels should constrict and close. If they don’t, as with Helen, the mother can bleed profusely. She may reach a point where her body can no longer compensate for the blood loss. The extent of the flow can be unpredictable and sometimes catastrophic. The surgical team’s response must be meticulous. And fast.</p><p></p><p>Helen’s team — an experienced obstetrician with her resident in training, a pediatrician, an anesthesiologist with an assistant, two nurses (one scrubbed-in, one fetching equipment), and three midwives — responded to her developing hemorrhage with a routine ingrained from rehearsal and real life.</p><p></p><p>“We are like a Formula One race team at a pit stop,” the anesthesiologist had reassured Helen by way of introduction.</p><p></p><p>The key to this well-oiled machine is standardization. It used to be that every obstetrician in the U.K. had his or her own signature strategy to manage an emergency. In the U.S., that still sometimes happens. But these days, every British doctor, whether newly qualified or approaching retirement, is required to follow the same guidelines for many aspects of maternity care, including treatment of bleeding. Postpartum hemorrhage guidelines are regularly updated by the Royal College of Obstetricians and Gynecologists and The National Institute for Health and Care Excellence, and then written into local protocols for practice in every National Health Service hospital. You don’t need to be a doctor to read the guidelines: They are freely available online. Women can find out exactly what standard of care to expect.</p><p></p><p>Helen’s was the kind of deceptively complex case that shows why a consistent approach is desirable. Her hemorrhage flared from minor (over 500 millimeters) to major (over 1 liter) to massive (over 2 liters) in less than an hour. First, the team gave her IV fluids to help replace the lost volume. After checking for bits of retained placenta, the obstetrician massaged Helen’s uterus to encourage its natural ability to contract, but her bleeding continued. The anesthesiologist lifted the surgical drapes to inject Helen’s thigh with a drug containing syntocinon, which stimulates the uterine muscle to tighten the blood vessels. The same medication was then given by a drip.</p><p></p><p>But there’s a catch: Drugs that narrow arteries can increase blood pressure. During her third trimester, Helen had developed preeclampsia, a type of hypertension induced by pregnancy that can lead to seizures and strokes. Not only does preeclampsia complicate treatment for bleeding, it makes hemorrhage more likely in the first place.</p><p></p><p>The immediate danger of more blood loss outweighed the risk of raising the blood pressure. The anesthesiologist followed protocol and administered two more drugs to intensify uterine contraction, with several minutes of watching and waiting in between. Still the blood flowed. The final step would be a transfusion.</p><p></p><p>Then, just as the team was about to dial up units of O-negative from the blood bank, the obstetrician noticed that her absorbent surgical swabs were taking longer to soak through with red. The uterus felt firmer, more like a bicep than loose tissue. Helen’s bleeding was under control. Due to the guidelines, a more serious crisis was averted. A transfusion wouldn’t be needed after all.</p><p></p><p>As a medical student at the University of Cambridge in England, I got to know Helen on the ward. This account of her pregnancy, labor and medical emergency is based on my observations and interviews with Helen, her partner Marcus and caregivers at West Suffolk Hospital. The hospital approved my access to interview patients, and Helen gave full consent to share her experience. It’s a tale that highlights the profoundly different approaches in the U.K. and the U.S. to maternal care — and to saving mothers’ lives.</p><p></p><p>“Ultimately, it’s a story I didn’t think I’d get to tell,” Helen said.</p><p></p><p>For a pregnant woman in the 1950s, the two childbirth complications most likely to prove fatal were hemorrhage and preeclampsia. Whether American or British, one in every 1,000 expectant and new mothers died.</p><p></p><p>British health authorities recognized this number was unacceptably high, given that nearly half of the deaths were considered preventable. Starting in the late 1940s, a national commitment was made to standardize maternity care across the NHS, assess each maternal fatality, and learn how it might have been avoided.</p><p></p><p>That campaign has succeeded. Today, the average mother in the U.K. receives more comprehensive and consistent care, ranging from earlier prenatal appointments to closer monitoring after she gives birth, than does her American counterpart. And if a mother dies, the U.K. investigates and tries to learn from it. Medical authorities in the U.K. view maternal deaths as public health failures that underscore deficiencies in health care systems. In the U.S., maternal deaths are too often treated as disconnected, private tragedies. If they are scrutinized by hospitals or regulators at all, the findings typically prompt institutional rather than national reforms. </p><p></p><p>Underlying these contrasts is a different view of the medical responsibility to mother and child. In the U.S., laudable aspirations for infant safety have intensified focus on the fetus — more sonograms, continuous fetal heart monitoring and granting rights to the unborn. But these measures may at times distract attention from the mother’s health.