Welcome to the Best of Birthful. Creator and host Adriana Lozada curated and edited each selection in this playlist of the show’s most popular episodes. It's a tailored introduction to the expansive catalog she amassed over the first five years of Birthful's 300+ shows.
Dr. Neel Shah, a Harvard Medical School professor, explains how the hospital you choose can be your #1 risk of having a Cesarean. Cesarean rates have increased dramatically over just one or two generations, and many of them are medically unnecessary. Adriana and Dr. Shah teach you how to take control of the risks and benefits of where you choose to give birth.
Here's the original episode in full. For more Birthful, visit the show page. For new episodes out each week, subscribe to Birthful. You can connect with us on Instagram @birthfulpodcast and email us at firstname.lastname@example.org
Download Birthful's Postpartum Plan FREE when you sign up for our weekly newsletter! Don't miss even more tips, insights, and news from Adriana and her guests!
We want to hear from you! Help us shape the future of our show by taking our survey. You will be automatically entered to win a $100 gift card. Winner will be announced when survey closes.
Hey, mighty one. With nearly 300 Birthful episodes in over five years, it may be hard to know where to begin listening to the show. To make it easier, we’ve put together the Best of Birthful series, which showcases some of our favorite or most relevant episodes. This is one of those. If you enjoy what you hear, make sure you subscribe. It’s free, and that way you won’t miss a thing. Enjoy.
Hello, mighty mammas and mammas to be and mighty dads and dads to be, mighty everybody. As always, thank you so much for listening and for all the love you give the show. So, for today’s show, I am super excited to talk to Dr. Neel Shah, an obstetrician who’s out to radically improve maternity care, and he’s gotten a really good start. Welcome, Neel. It’s so great to have you here today.
Dr. Neel Shah: Thank you so much for having me, Adriana.
Lozada: So, you’ve got a really powerful message and I’m so glad that people are picking up on it, but before we get into what that is, tell us a little bit about yourself and how you got to be so intrigued about cesarean rates.
Shah: Sure. So, I’m an obstetrician, but I became one by accident. I thought it was the last thing that I would do in medical school, and because of that I signed up to do it first, to get it over with, and turned out that I liked it, because you kind of get to do everything. You get to deliver babies, you have to do some primary care, you have to do some surgery. There are all these deep social justice issues in women’s health that frankly I hadn’t thought much about before I got to see it with my own eyes, and I liked being around people who cared about that stuff.
So, I ended up becoming an obstetrician, but along the way, I also had a background working in politics, and public policy, and thinking about healthcare improvement in general. And so, when I ended up caring for women and thinking about childbirth, I saw lots of opportunity there for improvement. So, now I’m in a job where I still deliver babies, and at Beth Israel Deaconess Medical Center in Boston. I spend one or two days a week seeing patients and the rest of my time I work as a professor, thinking about how we develop solutions to improving care in childbirth and other domains of healthcare.
Lozada: Which definitely brings us to this… I don’t want to say pet project, but this… Not obsession. What’s the word I’m looking for?
Shah: You can call it obsession and or a pet project. I think all of that’s accurate.
Lozada: Inspiration. Like your muse about cesarean rates. How did you end up there?
Shah: Well, so I spent a lot of time before even becoming an obstetrician thinking about the fact that in healthcare, we basically… There are two ways that people can get hurt inadvertently in our healthcare systems. One is when we as clinicians fail to do enough, and the other is when we do more than we should, and people get hurt both ways, but when you’re working inside of the healthcare delivery system, most of the efforts to make patients safer is focused on the too little problem, and there’s not a lot of really good thinking about how we deal with the problem of too much.
And for me, when I got my job as a professor, I was looking at childbirth, and trying to figure out what we can do to make things better, and it became very, very clear that the prototype of the too much problem, not just in childbirth, but the entire healthcare delivery system, is cesarean rates. This is an issue where we’ve seen a 500% increase in C-section rates in just the last generation or two of moms in the U.S. About half of those C-sections seem to be unnecessary. And we’re hurting people. Hundreds of thousands of women end up getting large incisions they never needed every year. Tens of thousands of those women get major surgical complications that could have been avoided. And in total, it’s about $5 billion of spending that we could be investing in improving care in much more productive ways.
