“Artisanal obstetrics” is deadly folly


At the turn of the 20th Century, obstetricians were deeply concerned about the inherent dangers of childbirth. Both infant and maternal mortality were approximately 10X higher than they are today. Obstetrics Prof. Joseph De Lee thought that preventive care was the answer and recommended routine use of forceps. The result of that hubris was disaster.

Based on a theory that childbirth is inherently ‘pathogenic,’ prominent American obstetricians recommended sweeping reforms. Leaders exhorted their colleagues to mitigate the perils of childbirth by performing operative deliveries prophylactically — a leap that resulted in catastrophic suffering…

Sadly, we don’t seem to have learned much about the dangers of hubris in obstetrics. Based on the theory that childbirth is inherently normal, a prominent American obstetrician is recommending sweeping reforms. He exhorts his colleagues to mitigate poor outcomes in childbirth by reducing the C-section rate — a leap that has resulted elsewhere (the United Kingdom) in catastrophic suffering.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]There’s not much daylight between artisanal obstetrics and the deadly Campaign for Normal Birth.[/pullquote]

That American obstetric leader is Neel Shah, MD, and ironically, he is the one who wrote the quote above.

Recently he recently had this to say on Twitter:

The best obstetricians I know *are* artisans, using their hands, minds, and hearts to solve for the gray zones in our field

The opposite of artisanal is industrial…

Not exactly. According to Oxford Dictionaries, artisanal means “a product made in a traditional or non-mechanized way.“

In that sense, the opposite of artisanal is modern and as between the two, modern obstetrics is far safer than traditional practice.

Dr. Shah’s Team Birth Project aims to reduce the C-section rate by practicing artisanal obstetrics.

Avoiding C-sections is also better for many moms. With Cesareans, there’s a longer recovery period, a greater risk of infection and an association with injury and death. And most are not medically necessary, says Dr. Neel Shah, who directs the Delivery Decisions Initiative at Ariadne Labs.

“We’re fairly confident that when you look nationally the plurality — if not the majority — of C-sections are probably avoidable,” says Shah.

Such beliefs probably sound familiar; midwives, self-proclaimed avatars of “traditional” childbirth practices, have been promoting them for decades.

No doubt Dr. Shah believes this every bit as fervently as Dr. De Lee believed in the need for widespread use of forceps. But this belief — that C-sections are “bad” and mostly unnecessary, was the foundation of the Royal College of Midwives’ Campaign for Normal Birth and we all know how that turned out.

Sadly, there’s not much daylight between artisanal obstetrics and the deadly Campaign for Normal Birth. Both focus on process (C-section rates) and assume that good outcomes (low perinatal and maternal mortality) will inevitably follow.

That’s not what happens. The RCM was forced to shutter their campaign in August of 2017 after tens, possibly hundreds, of babies and mothers died preventable deaths in the pursuit of lower C-section and intervention rates.


Tens of thousands of mothers and babies in England were harmed by potential lapses in maternity care in the past two years, the BBC has learned.

More than 276,000 incidents were logged by worried hospital staff between April 2015 and March 2017 – the equivalent of one mistake for every five births.

Most were minor or near misses, but almost a quarter of the incidents led to the mother or baby being harmed – and in 288 cases there was a death.

The cost has been astronomical.

Maternity is also the biggest cause of clinical negligence payouts, accounting for half of the cost of all claims.

Last year, £1.9bn of claims were made – a rise of 91% since 2004-05.

Is this what we wish to emulate? Apparently so since Dr. Shah has publicly aligned himself with UK midwifery leaders and their Normal Labour and Birth Research Conference.

There’s an additional reason why artisanal obstetrics is likely to be deadly. That’s because failing to follow guidelines leads to maternal deaths. The US maternal death rate is viewed as a scandal and the State of California lauded as the only state that has lowered its mortality rate.

What did they do in California?

…[I]mplementing large-scale interventions by integrating providers with public health services, begins with a bundle, a quality improvement toolkit defining best practices and the creation of learning collaboratives. The largest of CMQCC’s learning collaboratives, which includes 99 hospitals that collectively report more than 250,000 annual births, reduced severe maternal morbidity among women with hemorrhage by 20% using an obstetric hemorrhage toolkit.

A cornerstone of their approach is:

Hospitals must implement and sustain a standardized approach to managing known obstetric complications and emergencies involved in pregnancy and childbirth.

That is the exact opposite of artisanal obstetrics. A standardized — modern and industrialized —approach saves lives!

Artisanal obstetrics is deadly folly. It’s already been tried on a large scale in the UK and it has led to tremendous tragedy. Failing to follow standardized protocols is known to be a factor in preventable US maternal deaths. It’s an affection; it plays off the American upper class obsession with artisanal products, which is fundamentally a way to flaunt status not a reflection of quality.

Obstetricians have learned this lesson the hard way. A century ago, very little in obstetric practice was codified. Care was artisanal, variable, and sometimes dangerous.

Why go back to that?

Dr. Shah would do well to heed this warning and hopefully he will, since he is the one who actually wrote it.