Wow, who would have predicted how this episode turned out… I was unprepared for the couple who relinquished their baby born with spina bifida. Let’s talk a bit about spina bifida. It is one of several types of birth defects categorized as neural tube defects (NTDs). 

If you are thinking that you have never or rarely heard of this birth defect, it is highly likely because the incidence of these have declined greatly since folic acid became added to foods in 1998. The current incidence is 1 in every 2,875 births in the United States, according to the Centers for Disease Control. Folic acid was found to be a major protective factor in the prevention of NTDs and was subsequently recommended to be added to all bread products. Prior to the fortification of foods with folic acid, the incidence of spina bifida was around 1.06 per 1000 births. 

This is a notable example of a public health problem identified and addressed in a most efficient and cost-effective, low-risk way.

A spina bifida is created when the spinal cord, which normally closes during fetal development, doesn’t do so, and a space is created in the area where the opening remains. In the most severe form, the spinal column protrudes through to the outside of the body. The bifida must be surgically repaired after birth, and there is usually some degree of lasting impairment, like leg paralysis below the point that the spine that is affected, as well as orthopedic problems. Affected individuals can have difficulty with bowel and bladder control, as well as having spinal fluid accumulate in the brain. 

In the 1990s, maternal fetal medicine specialists perfected surgical techniques to repair spina bifida while the baby was still in utero, noting that there was a lesser degree of paralysis when repaired well before the fetus had completed development. 

Fetal surgery is performed today, usually somewhere between 22 and 26 weeks of gestation. During these surgeries, in what can only be described as amazing, the mother’s uterus is incised, the baby gently handled by the surgeon and the spinal defect repaired, after which the baby is tucked back into its mother’s womb and the uterus sutured closed. While there are substantial risks with fetal surgery, there are benefits to repairing some fetal defects while the baby is still developing. 

Every parent expects that their baby will be perfect at birth and when that is not the reality it is devastating. New parenthood is difficult enough in so many ways. Adding a special needs child to the situation changes the family dynamic dramatically. While it was difficult not to judge the couple giving their baby up, I suppose that only those among us who have walked in their shoes could truly understand. 

To another point in the episode, I hope you enjoyed midwife Trixie’s (played by Helen George) eloquent interactions with the Poplar council regarding the invaluable worth of the services provided by the Nonnatus House midwives as much as I did. She came armed with data and proved “large and in charge” with her remarks, despite the council leader’s attempt to diminish her knowledge and position as a midwife. 

Her statement that the council was spending 42% less via using the midwives, as the number of patient visits actually increased, highlighted the cost efficiency of midwives that is just as prevalent today. In a systematic review on the cost of maternity care models* published in 2023, the author notes, “An increase in the proportion of midwife led care from 8.9 to 40% would yield annual cost savings of U.S. $539 million for public funders, and a similar shift toward midwife led care would save the private health sector U.S. $1.35 billion.” 

Now that’s impressive! 

*Martin E, Ayoub B, Miller YD. A systematic review of the cost-effectiveness of maternity models of care. BMC Pregnancy Childbirth. 2023 Dec 13;23(1):859. doi: 10.1186/s12884-023-06180-6. PMID: 38093244; PMCID: PMC10717830.