#49 | Dr. Neel Shah OBGYN: Agency, Dignity, & The Number One Risk Factor for Cesarean Birth

On one hand, medicine is really inspiring because we see a full range of our capabilities and medical school and then there's a lot of things that like are deeply disillusioning. Because you see the full range of our fallibility and everything that doesn't work. Yeah, C section rates in our country vary from 7% to 70% at the hospital level, so it's a full order of magnitude. What that means is the biggest risk factor for getting a C section is not a person's personal preferences or risks, but which hospital they go to.

I'm Cynthia Overgard, owner of HypnoBirthing of Connecticut, childbirth advocate and postpartum support specialist. And I'm Trisha Ludwig, certified nurse midwife and international board certified lactation consultant. And this is the Down To Birth Podcast. Childbirth is something we're made to do. But how do we have our safest and most satisfying experience in today's medical culture? Let's dispel the myths and get down to birth.

Dr. Neil Shaw and obstetrician and professor at Harvard Medical School is dedicated to improving maternity care in the United States. Think part scientist, part sociologist. And you'll see how it's working maternity care has made him a globally recognized expert in tackling one of the biggest challenges for women giving birth today, the wildly variable and sometimes extreme sectarian rate across the nation. Today, Dr. Shah talks to us about one of the simplest yet most effective solutions for improving birth outcomes in the hospital based maternity system. So Neil, thank you so much for joining us on the show today, we're very excited to hear about the work that you're doing in maternity care. And to begin we'd really like to know about your experience in obstetric school and what you learned from that and how that experienced influence the work you do today.

Short for Well, thank you so much for having me. And thank you for being enterprising and creating this podcast. I hope a lot of people listen to it. And I hope that it makes them think about how we can have a better maternal health system. And you know, just what that means for us and what that means for society and humanity in general. So, we'll just start there. Let's lay out some ambitions for your podcast.

Yeah, that's a good one.

That's why we're here.

Yep. Well, I mean, I guess, maybe a good place to start is that obstetrics school is a thing that probably never ends, but I chose to be an obstetrician at the 11th hour, maybe the 13th hour, like in medical school was the thing I never thought I was going to do. So you can pick the order of rotations in medical school. And I chose to do ob gyn first to get it over with because it was the one thing I was clearly never going to do. So me as well. You know, get it done with and then you know, it turns out Yeah, kind of liked it. Yeah, well, maybe babies being delivered, getting to introduce a family to their newest member, like, you'd have to have no salt. And I think that's cool, right? So there's no existential crisis in the middle of the night if you're taking care of people on labor. So that was cool, but then ended up becoming like pretty enthusiastic about everything. I had a hard time choosing what to do and and then I left medical school actually, for a little while, after finishing all my rotations. I found that on one hand, medicine is really inspiring because you see the full range of our capabilities in medical school and it's a lot like TV. And then there's a lot of things that like are deeply disillusioning, because you see the full range of our fallibilities and everything that doesn't work. So, I mean, this is a long story, which I'll make short but I left medical school and working in politics, ended up going to school for public policy and ended up starting a nonprofit That was working on affordability of health care. And after all that, well on my way back to this. And it was for a whole set of reasons, including the fact that I couldn't choose what to do. And I like the fact that ob gyn do primary care, and they do surgery and they deliver babies. I liked that in the prenatal clinic, you see people like 14 times in nine months, and really get to know them during a critical period in their lives. And it's sort of my window into the American way of life. I liked how the people that went into the field, care about social justice, it's not that general surgeons don't just sit when you do women's health, you have to wear it on your sleeve in a different way. And I even know, that's what I liked about them. I just liked the people that went into it. And then it turned out, that's probably what I liked about them. The only thing really holding me up was that, you know, there weren't a lot of men in the field. And so I wasn't sure if I wanted to do that. And then it turns out, my wife is an aerospace engineer at MIT, and she's been one of the very few women Her field for a long time and told me to suck it up. So I did. And here I am. And so but but all that's to say is, I think, Mike for my whole career, which now, you know, it's been well over a decade, maybe a decade and a half since all that decision making. I've not been a traditional ob gyn trainee.

So tell us what's happening today in your work and what you know that you are out there doing it. And what you're finding because we know from the little bit that we know about you that you're taking a different approach than most ob's and really trying to help the maternity care system find a new and better path.