Lozada: Those are big numbers.
Lozada: I mean, a 500% increase over two generations? Did you say?
Shah: Yeah, so 500%, that’s right, and it’s happened so quickly that we’re now at a point where C-sections are the most common major surgery performed on human beings, and even as a surgeon myself, it’s hard for me to believe that one in three human beings needs a major surgery to be born, you know?
Lozada: Indeed. And especially when you consider… Absolutely. When you consider with specifically towards we’re dealing with birth, which is not an illness. It’s not… It’s a physiological process. It’s not… You’re not coming in with a situation that requires surgery in theory, right?
Shah: In theory.
Lozada: And I think it matches perfectly with your thoughts about the too much problem, and this, these numbers, and how it skyrocketed, how did we get here? What happened?
Shah: Well, it’s complicated, but the first thing I’ll say is that birth is a natural process, and theoretically, surgery should not be necessary, but nature can be cruel. In parts of the world people don’t have access to help, as many as one in 10 women can die in childbirth. And so, there’s a lot about our ability to help each other out that’s important, so I don’t want to dismiss that. But again, you can hurt people both ways, by not doing enough for them, and also by doing too much. Because we’ve gotten so good at doing C-sections, we’ve made them very safe, and so in the moment when you’re doing a C-section, you always feel like you’re doing the right thing.
I like to joke that I personally always do a C-section that’s necessary, because if the baby comes out looking perfect, you think, “Well, it’s a good thing I did a C-section.” And if a baby comes out looking blue, you think, “Oh, man. It’s a good thing I did a C-section.” So, it’s pretty good to be me, because I’m always right. That’s sort of the optics problem.
But when you step back, as we talked about, we’re doing a lot of harm, and the reasons why we’ve seen that 500% increase are mysterious. So, it’s not well explained by the fact that moms in the ‘70s looked different from moms now. There’s more… Moms are older, there’s more obesity, there’s more chronic conditions, like diabetes, and hypertension. There’s more in vitro babies. And all of that contributes, but we’ve seen C-section rates go up in 18-year-olds just as quickly as it’s gone up in 35-year-olds.
And because there are more 18-year-olds than 35-year-olds out there having babies, the demographic shifts in our country don’t really explain what’s going on. Reimbursement doesn’t explain it very well. Medical malpractice, even though it seems like it should, it doesn’t. Because during eras when medical malpractice policies haven’t changed, it’s continued to skyrocket. And then there’s this narrative out there that women are demanding C-sections, and it’s actually less than half a percent of moms that request them. And so, that doesn’t explain the 500% increase either.
Lozada: So, then what explains it? Or what have you found?
Shah: Well, this is gonna be a little bit of an abstraction, but basically over time, as our capabilities in healthcare have grown, so has the complexity of the healthcare system. And you know, it’s interesting to me that in pretty much every other domain of our lives, science has simplified. But in healthcare, scientific capability has just rendered tons of complexity, and what complexity creates is more opportunities to mess up. And so, if you think about it, the modern labor and delivery unit in 2017, it actually looks very different from the way it did in the ‘70s.
In 2017, a labor and delivery unit that a normal, healthy mom might walk into has all the functionality of a cardiac ICU. It has the ability to… An ICU isn’t defined by a ventilator. It’s defined by the ability to have one nurse per patient. So, the cardiac ICU does that, the labor floor does that. The cardiac ICU can monitor heart rates in real time. The labor floor does that all the time. The cardiac ICU can titrate medicines on a minute-to-minute basis. So does the labor floor. The only difference between the labor floor and the cardiac ICU functionally is that on the labor floor, the operating rooms are attached. So, what you have is actually the most intense treatment area of the entire hospital for the healthiest patients. And when you look at it that way, it doesn’t take a rocket scientist to figure out why we’re doing too much.