</p><p></p><p>By contrast, British medical professionals are legally required to prioritize a mother’s wellbeing if both she and her baby are in danger. They’re trained to stabilize mom first, and then tend to baby. “That sense that the woman (while the fetus is in utero) is the agent in charge is in place. I think that’s the right way,” said Denis Walsh, a midwife and associate professor in midwifery at the University of Nottingham. “Otherwise you start undermining individual women’s autonomy and then you go down a slippery slope.”</p><p></p><p>The numbers reflect the difference in national priorities. Today in the U.K., 8.9 women for every 100,000 live births die from complications of pregnancy or childbirth, according to the Institute for Health Metrics and Evaluation. In the U.S., this figure declined in tandem with Britain’s until 1990. It then reversed course, rising to 25.1 women per 100,000 in 2015, almost three times higher than the U.K., and among the worst in the Western world.</p><p></p><p>These U.S. deaths are not spread equally. Women who are poor, African American or live in a rural area are more likely to die during and after pregnancy. In the U.K., while inequalities persist when it comes to serious complications, according to 2012-2014 data, there is no statistically significant difference in mortality rates between women in the highest and lowest socioeconomic groups. All British women have equal access to public medical services, including free care and prescriptions from pregnancy through the postpartum period.</p><p></p><p>There is a significant gap between the U.K. and U.S. in outcomes for pregnancy-related conditions that are highly treatable but can lead to death if they are not recognized and managed in time. One in 1 million women die of preeclampsia in the U.K.; that’s less than a single death per year. By contrast, preeclampsia killed an estimated 50 to 70 women in the U.S. in 2016, accounting for 8 percent of maternal deaths. According to the most recent data available, hemorrhage is responsible for 6.5 percent of maternal deaths in the U.K. versus 11.4 percent in the U.S.</p><p></p><p>The U.K. has achieved these results while spending less on delivering babies. On average, the total price charged for a vaginal birth in the U.S. is $30,000 (£24,000), which rises to $50,000 (£39,000) for a cesarean section, according to Truven Health Analytics, a New York firm that collects health care data. The BBC reported that in the U.K. the average cost for a normal delivery or planned cesarean section on a hospital labor ward in 2016 was $2,300 (£1,755), while a complicated case like Helen’s rose to $3,400 (£2,582).</p><p></p><p>Ironically, the centerpiece of the U.K.’s strategy to reduce maternal mortality is an American import. In 1949, the British Congress on Obstetrics and Gynecology suggested adopting a new method for reviewing maternal deaths that was already practiced in some parts of the U.S. Fatalities in those regions were assessed by local committees of experts, who published reports in medical journals to educate the profession. The British minister of health agreed to try it. The result was the Report on Confidential Enquiries into Maternal Deaths in England and Wales, established in 1952.</p><p></p><p>The confidential inquiry has far outstripped its American forebears. Now run by MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries in the United Kingdom), its report drives training, assessment and practice in British obstetrics — including the types of treatment protocols that saved Helen Taylor’s life. Crucially, hospitals can neither opt out of MBRRACE’s surveillance nor ignore its recommendations.</p><p></p><p>In many parts of the U.S., such enquiries do not have the same prominence and clout. There is no federal-level scrutiny of maternal deaths, and only 26 states have an established committee (of varying methodology and rigor) to review them. Nor do all U.S. hospitals routinely examine whether a death could have been avoided. Procedures for treating complications such as preeclampsia, and for responding to emergencies such as hemorrhage, vary from one doctor, hospital and state to the next.</p><p></p><p>The Richard Doll building at the University of Oxford, named after the epidemiologist who saved millions of lives by establishing the link between smoking and lung cancer, is the home of MBRRACE. That the inquiry can declare itself “the international gold standard for maternity audit and quality-improvement programs” is due to more than 100 doctors and midwives who read the cases in their spare time for free. MBRRACE continues the search for answers begun in 1952: What are the causes of maternal deaths, why are they occurring, and how can they be prevented?</p><p></p><p>MBRRACE’s full report covers a three-year period and includes data on every woman in the U.K. who has died during pregnancy or up to six weeks after childbirth. It also discusses later maternal deaths — those occurring up to a year after delivery — and makes recommendations for improvements to care. Direct deaths from obstetric causes, such as hemorrhage, sepsis or blood clots, are distinguished from indirect deaths from conditions worsened but not caused by pregnancy, such as epilepsy or certain types of heart disease.