Sure. So yeah, I'm a practicing ob gyn at Beth Israel Deaconess Medical Center in Boston. So what that means for me in the pre pandemic days, and then I had a full day clinic every week, and then I spent time in the labor for now that we've needed more capacity on the hospital side. I'm spending more Just on labor and delivery at least once a week, sometimes more often than than the rest of the time I direct a research and social impact program at Harvard. The vision statement is a world in which every person can choose to grow their family with dignity. And that frame is intentional. It doesn't have the word maternal health, it doesn't have the word childbirth even. And it's premised on this idea that well, in every humanitarian disaster, whether it's a pandemic, a war, weather events like hurricane, maternal health suffers disproportionately. And it's partially because of the direct impact of the disaster but mostly because of the indirect ways that services gets disrupted and the well being of birthing people aren't isn't prioritized. And in many ways, I think the well being of people giving birth as a bellwether for the well being of all of us. And that just requires a much wider frame and childbirth because childbirth isn't just a transient episode and lives of some people. It's the foundational episode in the lives of all people. And we needed an approach that took into account that not only is that the case, but it's a function of keeping people safe within the four walls of the hospital, but also making sure that people are well supported in the communities where they live their lives. And also recognizing that it's a gender equity issue. It's a racial justice issue, and it's also a generational justice issue. In our country, right now, there's a sense that opportunity is eroding for people. And one of the leading indicators that is quantitative and verifiable as an American today is 50% more likely to die in childbirth and her own mother was and three to four times more likely to die if she's black.

And one of the statistics that I saw online and something that you quoted was what caught my eye when you said the C section rate in one generation has gone up. 500%.

So in the early 1970s, the Cesarean rate in our  country was 5% and now it's over 32%. And if you were to pick three statistics to describe the generational change in childbirth is that over that time we've intervened in childbirth 500% more with major abdominal surgery. And for that term, infants are zero percent better off, and moms are 50% more likely to die.

And we're the only industrialized nation where it has gotten worse over these decades, every single other industrialized nation has improved significantly over the same period. Yeah. It's remarkable. So it's interesting that you pointed out the whole difference in not only the generational, but in women of color, black women, ethnicity, it just the obvious fact is this has nothing to do with women's bodies. It has to do with culture society. So what I'd love to ask you is, you never had the intention initially of going into this field. You must have of course, like any of us, you must have gone into it with certain assumptions and I would love to know the Clearly you're in the minority about of Obstetricians who are forging this path right now. And I'd love to know what assumptions you had that were just shattered early on where you just recognized these problems. And you must have started to recognize you are different from a lot of your peers, probably, or else we wouldn't be facing the problems that we're having right now.

I mean, those are good questions. I think that social progress and the business of improving systems is not about individuals. And I think part of the difference is that I have the privilege of being able to question my assumptions. But generally speaking, most of us are products of the systems that we work in. There's a quote that I love from a Dartmouth professor named Paul Belden, which is that every system is perfectly designed to get the results that it gets. I mean, I guess, pretty early on, I mean, my whole idea of medicine was based on T When I went to medical school, and so I think, right away the fact that doctors are not omniscient, that the health care system is highly imperfect. And actually what really motivated me at the beginning was that realizing that there's two forms of expertise in any healthcare interaction, first of all, healthcare is a team sport. Meaning it's a partnership between somebody who needs care and somebody who's providing it. And there's technical knowledge, which is one form of expertise. And then there's lived experience, which is another form of expertise, and that they're complimentary and that both count equally, but our system isn't designed to attend to people's lived experience very well. And in fact, there's something that we seem to have gotten backwards throughout healthcare that matters disproportionately in childbirth, which is that we, in our sharp focus on mortality and safety Forget that people have goals other than emerging unscathed from the process.

Our first podcast episode is called is a healthy mom and baby all that matters. Yeah, because it's the most important thing we all agree. But by no means is it all that matters in a good birth outcome because the assumption with the prevalence of unnecessary cesareans is like, well, let's not take any chances. Let's just do osirian let's not take any chances let's just induce you. I think that's very misleading because that is far more likely to result in a an adverse outcome. So it's a little deceptive, isn't it? And I feel like that argument implies or asserts, like, I don't want to take any chances. I just want a good outcome here but it's the argument really says if you really are after, nothing but a good outcome, nothing but the healthy mom and baby at the end is a 50% says Aaron rate really going To get you that outcome, and statistically The answer is no. Isn't the implication part of what's complicating this whole thing?