Lozada: And which that in itself was a huge development in terms of shifting maternity care in general, for sure.
Shah: Well, yeah. I mean, if you think about it, everyone who’s listening, I would bet that nearly everybody listening, their grandparents were born at home. And it’s just, again, in the last generation or two, that we’ve institutionalized birth and death, honestly. And honestly, we mess both up in very similar ways. By taking life’s only two certainties and treating them as pathologies.
Lozada: So, it’s very complex how the system is set up in the labor and delivery floor. Okay, so we established that. What does that mean for moms and how does that relate to cesarean section rates?
Shah: What it means is… Here’s the thing. So, the 500% increase over time is disturbing, but the plot thickens, because if you just look at any moment in time, like you take the year 2017, and then you freeze time and you look across the United States, which is what scientists like me like to do, and you look at C-section rates from one hospital compared to the next, it turns out that the variation in C-section rates from one hospital to the next is 10 fold. The lowest C-section rates at a hospital is 7% and the highest is 70%. And then you’re like, “Okay. Well, that’s kind of wild. That’s a lot of variation.”
But some hospitals may take care of sicker patients than others, so then you account for that, and it turns out you see 15-fold variation. You see more variation, not less. And what that means is in 2017, the biggest risk factor for the most common surgery performed on Earth is not a woman’s preferences or risks, but literally which hospital she goes to, like which door she walks through. And that’s crazy. That’s wrong. Your number one risk factor should not be the hospital that you show up at. And a lot of it, in that, we found was probably the clue to figuring out what’s going on with C-section rates, why we overdo it, and more importantly, what we can do about it.
Lozada: Huge. So, answer for me those questions. What did you find out and what can moms do about it?
Shah: Well, those are a couple questions, but the first thing is that given the complexity of these environments, what seems to explain the differences from place to place, at least partly, are people’s ability to manage that complexity. Okay, so just bear with me for a second. Let’s use a restaurant analogy. Most people don’t pick their restaurants based on who their waiter is gonna be. Most people. But in healthcare, most people pick which hospital they’re gonna deliver at based on who their obstetrician is gonna be. Now, I’m not saying that waiters and obstetricians are the same, but people generally realize that you can have the best waiter, the best chef, the best ingredients, the best menu, and still get a terrible meal at the end. That’s the sort of idea of systemness, that the whole thing has to kind of work together.
And on labor floors, it’s a very similar thing. You can have the best doctor, but there are a lot of moving parts and they all have to sort of be in sync. That’s what I mean by your ability to manage complexity, and in every industry, management and performance are linked. Of course. That’s why business schools exist. But on labor and delivery units, this hadn’t been something that had been well understood or well studied, and as it turns out, the people that are running labor and delivery units have some of the hardest jobs in healthcare. Because if you think about it, if you’re the one that’s figuring out how to staff your labor floor, you have no idea when your customers are gonna show up.
And then once they show up, you don’t know how long their labor is going to take, and then you don’t know which one of them might become sick enough to need you to deploy resources, like a blood bank, or an operating room. And so, that’s a really, really difficult management challenge, and we found that there are some people that do it really, really well, and other people who do it frankly pretty poorly. And the people who do it well are much better prepared to take safe care of their patients, both in terms of the too little and the too much problem.
Lozada: So, what are some of these conditions that you saw that are more supportive of a lower cesarean rate? What constitutes a better management of their complexities?
Shah: Well, one of the biggest, which I’m guessing your audience knows very well, is just being able to provide birth support. Your ability to provide that support by deploying your staff in ways that make sure that the right patient gets the right care at the right time. But the step back answer is that it turns out we’ve got lots of evidence from a management point of view, from a design point of view, that the environment around your doctor or your midwife really, really influences the care that you get. That’s really the big insight. Most patients think that the care that they get depends on how they’re doing, and the truth is the care that you get depends equally on how everyone else on the labor floor is doing. The other patients and the staff.