</p><p></p><p>When a woman dies, the delivery unit responsible for her care submits a local report, which includes perspectives of the health professionals who treated her, and a copy of her medical notes. First, a pathologist reviews the documents to pronounce the cause of death. Next, 10 to 15 practitioners from specialties including obstetrics, anesthesiology, emergency medicine, psychiatry and midwifery piece together what happened, and decide whether the death could have been prevented.</p><p></p><p>Data about maternal age, race and cause of death is extracted and analyzed. Also counted are the survivors who must grow up without a mother’s care. The 2012–2014 report states that “the women who died left behind a further 253 children, thus together a total of 358 motherless children remain.” The individual women are not named, but their stories are preserved in the report through short vignettes. Marian Knight, head of MBRRACE’s maternal program, who trained in obstetrics and is now professor of maternal and child population health at the University of Oxford, insists that statistics alone do not have the same impact.</p><p></p><p>“Stories are what make the difference,” Knight told me. “That’s what people remember. In the States, they are just collecting numbers. It’s all very well to know a woman died of sepsis, but to know that she died of sepsis because nobody measured her temperature, as they had no thermometers on the postnatal ward, that’s where the instruction Put a thermometer on your postnatal ward might make a difference. It’s not just the what, it’s the why.”</p><p></p><p>MBRRACE doesn’t seek to blame individual health professionals, but rather to learn from systemic mistakes. These lessons feed back into NICE’s and the Royal College’s guidelines, standardizing care from Inverness to Southampton. Committing to predetermined pathways of treatment, as in Helen’s delivery, requires humility from clinicians. The power of protocols — informed by the profession’s collective experience and research findings — is that, over time, they will result in better outcomes than one doctor’s instinct.</p><p></p><p>Catherine Aiken, fellow in maternal-fetal medicine at Addenbrooke’s Hospital in Cambridge, interned at Yale New Haven Hospital before returning to the U.K. “As a behemoth organization, [the NHS] is good at agreeing that there is a way of taking a woman’s observations [vital signs] in labor. If you don’t have a thermometer, the whole thing grinds to a halt until you find one, which can be frustrating at times,” she said. “You have to remind yourself in the moment this is good, and ultimately it will save lives because you have less of the stupid mistakes.”</p><p></p><p>There are, of course, moments when deviating from a protocol is defensible, but “you should have something that makes you think very hard before you override a safety mechanism in any situation,” Aiken added. “I’m glad that I work in an operation where I would be stopped if I were doing something off-piste,” or in other words, not recognized as best practice.</p><p></p><p>MBRRACE’s findings also influence how interns and residents are evaluated. Questions about the confidential inquiry appear on the Royal College’s examinations, which all aspiring obstetricians and gynecologists must pass.</p><p></p><p>The Care Quality Commission, which inspects medical services nationwide, takes MBRRACE’s report to birthing units and labor wards to ask doctors and midwives how they are integrating its findings. PROMPT (Practical Obstetric Multi-Professional Training), a nonprofit formed in response to evidence from the confidential inquiry, runs drills and refresher courses for obstetricians, anesthesiologists and midwives. Protocols are practiced in simulated emergencies to make the pit stop in real crises as efficient as possible.</p><p></p><p>Despite these measures, the U.K. appears to be one of the poorer-performing European Union countries. France and the Netherlands, the two other nations that conduct enquiries comparable to MBBRACE, have lower maternal mortality ratios (7.6 per 100,000 live births, and 6.3 per 100,000 respectively).</p><p></p><p>Does comparison with the U.S. mask the U.K.’s shortcomings? Defenders of the British system say the NHS is simply more vigilant in defining and identifying all pregnancy-related deaths. If you search hard enough for bad news, you are likely to find more of it. In the U.K., 85 percent of women who die of causes connected to pregnancy or childbirth have an autopsy, versus 49 percent in the Netherlands and 29 percent in France.</p><p></p><p>“I’m pretty sure we’re very close, if not perfect, at identifying all of our maternal cases. So obviously our rates look higher,” Knight said.</p><p></p><p>The U.S. lags behind the U.K. in this area too. In the U.S., for deaths listed as related to pregnancy on death certificates from 2011 to 2013, the autopsy rate is estimated at close to 60 percent, said Dr. William Callaghan, chief of the Maternal and Infant Health Branch of the U.S. Centers for Disease Control and Prevention. “There is little to no standardization regarding autopsy,” he said. “States and even localities have their own practices.”