Life & Culture

The unit that delivers

Jerusalem's Shaare Zedek maternity unit might just be the busiest in the western world - and the most efficient.


Birth rates are sky high and intensive care baby units are running out of space for cribs. But while British hospitals might buckle under these conditions, Jerusalem's Shaare Zedek Medical Centre is thriving.

In fact, the growth in demand at Shaare Zedek's maternity department has been larger than most British hospitals can imagine. In 1992 there were 4,600 deliveries; last year there were 14,000. Shaare Zedek believes that this makes it the busiest maternity hospital in the western world, and is currently building a five-storey extension to better accommodate the human traffic.

Midwives are not just managing the pressure, they are excelling - the figures confirm this. In Britain, the fact that one-in-four babies is born by caesarean section is a source of great concern, and there is consternation in Israel that rates are in the high teens. At Shaare Zedek the rate is just 11.5 per cent. There, only five per cent of deliveries involve instruments, while British hospitals average well over double that. Perinatal mortality rates are low, at six per 1,000.

Shaare Zedek's director general Yonatan Halevy says there are two main reason for these statistics. "Fifty per cent of the gap is to do with quality - quality of care, the devotion of the obstetricians. The other 50 per cent reflects our patients. When you serve a population of large families - a woman who comes to give birth to her fifth child where the previous four or five were born naturally - her chance of needing a caesarean is probably much lower than a London mother who comes to give birth to a first or second child."

However, the low caesarean rate is not simply a question of demographics. Says Halevy: "It is very fashionable to go for an elective caesarean these days with no medical invitation. We are very stubborn about that.

In England you have to write down everything

"We do it only very selectively when the woman absolutely insists. That is after she gets all the explanations telling her why she shouldn't do it."

A visit to the hospital, with its 15 delivery rooms and 150 postnatal beds, tells the story of its success more than any statistic. Though an average day brings 40 new babies, the atmosphere is calm and the place runs like clockwork - or in midwife Gabriel Louis-Adut's words, "it's like a factory here". Relaxing after the birth of her third baby Tzipora Gerber, who is originally from Manchester, describes the hospital as "very efficient".

So what is the secret of Shaare Zedek's success? Staffing levels are high, and all the midwives are regulars - unlike in Britain, there is no need for agency midwives, who come at a premium. And they are well stocked with supplies.

Midwife Rochelle Schwebel trained and worked in her native London before coming to Israel five years ago, and still flies to London for occasional stints at the Royal Free Hospital. There, she finds that financial constraints are taking their toll on even basic supplies. "One thing that really struck me when I was back was that I was constantly looking around for equipment, while here things are better stocked and I don't need to go searching," she says.

The turnaround of birthing rooms for the next patient is astoundingly fast. In Britain, the midwives are expected to take part of the responsibility for preparing rooms. At Shaare Zedek, a team of three orderlies sweeps in, cleaning the place from top to bottom, changing sheets, and replenishing equipment.

And the hospital has managed to use the fact that it is so busy to its advantage. "Perhaps most importantly, our large number of deliveries affords us a level of experience which gives us the medical confidence to reduce hospital stays without ever compromising on the safety of either mother or infant," says Halevy.

On the wards, midwives stress that this is not just management-speak. Schwebel says that while she was used to what she calls "a lot of defensive practice" in London, this is less widespread at Shaare Zedek. In particular, the strong medical leadership ensures a culture of confident decision-making. This is a major factor in the low caesarean and instrumental birth rates, she believes.

The differing legal emphasis between Britain and Israel also means that her patients at Shaare Zedek receive more of her attention than in London, where she is often tied up with paperwork. "In England, [as a midwife] you have to write down every little thing because of fear of litigation; here you don't," she says.

Shaare Zedek's staff admit that they cannot take all the credit for the smooth operation of their maternity department - the patients play their part. Because so many women have already given birth many times before, they are experienced and speedy in labour. Schwebel says with a laugh that she "catches" babies "because when it's not the first birth they give birth very quickly - it's like a conveyor belt."

The reason for the high proportion of experienced mothers is that as many as eight in 10 maternity patients are religious, either Jewish or Muslim. In Jerusalem, mothers can choose their hospital, but Shaare Zedek is the favourite among the religious. In part this is because it was established in 1902 as an Orthodox hospital and continues to run in accordance with halachah and employs a majority of devout staff. "The staff have the right idea about who is really in control," says Garber. "They do their best medically but they know it's Hashem."

The popularity with religious women is also self-perpetuating - they go because so many others do. "They are from a closed society and feel that here they don't have to contend with the big wide world," says neonatology director Michael Kaplan.

Yet while Shaare Zedek's demographic means easy births on the one hand, it also brings its challenges. Jerusalem's Muslims mostly choose Arab-run hospitals in East Jerusalem, and when they go to Shaare Zedek it is often because there is a complication. This means Shaare Zedek's population of intensive care babies is out of proportion with the number of births. And while only one-in-five babies in the normal nursery is Muslim, in the intensive care section the ratio is double that.

"We are more advanced here in terms of technology, doctors and nurses - this is the reason they come," explains Nelly Komcam, an East Jerusalem Palestinian who is assistant head nurse of the intensive care unit. As she speaks, a baby born at 26 weeks weighing one pound and 11 ounces is in a relatively stable condition in a crib next to her.

While this disproportionate need for intensive care places a burden on Shaare Zedek, it leads to the hospital generating a message of coexistence that parents take back to their communities.

As Komcam looks after intensive care babies, Arabs and Charedim attend to their babies at close quarters.

And even the most tragic of outcomes can bring unity. Michael Schimmel, director of the Neonatal Intensive Care Unit, recalls an occasion when he cared for an Arab family that lost a baby. "I was there looking like a settler and the father was crying on my shoulder," he says.

"The effect of sharing sorrow changes something in the minds of people - it makes them realise we are not enemies, not evil."

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