We’ve got some research that is starting to suggest that the difference between showing up on a busy labor floor and a quiet labor floor as a woman is the same thing as aging several years in terms of your risk of getting a C-section or other bad outcomes.
Shah: Not that a C-section is a bad outcome in and of itself, but your risk of hemorrhage, your risk of infection, all of that is dependent on what’s going on around you, and yeah, being on a busy labor floor can be the equivalent of aging like six, seven years, which in childbirth matters.
But I mean like when we think about risk as clinicians, that’s a really powerful framing. Because you know, we think about age as a risk for diabetes, hypertension, all kinds of things in healthcare, and the fact that a busy labor floor can confer the same risk is huge. But it also suggests that when we’re trying to develop a solution, we should be developing a solution in that sandbox, and not only thinking about tort reform.
Lozada: Right. So, I know that in your studies, you looked… It included birth centers, as well. Right?
Shah: Yeah. I’ve spent… It’s been such an education for me to spend some time in birth centers. There is a lot to be learned from looking at birth centers and comparing them to hospitals. Even though birth centers are fundamentally set up to take care of a different patient population and hospitals have to care for low-risk people and high-risk people, and birth centers only have to care for low-risk people. And that sets up different challenges.
So, I very much appreciate that difference, but it wasn’t until I went to a birth center, for instance, that I realized that the birth center assumes that women are gonna be walking around in labor. And that changes everything about the way that the workflow goes, the way it’s designed, whereas the hospital, the bed is in the center of the room, and we think of patients and beds almost in synonymous terms when we do facility planning. You know, we have the only part of the hospital that routinely admits people that don’t need a bed right away. And that actually blows people’s minds, when you talk to people who are not in the childbirth world.
So, that’s one big difference. I think birth centers generally are much better about admitting people at the right time and preparing their patients for early labor. Often the sort of ambiguity around early labor is what leads to upstream interventions before they need to happen. There are a lot of best practices that I saw at birth centers that I think confer lessons that we could try to adopt in hospital settings, too. And I also think there’s a big opportunity in our country to scale up the availability of birth centers for moms who want that option.
Lozada: And I think that is a huge point, because in a lot of places, there’s just… There isn’t the choice. You only can go into this very busy hospital, because that’s the only thing, or a small hospital in a rural area.
Shah: That’s right. I mean, I think people often don’t have choices. Within the degrees of freedom they do have to pick where they go, I think that there’s room to improve the way that people are able to pick the best place to have a baby for them, and we can talk about that separately, but it is a big issue that basically there’s only one model here, which is the ICU. Whether you’re low risk or high risk. Whereas in the U.K., there are four different kinds of birth settings. You can have a baby at home, and it’s actually deemed to be safer for a certain defined population of people. You can have a baby in what they call a free-standing birth center, in an alongside birth center that’s affiliated with a hospital, or in a normal hospital labor and delivery unit. But women are offered all four choices. They can choose what best fits what they want.
Lozada: And I know you have studied also how the U.K. does their models, and I read an article somewhere, and I will link it to the show notes, that you said… I paraphrased the title, but it was something like, “I am an obstetrician and I don’t necessarily think all babies should be born in hospitals.” Or something. What was.. .Am I right with the title? Was I close enough?
Shah: That was more or less it. Yeah. Yeah, I mean, so what happened was the U.K. two years ago, they have an institute called the National Institutes for Health and Care Excellence, which is sort of like their FDA, and they’re the ones who put out guidelines for their healthcare system to follow, and that institute in the U.K. two years ago said that it was safer. Not safe, but safer for a low-risk mom for whom it was her second baby, or more, to have her baby outside the hospital with a midwife, than with an obstetrician in the hospital. Safer.