</p><p></p><p>Last year, at the age of 42, Helen Taylor had almost given up hope she would ever hold her own baby. After 12 years of trying, and three unsuccessful cycles of in vitro fertilization provided free by the NHS, the chances looked slim.</p><p></p><p>Balancing her job as a primary school teacher with IVF treatment was “incredibly hard,” she said. After one appointment, she had to lead a sex education class, “talking about eggs and sperm.”</p><p></p><p>“You had to leave it behind, leave it in the car, and then go into the classroom, put a smile on your face and try and forget about it.” She paused. “You start to bury it a bit.”</p><p></p><p>After the third failed IVF cycle, a private fertility doctor had bluntly told her the few eggs she had were “poor quality.”</p><p></p><p>“You’re really scraping the barrel,” he said.</p><p></p><p>Devastated but determined, Helen and her partner Marcus decided to pay for one final attempt. This time they opted for an egg donor. She was 34 years old, a Caucasian brunette with blue eyes. That’s all they knew.</p><p></p><p>After implanting a couple of embryos in Helen’s womb in November 2016, her doctor told her to wait two weeks before taking a pregnancy test. But after 10 days, Helen noticed some light spotting: the familiar sign of failure. The next morning, her birthday, she just wanted to get the bad news over with. Three minutes later she was staring at a pair of blue lines. After another four tests, she let herself believe it was true.</p><p></p><p>Maternal care in the U.K. and the U.S. begins to diverge early in the first trimester. When she was less than a month pregnant, Helen shared the news with her family doctor, following the NHS recommendation to do so as soon as possible. In the U.S., the American Congress of Obstetricians and Gynecologists says care should be initiated by 10 to 12 weeks, and the first point of contact is likely to be an OB-GYN practice. In Britain, it’s usually a community midwife, and Helen was put in touch with the local branch in Sudbury.</p><p></p><p>A kindly 40-something woman led the first meeting, known as the “Booking Appointment,” and talked Helen through what to expect from the next months. As a first-time mom, she would be scheduled for 10 prenatal sessions (which would have been seven sessions if this were her second child), and was reassured there would be no limit if she had trouble.</p><p></p><p>They spent over an hour going through Helen’s past medical history, checking her weight and blood pressure, testing her urine and discussing diet and self-care. The midwife encouraged Helen to consider the NHS “Bump, Birth and Beyond” prenatal classes, a breastfeeding workshop, screening tests for fetal abnormalities and immunizations. She asked whether Helen had concerns about her mental health or domestic violence. (She didn’t.) Screening for both is mandatory in the U.K., but not in the U.S.</p><p></p><p>To each midwife appointment Helen brought her NHS pregnancy booklet — “maternity notes” — given to every expectant mother. It is designed to ensure that all risk factors are considered, with checklists of questions and space for the midwife’s comments on mom and baby’s progress. At delivery, this booklet provides useful information to the medical team.</p><p></p><p>Perhaps the biggest difference compared with the U.S. is the way pregnancies are quickly triaged into two broad categories: low or high risk. Low-risk women — those deemed unlikely to have complications — account for 45 percent of pregnancies, and see a midwife every four weeks. A quarter of these women will end up being escalated to the care of an attending obstetrician during or just before labor. But if a pregnancy is uneventful it is possible, even probable, that the woman will not see a doctor over the entire nine months.</p><p></p><p>In the U.K., all planned births, from home deliveries to complex C-sections, are attended by midwives, whereas in the U.S., midwives are present at just 8 percent of births. Helen would have liked to deliver on a midwife-led birthing unit, but her pregnancy was high risk from the outset because she was over 40 and had conceived by donor IVF, both of which increased the likelihood of complications, including preeclampsia and hemorrhage.</p><p></p><p>Other factors that can elevate risk include pre-existing medical conditions, increased maternal age or substance abuse. Risk factors may also relate to the baby: If there is more than one in the womb, or if the fetus is small for its age, moves less than expected, or in the last days of pregnancy is positioned breech (with bottom or legs at the lowest point in the uterus).</p><p></p><p>High-risk women see an obstetrician and a midwife, as well as a specialist if the mother has a co-morbidity — a disease or disorder that could complicate pregnancy and childbirth. Their deliveries take place on hospital labor wards, overseen by an attending obstetrician. Helen’s midwife automatically checked the “location of birth” box that said “Labor ward.”</p><p></p><p>Risk can change as pregnancy progresses. With this in mind, many hospitals are designed with their maternity unit next to the labor ward. “We are very good at sliding people between the high- and low-risk models of care,” said Sally Collins, associate professor of obstetrics at the University of Oxford. Or, as Helen said to Marcus, “No one can know what’s going to happen. You better cover all your contingencies.”