Well, there's a couple things that I think make it hard one is that let's take the C section rate example. There's no counterfactual. So what that means is like when I do a C section, I'm always right. The baby comes out looking perfect with high Apgar scores. Think well, it's a good thing. I did a C section. And if the baby comes out blue and lackluster with low Apgar scores, I'm like, well see, I should have done a C section. So it's pretty good to be me because I'm always right. And there's like, pretty much like confirmation bias all the way through. I think that's part of it. I think. The other thing is that most of the current system grew up based on historical roots. So not that long ago. At the turn of the 20th century. A lot of people died in childbirth, like it's true maternal mortality is going up. But first, we should recognize that it's the canary in the coal mine of a much deeper and wider problem because for every death, there are 10s of thousands of people who say suffer from undertreated illnesses, economic disempowerment, social isolation, everything else has been tagged on to motherhood in, you know, the year 2020 in America, but death is relatively rare still in 2020. So a lot of the current system grew up around that beer, where, you know, when chloroform thing, and Twilight sleep became a thing, there is a sort of tension between people's comfort and their control over the process. And people in the, you know, mid 20th century chose comfort over control. And yeah, it just sort of led to the system where we attend to your safety first and then we treat dignity as a secondary luxury. And now we're starting to learn especially as we examine these deaths and these injuries that are probably attending to your dignity first as a way of making you safe, right?

Yes, like this is the position I want to give birth in Yeah. The mother will almost invariably choose a safer position than what she would likely be placed into in a traditional hospital. Well, that's for sure. I mean, the only reason we give birth on our backs are because of the way anesthesia works, combined with what's convenient for the person doing the delivery, precisely.

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I want to get into a little bit about the variance and C section rate from institution to institution and what you've seen in some of your work about why that might be we know that some hospitals have a C section rate of over 50%, and others have a C section rate under 15%. So how is there such a discrepancy?

Sure, maybe just to level set? Yeah, C section rates in our country vary from 7% to 70% of the hospital level. So it's an order of magnitude. There's no other healthcare service that varies that much. And then when you account for the risk of people wish there's various ways of doing that, but you actually see more variation not less. What that means. His biggest risk factor for getting a C section is not a person's personal preferences or risks, but which hospital they go to. Now, if you're privileged enough to have the choice, and you live like in a major urban area, and you've got health insurance that offers choices, that's probably important. A lot of people don't have that choice that's mentioning both because 80% of the landmass of the United States is rural, and one in five American families lives in one of those places. And there's only one hospital and it's three hours away, or because their insurance just sort of locks them into a place. I think the other thing that's sort of important to recognize is that C section rates at the national level, hospital level and at the individual, Doctor level mean three different things, which people often don't understand. But at the hospital level, a hospital c section rate is really just telling you something about the quality of labor management. The way to have less c sections is to manage labor better means to offer more labor support. So one thing that I think c section rates can tell you reliably is how good a places at supporting people's labor. Now, anything that's complicated is that C section rate, you can harm people from doing too much too soon and from doing too little too late. And most things that we're trying to improve in health care, the right answer is zero. If you're going after mortality, you want zero mortality. You've got clarity of what the target is, and it's zero or C section rates, the safe c section rate is not zero. Right. And we don't know what it is. Because it depends on so many things. Right. And so we know it's not 70% it's definitely Yeah.

So didn't The World Health Organization do some research on that a few decades ago and find the tipping point was approximately 10%. Worldwide. WHO recommended it country level rate of 10 to 15%. Yeah, my team did a research study at 100 In 94 countries a couple of years ago, that just tried to connect the dots between a country level c section rate and the country level infant and maternal mortality rate, and saw a difference after 19%. But at the country level, what a C section it really tells you is basically how robust the healthcare system is probably more complicated answer, but it doesn't translate to a hospital should have a 10 to 15% rate.