And the argument was that for the baby, it’s basically equivalently safe in terms of the outcomes for the baby, but the hospital risks of getting an unnecessary intervention like a surgery are much, much higher. And the New England Journal of Medicine, which is sort of like the standard bearer for my field, invited me to write a response. And at first, I thought I really like my job. I don’t think I want to do that. And frankly, I thought the U.K. was kind of crazy, having not known very much about how things work over there.
But then I read more into it and I realized that there’s nothing inherently safe about a home or a hospital, and that there are totally legitimate reasons to want to have a baby at home, and there’s huge opportunity to make homes safer than they are right now, because it’s not about the home. There’s nothing magical about it. It’s about the system around the home. And similarly, there are safety concerns at hospitals, and there’s opportunities to improve hospitals, too. So, I made the case that it could… Which seemed radical within my profession, that there could be a reason to want to have a baby at home, and that there could be an opportunity to make homes safer, and maybe that’s where we ought to focus as opposed to just having a very dichotomous debate about what’s inherently safer.
Lozada: Right. And from what I understand, the crux of it goes back to that system, right? Of how well caregivers at home work with caregivers in hospitals to be able to provide that seamless and supportive transfer of care in case of a need for the ICU, basically.
Shah: Right. I mean, it’s all about expectations, but for first-time moms who try to have babies at home, the data in the U.K., and in Canada, and the Netherlands, and other countries who’ve tried to build these systems up, where you have that kind of integration, what they show is about half of moms, if it’s their first time, who start off at home, end up needing the hospital in the end. And when I first saw that I was like, “Man, what are they doing? This is crazy. Why would they set moms up so that half of them end up needing to be transferred to the hospital?” The hospital would say, “Who are you?” I mean, and that’s what we’re used to seeing.
Whereas in the U.K. it’s not seamless, but it’s so much better, right? They send a midwife to you and you get one-to-one support from a qualified midwife, which is amazing, and then well ahead of when something terrible would happen, they’ve got really clear protocols, where they transfer you, and within 30 minutes you end up in a hospital and they know exactly who you are and there’s a handoff, and it look sand works very different.
Lozada: Yeah. And I’m sure, because I know that’s the case here in the U.S., that not all transfers of going to the hospital are because something bad is happening, either. It could also be like mom decides, that says, “You know what? I can’t do this. I want an epidural and I can’t get an epidural at home and I’ve changed my mind, so let’s go in.”
Shah: Which is totally cool, right? And that’s actually… That was the big insight that I tried to convey in that article, was that a 50% transfer rate isn’t a sign of health system failure. It’s actually a signal of success. If you’re able to successfully transfer 50% of your patients and get really good outcomes, it just depends if you’re a glass half-full or half-empty person. But one way of looking at it is that you’re giving half of first-time moms a shot at having their baby at home, and if you really think about it, the only reason to be tethered to a hospital bed under fluorescent lighting when you’re having your baby is because you believe it’s safer, right? But if that’s not the case, why wouldn’t you want the intimacy and privacy and comfort of your home?
Lozada: So, let’s bring it back to that individual mom. Faced with this new information, what can she do to try to have… not fall into that increased cesarean risk?
Shah: Well, there’s probably a few things that moms can do both individually and collectively, and I want to talk about both. So, I think individually, one thing that seems to make a big difference is being intentional about where you go for care, and I think you obviously… Your relationship with your primary provider, your midwife, or your obstetrician, matters a lot. Because you see them a lot and they make really consequential decisions for you. So, having that relationship matters a lot, but it equally matters where you’ll be delivering your baby, and I think paying attention to the hospital or facility C-section rate matters. And if it’s very high, it doesn’t mean that you automatically shouldn’t go there, but it should be a starting point for conversations about why that’s the case and how that might apply to you personally.
I think the other thing is going in mentally prepared for what labor is. I mean, I think if you have goals, you have the goal of having a natural delivery, I think it’s important to think about it and prepare for it the way you would for any other athletic event, which is what this is. I mean, it’s not dissimilar from a marathon, and so you may want to think like what does my support look like? Do I want a coach there?