</p><p></p><p>Helen went back to the IVF clinic for an early ultrasound scan. The NHS routinely offers two ultrasounds for every low-risk pregnancy: at 12 weeks and 20 weeks. High-risk women may be scanned more regularly.</p><p></p><p>As the sonographer moved the probe over Helen’s jellied tummy, she paused.</p><p></p><p>“There isn’t just one heartbeat. There are two.”</p><p></p><p>“Oh my god, oh my god, oh my god.”</p><p></p><p>“Does she say anything else?” the sonographer laughed, turning to Marcus.</p><p></p><p>Despite her excitement, Helen knew twins increased the likelihood of complications. She was booked for a scan every two weeks from 20 weeks, and then would see a doctor for 10 minutes to talk through the results. More business-like than meetings with the midwife, these appointments would give Helen a formal reassurance that the pregnancy was going according to plan.</p><p></p><p>The first trimester started with nausea, but by the second, Helen was in her element. “It was brilliant,” she said, beaming. “You’re in a position where you can tell everybody, everyone knows, you’ve got a bump but it’s not massive and weighing you down.”</p><p></p><p>An ongoing complication of pregnancy for Helen was over-Googling. “I would go to the midwife with a list of questions that I was worrying about,” she said, such as what might be causing a rhythmic beat, not as fast as a heart pumping, deep in her abdomen. “Oh, that’s probably baby hiccups,” the midwife said. “Totally normal.” Her WhatsApp group of six other moms and dads from prenatal classes added to this pool of practical wisdom.</p><p></p><p>As if on a timer, at 28 weeks — the beginning of her third trimester — Helen’s usually low blood pressure started to rise. Her feet swelled, then her ankles, then her calves: the telltale signs of preeclampsia. Although Helen’s blood pressure was at the upper end of normal, the midwife sent her to the hospital twice a week for closer monitoring. There, an obstetrician prescribed labetalol — a drug that widens the arteries to lower the pressure.</p><p></p><p>On the 34-week scan, the babies were fortunately in the correct position: head-down, four feet kicking above Helen’s navel. A vaginal delivery still looked likely.</p><p></p><p>Helen wanted her delivery to be as natural as possible, even though she was resigned to the necessity of being induced at 37 or 38 weeks if the babies hadn’t arrived by then, standard practice for the delivery of twins.</p><p></p><p>“Natural birth” — now called “physiological birth” within the midwifery profession — is a common request in the U.K., and not something women have to fight for. It tends to be defined by what it is not: no induction, minimal medical involvement and certainly no cesarean section. Every pregnant woman is encouraged to write a birth plan with her midwife, which includes the desired location of birth, medical interventions mom would agree to, the role a partner is to have (cutting the cord, for example), and forms of acceptable pain relief.</p><p></p><p>Making it more likely that U.K. women get the kind of delivery they want is due to the influence of midwives. The NHS employs over 21,000 midwives, compared with 4,710 OB-GYNs. Unlike obstetric nurses in the U.S., midwives in Britain do not work under the auspices of obstetricians. Midwives are independent practitioners in their own right, but trained to recognize when a woman or her baby is in trouble and needs an obstetrician’s eye.</p><p></p><p>“A midwife looks at a pregnant woman and sees a beautiful, normal, physiological, wonderful event about to happen,” Oxford’s Sally Collins told me. “An obstetrician looks at a pregnant woman and sees a disaster lying in wait for them. If you’ve got these two health care professionals working together as a team and meeting in the middle, what you end up with is really good health care. The normal women are normalized and the high-risk women are medicalized.”</p><p></p><p>Thirty-five weeks pregnant to the day, Helen was at home in the twins’ new jungle-themed nursery. Her induction date was over a fortnight away, but she was already hanging up the tiny clothes handed down from her nieces.</p><p></p><p>At 4:30 p.m., the phone rang. The line was crackly, as usual in her rural neighborhood, but she could just make out the voice of a midwife at the other end.</p><p></p><p>“Your urine reading is not good, the protein level is very high. You need to come in.”</p><p></p><p>Helen had a doctor’s appointment the following morning and suggested she could talk through the results then.</p><p></p><p>“No, you need to come now.”</p><p></p><p>Hearts racing, Helen and Marcus drove the 40 minutes to West Suffolk Hospital, forgetting their pregnancy notes in the rush. On arrival, the midwife repeated the urine test, which showed 370 mL/deciliter of protein, or more than 12 times the normal level. Helen’s blood pressure was up, too, exacerbated by anxiety. Another midwife strapped a fetal heart monitor around Helen’s large bump: 138 and 125 per minute, both babies beating perfectly normally, oblivious to what was about to happen.</p><p></p><p>Helen’s preeclampsia had worsened rapidly. In line with NICE protocol, the obstetrician-on-call decided that immediate induction and delivery was imperative.