But for those nations that can sustain a rate greater than 20%, because they have the infrastructure to do so. Is there not a footnote there that has to do with the correlation between those high rates and increased maternal mortality? There may be

Yeah, I mean, so one of the things that's a little bit of a smoking gun in our country is that most people who give birth have more than one child and if you have a C section rate the first time you've got a 90% chance of getting a C section the second time, and the first c section is pretty straightforward. And a second one's little more complicated. And the more of them you do, the more complicated it gets. And sometimes I'm doing a C section and it feels like operating on a melted box of crayons.

Yeah, and sometimes the placenta can get caught up in that tissue. First of all, obstetricians are the only surgeons that cut them the same scar over and over again, if you're a different kind of surgeon, if you're like a vascular surgeon or an orthopedic surgeon, and you have to go cut in a place you cut before, that's a bad day in your work week. For me, that's like Friday, you know, or Monday, it's like every day, and so yeah, you can't get surgical complications without doing surgery. And there's one complication in particular, that's caused by C sections called placenta accreta. Where the placenta gets caught up and all that scar tissue is well sent as an organ that only exists in pregnancy. It's a big bag of blood vessels, it's 25% of everything of the heart pumps. And when that condition occurs, people can bleed a lot and sometimes to death. And placenta accreta has become 800 to 1200 percent more common in the last one day. To generations of people and so deadly condition. So there is a relationship between C sections and mortality.

Do you try to talk women out of scheduling a C section? If they've already had one? Do you try to encourage a VBAC? What do you do to manage that risk in your practice? I mean,

in my personal practice? Yeah, I mean, I think part of what's hard is that moms are generally expected to suck it up, like moms are resilient. So if you've had a C section the first time, you don't really know what the alternative was, and then you just you're like, Well, you know, there are a number of reasons why it may seem sensible. It was confirmation bias, it was safe The first time you got through it, it's scheduled, there's more predictability. And so I do try to describe some of the statistical risks with any surgery. But including the fact that taking care of a newborn infant is harder when you've got a 10 centimeter incision in your belly that's going to take weeks to recover from and for people for whom that's compelling, or for whatever reason, they want to labor they should get the chance to do that.

Do you keep track of what your C section rate is? And are hospitals required to report those numbers? hospitals are required to report their overall c section rate numbers to the Joint Commission increasingly to insurance companies to the public. I think I haven't seen and I've only seen audits. I haven't seen that.

Yeah. So the Joint Commission processes an audit system. And I think that there's a few departments of public health that do publish publicly. And like the LeapFrog group, there's a few watchdog groups, Consumer Reports used to do at US News actually had a whole focus on maternal health where they published c section rates of a number of hospitals last fall.

Are those audited? Or did they just call the hospital and say, What is your C section rate? Because the only time I ever saw it, that was how it was conducted, and it just didn't seem very credible to me.

Yeah, I think, you know, in overall c section rate actually isn't that meaningful. What's more meaningful is the C section rate. Low Risk people, and a little bit harder to get at Burton number of reasons, but I think most hospitals now have to internally audit at the very least. And many hospitals also report individual rates back to their doctors, including in my hospital, I get a quarterly report. One of the things he started to do recently actually, as measured nurse specific c section rates, because in most of America, you know, it's the RN, that's actually managed labor.

That's such a good point to look at. I mean, that's such an obvious and good point to look at. But I haven't really heard people talking about that much before.

No, because nurses don't bill. It So is there a big variance from Do you see a big variance nurse that you get, which is basically brew lead influences your odds of getting a C section up to five fold, potentially, depending on? Yeah. And in those cases, those people who are consistently low it's worth learning from them. What are what are Are they doing and it seems to be that they're supporting labor, they're spending more time. And that's.

So again, it keeps coming back to labor support consistent and more available labor support.

Yeah, it's defining what labor support means. And maybe maybe this is a little bit of a patch. But it turns out that 90% of Sentinel events in healthcare are failures of communication anymore. So whether it's c section rates or morbidity or mortality, like the leading cause of mortality isn't what's on the death certificate, it's not hemorrhage. Like that's not the cause. That's just what happened. The difference, the difference between people who make it through episodes like that, and people who don't are right down to communication and teamwork, that's when people express concern around pain or other things and they're not hurt or whatever. Basically, the team that comes together to take care of a person and labor comes together randomly for every person every time everywhere in the world. So you can predict when a person's on flavor and They don't know who's gonna be taking care of. And then that team on its pilot voyage has become a performing or one of the most important moments of our lives. So we've put a lot of time and attention to thinking about how you do that. Well. We have a program called teen birth that basically is focused on enabling effective teamwork education room.

