On today’s segment of “Doctor’s Call”, I discussed the recent, provocative New England Journal of Medicine opinion piece written by BIDMC obstetrician, Dr. Neel Shah. I also discuss medical marijuana, its adverse effects, clinical benefits and MA policy for legal prescribing. Listen to the interesting discussion with hosts Jaclyn Cashman and Hillary Chabot here.
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“Is it Safer to Give Birth in the U.K.?”
In this article, obstetrician Neel Shah, MD suggests that most “women with straightforward pregnancies may be better off giving birth in the United Kingdom.” What prompted this opinion? Recent guidelines by the U.K.’s National Institute for Health and Care Excellence (NICE) stated that healthy women with uncomplicated, low-risk pregnancies are “safer giving birth at home or in a midwife-led unit than in a hospital led by an obstetrician.” This prompted other questions such as, ‘Are midwives safer than doctors?’ and ‘Are homes safer than hospitals for childbirth?’ Let’s look at some data. As pointed out in the article:
- 1/3 of births are via major abdominal surgery, a.k.a. Cesarean section
- C-sections are the most common surgery globally
- From 1970 to 2010, the rate of C-sections increased 500%
This large amount of major surgeries in low-risk, healthy pregnant women is not without consequences: it translates to 20,000 avoidable complications in young, otherwise healthy women. And it comes at a cost of $5 billion! Dr. Shah’s take-home message: the American health system encompasses a ‘do too much’ philosophy and practice, and this can lead to major complications including severe infection, hemorrhage (bleeding) and organ damage. Key differences between home birth in the U.S. vs the U.K.:
- the U.S. offers a lay midwife for home childbirth vs. a credentialed, qualified midwife in the U.K.
- Complications during a home delivery in the U.S. leads to transport to an E.R. that may not know the pregnant woman; vs. in the U.K. where clear protocols are in place for transfers to a hospital (location, step-by-step procedures, etc); midwives in the U.K. have a MUCH bigger role
- –> according to Dr. Shah, “We don’t have a coordinated system in the U.S. where half the countries don’t have a single midwife or OB to care for women.”
So, will these childbirth guidelines by NICE be seen in the U.S.? Dr. Shah thinks it “unlikely that U.S. OBs will support birth outside hospitals in light of gaps in access to safe, quality, coordinated care.” He also points out that 45% of 1st-time mothers in the U.K. who plan on home births get transferred to the hospital during labor. But this shouldn’t be perceived as a failure, but rather a successful implementation of established protocols and coordination of care, as patients upon transfer to hospitals have good outcomes. The U.K. guidelines emphasize that women ultimately are encouraged to give birth according to their preference and that of their family. The guidelines simply enable women and their loved ones to make informed decisions about their childbirth options. Insightful piece by Neel Shah, MD.
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Medical Marijuana in Massachusetts
What is Marijuana?
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it’s a green/brown/gray mix of dried, crumbled leaves from the marijuana plant
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it can be rolled up and smoked like a cigarette or cigar or in a pipe; others mix it into food
Adverse Effects of Marijuana
- Impairment of memory, learning and behavior (marijuana binds the CB1 receptor which is found in multiple parts of the brain, e.g. hippocampus, amygdala, nucleus accumbens ‘reward center’)
- Chronic bronchitis (just like tobacco)
- Constipation
- Cardiac (increased heart rate, vasoconstriction)
- Addiction, especially among daily users
*Adolescents –> early use (before age 15 yrs) is associated with increased brain damage than later use: change in brain structure, lower GPA, increased suspension, increased dropout, and increased unemployment
Medical Benefits of Marijuana
- not FDA-approved
- several states have approved “medical marijuana” for health reasons, e.g. treatment of nausea due to cancer chemotherapy; appetite stimulant in severe weight loss due to HIV/AIDS
Policy in Massachusetts
- A qualifying patient who suffers from a debilitating medical condition may possess a 60-day supply of marijuana IF they have a written certification from a MA licensed physician who is registered with the MA Dept of Public Health
Who is a Qualified Patient?
- over 18 years of age (with rarest of exceptions)
- debilitating medical condition includes cancer, HIV/AIDS, Hepatitis C, Crohn’s disease, Parkinson’s disease, ALS (Lou Gehrig’s), Multiple Sclerosis, glaucoma and several other illnesses
- ‘debilitating’ can refer to weakness, wasting (cachexia), intractable pain, nausea
REFERENCES
Shah – NEJM
WBUR Commonhealth – Childbirth coverage
Mass.gov – marijuana
National Institute on Drug Abuse – Marijuana http://www.drugabuse.gov/publications/drugfacts/marijuana