</p><p></p><p>Helen was given a steroid shot to accelerate the babies’ lung development over those final hours. Entering the world five weeks early, the twins might struggle to breathe unassisted.</p><p></p><p>It was the end of a weeklong heatwave in the U.K. with temperatures over 90 degrees, the hottest June days in 40 years. Helen settled into a six-bed bay on ward F11 for the night. The window safety catches opened less than a hand’s breadth and there was no air conditioning. Three other women were on the ward, too, separated by disposable fabric curtains.</p><p></p><p>“They’re going through their own experiences and you don’t really want to share that, but because they’re next to you, you do,” Helen told me later. Two were moved to the labor suite in the early hours as their deliveries progressed, while the remaining woman endured the first stages of labor that night, gasping with each contraction.</p><p></p><p>The next morning I met Helen for the first time. Wearing a loose jersey dress, she was propped up in bed to ease her back pain, with her legs stretched out, shiny and swollen as though a needle might pop them. She had made herself at home, unpacking her pregnancy kit: a half-liter bottle of Gaviscon antacid, a large tangerine-colored birthing ball, “To Kill a Mockingbird,” cereal bars, and “What to Expect When You’re Expecting,” the American pregnancy Bible. As 3 milliliters of prostaglandin hormone were infused through a pessary (a ring-shape device which sits in the vagina and delivers medication to start the contractions), Marcus fell asleep in the chair beside her.</p><p></p><p>After 24 hours in the hospital and three pessaries, not much was happening. Helen’s Bishop’s score was five, meaning that her cervix was still too narrow for delivery. “I had some period cramps and a little bit of backache,” Helen said, “but I’m meant to be having full-on contractions, and there was just nothing, which I really wasn’t expecting.”</p><p></p><p>It was agreed that the next day an obstetrician would break Helen’s waters. “It sounds like a hook,” Helen recalled. “You have to have your legs up in stirrups and then they literally find where the cervix is and tear [the membranes], which was incredibly painful,” so bad that she had to be on a painkiller, nitrous oxide, known as “gas and air.” A syntocinon drip was started at 6 milliliters per hour to coax the uterus toward delivery. Helen was allocated her own midwife for the day, and was pleased that this woman “was totally focused on us.”</p><p></p><p>After examining Helen’s cervix, still far from the 10-centimeter dilation needed for active labor, the obstetrician increased the drip. This happened four times over the course of the day.</p><p></p><p>“I got more and more disheartened because I was really set on a vaginal birth and it all being as natural as possible,” said Helen. After eight hours, she had reached 60 milliliters per hour, the recommended maximum amount. The obstetrician agreed to go one dose higher. Without saying a word, she seemed to understand how much Helen wanted to avoid surgery.</p><p></p><p>During the last half hour on the drip, Helen anxiously searched the U.K. parenting website Mumsnet on her phone to see what other women had done in her situation. “I thought, could I just leave it and go another day and see what happens?” But with her waters already broken, the risk of infection was too high.</p><p></p><p>By 10 p.m., Helen was exhausted. Other than a hurried slice of toast and jam for breakfast, she hadn’t eaten all day. “It was definitely my decision to say I’ve had enough of being on the drip, it’s not working and I can feel it’s not working.”</p><p></p><p>The obstetrician nodded.</p><p></p><p>“We’re going to have to do a C-section.”</p><p></p><p>For Helen, this felt like a failure.</p><p></p><p>NHS doctors and midwives are working together to reduce the number of cesarean sections in the U.K. C-sections are one of the most common operations in the world (and the most common inpatient surgery in the U.S.), but far from all of them are necessary. Incidence of surgical births has been steadily rising — from one in 10 births 30 years ago, to almost one in four today. For the U.S., this number is even higher: one in three pregnancies end in a C-section.</p><p></p><p>Most are emergency procedures, but too many are elective. The World Health Organization suggests that an “ideal rate” of C-sections is 10 to 15 percent of total births, which would maximize survival of mothers and babies without causing needless complications.</p><p></p><p>In the U.K., many hospitals are seeking to reduce the number of C-sections that are requested by patients but are not medically indicated. The NHS supports vaginal delivery for even complicated presentations, sometimes when the baby is in the breech position (head uppermost), commonly for twin deliveries and often after a mother has had a prior C-section (known as vaginal births after cesarean, or VBACs). Counseling and individualized birth plans have enabled skeptical women to choose a vaginal delivery tailored to their needs rather than default to surgery.</p><p></p><p>Besides the immediate dangers, including postpartum hemorrhage and infection, C-sections increase the risk of problems in subsequent pregnancies. The placenta is more likely to embed on an old cesarean scar, where the uterus is thinner, and sometimes invades the uterine muscle, which can cause serious organ damage or even death.