That's between providers, the team of providers, but also and more importantly, between the provider and the patient or the client. Yeah, primarily, the person giving birth at the center of the team. And then at minimum, in most settings, it's an RN and a delivering provider, but it could also include support people who was it turns out every inpatient room in America for the 99% of births that happened in a hospital, every room in the hospital has a dry erase whiteboard in it for some reason, usually small there In the corner, and then for nurses to talk to themselves are highly variable and the information that's on them. And we spent several years and probably millions of dollars, coming up with a solution that ended up becoming a bigger whiteboard. And it sits across the mom's head wall. we simplified the content. We made it big so that everyone can see it and understand it. It only has four components. There's a place where you write down every member of the team starting with the mom herself. That's not just the you know, people's names. It's so that for psychological safety, so everybody has a role, and they have the woman feel she can has a place and a voice to speak up.

Yep, yeah. And also, you know, in places that are very hard for the nurse to who's managing all the labor but may not feel empowered. And then there's a place where you write down things only the mother can tell you that we call preferences, but can be preferences symptoms, things that are neither like how much energy There's a place where you write down the plan, like what's happening. And the plan isn't always to do something sometimes just to monitor and support. And then this is free write down the next time that he will come back together again. And that's it. And that's so that people in labor don't feel like passengers on a plane that's being held on the tarmac with a pilot on what's happening, which is like every person in America, that's like the whole frickin thing. And it turns out that transforms care. It's amazing. Has this has this been implemented across the board somewhere? Where's the pilot? Where's this but we ran a trial with 10s of thousands of families and hundreds of clinicians across the country in Massachusetts and Oklahoma and Washington. And we found that first of all, clinicians don't need it. Even in Tulsa, like, over time, they feel like they can recover efficiency, through better communication, they actually enjoy being really aligned with the people they're caring for, and the team that they're a part of and that they Believe it helps them make better decisions over time. And then the people giving birth, they believe that have a better understanding of what's happening to them, that they have the role in their care that they want, and that their decisions influence what happened to them. The more that the huddles and the whiteboard are used, the more likely they are to believe that. So it makes us believe that maybe we've like, returned a little dignity of the process. We've also found that this seems to potentially decrease the section rates and decrease morbidity rates, everything from unexpected newborn complications to severe maternal morbidity and postpartum depression. And I'm sure it's significantly increases maternal satisfaction with their breadth of experience.

Yeah, because I think you know, a lot of times people think of patient experience as like customer satisfaction, which it's not it's about dignity and people satisfaction depends on their baseline expectations and our expectations of childbirth are very low. Like we're talking about if you walk out with a live Baby, you're like, Well, that was fine. Job well done. Yeah. But no, it feels like more meaningful that They're understanding what's happening to them and the role they want. And now we're working on scaling that up, and actually seeing if we can use this to improve, some of the injustices have touched on too, including racial equity, where I'm really hoping it helps us with agency. Because people in labor across the board, have limited agency because they're in labor. So even if you come in really, really well informed and really empowered and really privileged if you're Serena Williams, doesn't make a difference. If you don't have agency which some people have more than others, depending on whatever else is going on in our society that doles out power and privilege,

it all seems to be coming down to the root thing, the root issue being ability to communicate, to trust that your communication is going to be believed, heard, supported, and further communicated down the line.

That's the hope Trisha, you know, I would say that agency is having your lived experience matter, period. And, you know, there's something magical about a whiteboard. It's not a panacea. But it is the excuse to do I mean, putting a whiteboard in is a sleight of hand, because it's not threatening. The whiteboards are already in the room, we just make a bigger, better one, whatever, everything that's on the board are things that people already think they're doing anyway, they might not be doing it reliably for every person every time, but doesn't threaten anybody. But what it does is it creates the excuse for the actual hard work of teaming, partnering, supporting, being accountable, all those things.