I also think that there are a lot of things that are legitimately preference sensitive about the way that you want your birth to go, and it’s very reasonable and a good idea to assert those preferences, but also realize that things can change, and they could be the circumstances around your birth, or it could just be that you changed your mind and want an epidural, and that’s totally fine. But going in with at least a strawman in your mind of what… among the things that you have the freedom to choose, how you’d like it to go. Who you want in the room to support you, all the way through to do you want the baby on your chest right away, all these things are important.
Collectively, I think moms, there’s a huge opportunity for moms to assert their voice around… In order to get what I think that they deserve. And ultimately, nothing will change to improve the system unless moms are demanding it. Maybe what I would add to that is that I think that there’s a window of opportunity right now to help better support our moms not just around the moment of childbirth, but in everything that comes afterwards, from the mood challenges, which are a real thing, and affect the plurality of moms because of the physiological event, and the enormous upheaval in your life, to working moms that have to balance all that with going to work and earning their livelihood.
What I’m seeing is that there’s… The March for Moms, I’m not sure if it would have been possible a few years ago. We really just created a canvas and a wire frame, and then it filled itself in. And I think it’s because there’s a moment right now where there’s real momentum behind improving maternal health and making things better for moms. If you recall, in the 2008 presidential election cycle, death panels were a thing, right? And then just one election cycle later, we went from death panels to actually being able to pay people to have meaningful end of life conversations. To the book Being Mortal being at the top of the bestseller list, and to having a really productive national conversation about end of life care.
In this election cycle, despite how intense it was, one of the things that came out of it was we were having a really productive national dialog about the opioid epidemic. My hope is in the next election cycle we’ll be able to have a similarly productive dialog about the beginning of life and about childbirth, and about supporting our moms. That’s where I see this going.
Lozada: And I am so excited. I want to… Yes. Please. Yes. Neel, do you have a favorite book or recommendations for listeners in terms of birth? Books that you think everyone should read?
Shah: Hm. That’s a really good question. It’s actually been a while, honestly, since I’ve read a book about childbirth in general, but when I first got my job a few years ago, I spent a lot of time reading about the history of childbirth in the country, and how our modern childbirth system evolved. And so, I don’t know if I have a specific book, but I do think that it’s one of the things that’s really interesting to read about is how we got where we got.
Lozada: Neel, thank you so, so much for this wonderful talk. If listeners want to follow what you do, or connect with you, or just learn more, how can they do that?
Shah: I’m on social media. I’m easy to find on Google. And I like to share what I’m thinking, so that would be certainly one good way to connect.
Lozada: Fantastic. So, can you spell your name for listeners? Because…
Shah: Yes. Yeah. So, I spell my name, my name is Neel, so I spell it N-E-E-L, and my last name is Shah, S-H-A-H, and so my Twitter handle is @Neel_Shah.
Lozada: Beautiful. Thank you so, so much for this talk.
Shah: Thank you so much for having me.
Lozada: You’ve been listening to a Best of Birthful episode. To listen to the original, longer version of this episode, click on the link in the show notes. And there are many more where this came from. Look for episodes with the words Best of Birthful in the title to continue your deep dive to inform your intuition. You can find the in-depth show notes for this episode at Birthful.com. You can also connect with us directly on Instagram. We’re @BirthfulPodcast.
Birthful was created by me, Adriana Lozada, and is a production of Lantigua Williams & Co. The show’s senior producer is Paulina Velasco. Virginia Lora is the managing producer. Cedric Wilson is our lead producer. Alie Kilts contributed to the production of the Best Of Birthful series. Thank you for listening to and sharing Birthful. Be sure to subscribe on Apple Podcasts, Amazon Music, Spotify, and everywhere you listen. Come back every week for more ways to inform your intuition.
Lozada, Adriana, host. “Best of Birthful: What You Need to Know About Where You’re Giving Birth.”
Lantigua Williams & Co., October 10, 2020. Birthful.com.