</p><p></p><p>NICE states that women should have the right to choose a C-section, but many hospitals in the U.K. are extremely reluctant to perform them unless strictly necessary or if the woman is diagnosed by a psychiatrist to have tokophobia, a fear of childbirth.</p><p></p><p>Jac Reeve, an attending obstetrician and gynecologist at West Suffolk Hospital, said she’s “very anti” performing C-sections simply because a patient wants one. “I take the ‘first do no harm’ principle as fundamental,” she said. “For me, cutting someone open when there is no need to is first doing harm.”</p><p></p><p>Nevertheless, when options for a vaginal birth have been exhausted or deemed unsafe, emergency cesareans can be the only choice for mom and baby. That was Helen’s situation.</p><p></p><p>On Sunday night at 10:30 p.m., Helen was prepped for surgery. The anesthesiologist, obstetrician and a midwife each carefully explained to Helen every stage of what was about to happen and she consented.</p><p></p><p>“I was petrified,” she recalled. “I probably looked very calm. I’m almost glad it happened that quickly, because if I’d have had time to sit and think about it, I’d have felt even more scared.”</p><p></p><p>She perched on the edge of the operating table in the blue backless gown she had worn all day, not resisting as an IV drip was placed in her arm. She leaned forward as the injected local anesthetic tingled her lower spine before the larger epidural needle went in. The anesthesiologist tapped her thighs to test the numbness as it spread. He touched an ice cube to Helen’s leg, then over her tummy, asking if she could feel its chill.</p><p></p><p>A surgical drape was hoisted, dividing the intimacy of expectant parenthood from the business of surgery. At Helen’s side sat Marcus, togged in navy scrubs, a yellow cap and disposable booties. “I look like a doctor now,” he said. Three senior midwives stood around the couple, soothing them with jokes and stories.</p><p></p><p>“This is going to feel like someone washing up in your stomach,” said the obstetrician. Scalpel to skin at 11:53 p.m. “I don’t know why, but I kept waiting for the knife to go in,” Helen remembered. “Obviously, I wouldn’t have been able to feel that. It was only then that I felt this rummaging sensation. They’re in!”</p><p></p><p>One of the midwives leaned firmly on Helen’s stomach to push the twins towards the incision. Even though she hadn’t been allowed to eat before surgery, Helen was sick four times, and felt relief only after a shot of anti-nausea medication.</p><p></p><p>Helen listened to her son and daughter before she saw them, relieved that their lungs were strong enough to cry. Those first screams in stereo were the happiest sounds of her life. It took 15 minutes until she finally held them, one in the nook of each arm, just 5 pounds, 1 ounce, and 5 pounds, 6 ounces, swaddled and topped in pink and cream knitted hats. Helen stroked a spot of milky vernix from her son’s cheek. Marcus took a picture on his iPad.</p><p></p><p>“It’s strange, because I look at the photos now,” Helen said, “I’m cuddling these two babies, and I think to myself, ‘I was bleeding out at that point.’”</p><p></p><p>It was an emergency landing, but everyone survived. Pilots learn early in their training that every descent is a calculated crash, nothing less. The same is true for obstetricians.</p><p></p><p>For Helen, the post-op hours passed in a haze. “I may have slept slightly. I remember being checked on a lot, and they’d ask me if I could feel my legs yet, and I couldn’t,” she recalled. “They were monitoring my blood pressure the whole time, and they’d come in and take readings every so often.”</p><p></p><p>The obstetrician who performed the C-section visited Helen the next morning on her rounds. “You had me really worried there,” she said, her poker face breaking into a smile.</p><p></p><p>A midwife arrived to ask Helen if she wanted to express colostrum, the first milk, for the twins in NICU. “It was just what I needed really because I felt slightly disconnected because they weren’t with me,” Helen said. “By doing that, I felt like I was helping.”</p><p></p><p>Another midwife came to check Helen’s pain level. Halfway out the door, she turned back, “You don’t look like someone who’s lost three liters of blood.”</p><p></p><p>An hour later, when I went to see Helen, she told me about the midwife’s comment. I had to agree. Helen struck me as animated, even vibrant, showing few signs of the physical and emotional strains of the past 24 hours. I thought to myself: “How should someone look who for 12 years has longed for a baby, and then gets two?”</p><p></p><p>Contrary to what some obstetricians still believe, delivery does not always cure preeclampsia. Its course is variable, with the potential for devastating outcomes post-partum. Helen was offered a transfusion two days later to recover some much-needed energy after the hemorrhage. “My first reaction was, ‘No, I don’t want any more medical intervention,’” she said, but after talking to her sister-in-law, who had also suffered a hemorrhage with her first baby, Helen changed her mind. Although she felt somewhat better after the transfusion, her blood pressure remained stubbornly high, peaking at 177/97 three days after the birth. She was prescribed a drug to help prevent these spikes, which she would continue to take for several weeks.