And when you're speaking of agency, or you're specifically speaking about the woman in labor, having the agency to express herself, yes, I'm recognizing that. We're all products of systems. At the end of the day, I'm a systems designer. Really, there's power differentials and dynamics and those ropes. Yeah, agency is about empowering. And, and making sure that a person's lived experience, whether it was before they entered the room or what they're feeling in the room is part of the information knowing that, you know, obstetrics is like it's, you know, like midwifery and all of childbirth, the whole enterprise is fraught with uncertainty, there's no black or white at three, if someone's been pushing for three hours and four hours and five, you just have to decide what's going to happen. And so you have to make a call. Those are tough things. And right now, what happens is that people make those calls tacitly in their head, based on their technical knowledge and expertise. But they should make those decisions with all the information that should be available to them, which lives in everybody's brain, the nurse who spent more time at the bedside than anyone else, and then the person who can tell you how much energy they have, or whatever else they may want to tell you, or how much desire they have to go along with the energy, how much desire they have to keep going or were not.

Yep. So we've talked a lot about how we can improve conditions for on the end The providers, what providers can do differently from the systemic perspective? What can parents do differently? Um, I don't want to put the onus on parents too much any more than I would for the rest of us and society. So I would, you know, blow that question up and say that we all have a stake in the well being of people who are giving birth, which means when we have a literal stake, you know, birthing people matter to humanity, just leave it there. And so, we have a responsibility that comes with that stake that's shared. But right now, we don't invest in that responsibility. We treat the whole enterprise of childbirth as a cost rather than as an investment. So that applies to preparing yourself, I guess, if you're a person who's pregnant, and, you know, educating yourself to the degree that you're able to, with people within the agency that you have, for example, I mentioned that black people are three to four times More likely to die in New York City, they're 12 times more likely to die. And that's because they are in New York. Yep. I didn't know that. Yeah.

And it's how come because it's a really racially segregated city. And there's a big difference between being on the Upper East Side. And, you know, being in the Bronx, in terms of what the hospitals look like, how they're resourced, and what the communities look like, what housing looks like, fixing our country starts by helping the most vulnerable, because it's hard enough for that person who has those privileges. It's hard enough, it's not easy by any means for them. But it you know, in our country in the Mississippi Delta region of Arkansas right now, we've got families that live on a couple dollars a day and have one place to go to. And the providers that take care of them have a totally different lived experience, and they do. And if we really, really, really want to fix it, we've got to fix it for them. One of

the points you made in the conversation was about the impact of C section on postpartum health because Caring for a new baby after having a C section is, is a lot more challenging. And we know that women who have C sections can have higher rates of postpartum mental illness. So how do you counsel a woman? And how do you feel about women who want to have elective cesarean?

I mean, I think one thing is whether people want to have a C section or end up with one, we have to be thoughtful about not invalidating their choices or their experiences. Because I mean, I get dragged on Twitter, like nearly every day, one of my early lessons and talking about decreasing c section rates was that there are a lot of people who felt their experiences were being invalidated and didn't feel seen and people's birth experiences are very personal and matter to them. So and then to be totally honest with you, like, I think most people who think they want c section may not be seeing the full picture. And so there might be an opportunity to like add points of information, but it's not my job to change their mind. per se, it's just really to counsel them, and then honor their choices and I have done elective primary sections. And I think I've done them for good reasons. For people for whom something about their life or their circumstances, their their baseline mental health and anxiety, their past traumatic history, you know that the world is just not black and white.

Did you ever study sociology? I mean, what's given you this global perspective, the societal perspective that I think is quite uncommon? Is it just who you are? Or was something in your past? What influenced you to have this perspective? I think it's probably a little bit personality and just being a dilettante. You know, I'm not an economist, but I am an armchair a lot of things, or sociologists, but I think a little bit is just, you know, in my own work, I feel like vision and values is where you start. And that's allowed me to be agnostic about methods, and it's allowed me to really follow my curiosity to start with rates and then realize that C section rates are really about labor management and labor management is really about supporting people and supporting people is really about equity. And equity is really about valuing birthing people at the end of the day so you can't not see that once you start going down that pathway. And then if you really want to fix it, you have to go after the roots.

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Thank you both for your curiosity because you both have professional roles yourself and you're providing services directly but you're also reflecting on how things could be better and we just need more of that.