</p><p></p><p>On July 4, after 11 days of recovery and care, mother and babies left the hospital, finally free.</p><p></p><p>In both the U.K. and the U.S., the demographics of maternity are changing. Women tend to delay motherhood to an older age, and obesity and pre-existing conditions like diabetes are more common. Despite the associated rise in high-risk pregnancies, the U.K. government set an ambitious goal in 2015: to reduce maternal mortality by a further 20 percent before 2020, and 50 percent by 2030. MBRRACE is expanding its mission, to learn from near-misses as well as fatalities, morbidity as well as mortality. The U.K. Obstetric Surveillance System is part of this effort, and sends out monthly forms to hospitals nationwide asking about recent cases of specific severe maternal morbidity. It is not mandatory for clinicians to reply; nevertheless, 93 percent of the cards are returned with information.</p><p></p><p>U.K. maternity services, though, face a looming crisis. One in three midwives in England is now in his or her fifties or sixties — a “retirement time-bomb,” according to an October 2015 report by the Royal College of Midwives. Funding for training has been cut, and pay has been frozen. Diminished numbers of practitioners are entering and staying in the profession, while total births rose by 10,000 last year. Currently there are 3,500 fewer full-time midwives in England than required for the volume of work. This, as well as a shortage of beds, forced 40 percent of maternity units to close temporarily at least once in 2016.</p><p></p><p>“The single biggest thing we can do in the U.K. to improve obstetric care is to value our midwives,” Collins said. “Not just train more but retain the quality we have got. We are losing them like a hemorrhage, and it’s desperately sad.”</p><p></p><p>The heaviest things Helen picks up these days are the babies. Resuming her old habit, she incessantly Googles the significance of each of their new sounds and gestures.</p><p></p><p>In the U.S., new mothers are usually sent home with only their family and friends for support. While the newborn is supposed to see the pediatrician early and often, the mom typically doesn’t see her doctor for a follow-up for four to six weeks, which can delay recognition of postpartum depression and other serious problems.</p><p></p><p>In Helen’s case, a community midwife and a “health visitor” (an NHS professional who takes over fully from the midwife two weeks postpartum if everything is going well) dropped in the day after she and the twins arrived home. In the first two weeks after discharge, every woman in the U.K. should receive four visits, or more if either mom or baby is having problems. There is also a 24-hour obstetric triage helpline that new mothers can call with any concerns.</p><p></p><p>When I visited Helen one recent sunny morning, she sat in her living room, the music from the mobile on the babies’ downstairs crib tinkling in the background. “It’s funny how naïve I was,” she told me, remembering her pre-birth expectations that feeding twins at the same time would be a breeze. “It’s really tricky!” Like an athlete, she’s tested different techniques with the help of her coaches, the neonatal nurse and lactation consultant, both NHS employees who help with premature babies and suckling difficulties. In bed, surrounded by a dam of pillows, two pairs of blue eyes staring up at her, Helen likes to tuck each baby under an arm and support their heads in her hands, known as the “rugby ball hold.” After feeding, brother and sister fall asleep in a star pose, arms stretched up and heads together. The health visitor told Helen it’s a sign of contentment.</p><p></p><p>There is barely a minute in the day for Helen to worry about her own recovery. If she does, the twins are on her mind: “I do need to be healthy, I do need to get a certain amount of sleep because otherwise I’m no good to these babies. It’s always in terms of, am I going to be strong enough to look after them?” Marcus spends time with his son and daughter after work in the evenings so Helen can get some rest, and the babies’ grandparents are regular visitors.</p><p></p><p>Luckily, the health care team is keeping an eye on mom. “I didn’t have to be too worried, because they were being overly cautious for me,” Helen said. The midwife suggested compression stockings to guard against clots. Helen’s scar will be troublesome for a while longer, but there has been no infection or bleeding, and driving is now possible. She can see her anklebones again. Her latest blood pressure is within the normal range, and she is due to come off the tablets in several days.</p><p></p><p>At the six-week appointment in the local clinic, the babies are on track with their weight — in fact they’re “thriving.” It's the word all mothers are relieved to hear. The health visitor laid the twins down, turning her full attention to the other person in the room. Any pain, exhaustion, sadness, bleeding, anxiety, headaches, dizziness?</p><p></p><p>She starts with a simple question:</p><p></p><p>“So, Helen, how are you?”</p><p></p><p>Nina Martin of ProPublica contributed to this article.</p>
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