Cesarean Risk: What’s Your Place of Birth Got to Do With It?

Cesarean rates have increased 500% in one generation, and about half of them may be unnecessary. Harvard Medical School professor and ACOG Fellow Dr. Neel Shah talks with Adriana about how the hospital you choose can be your #1 risk of having a surgical birth, how we got here, and what you can do about it.

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What we talked about:

  • The medical conundrum of undertreatment vs. overtreatment
  • The 500% increase in cesarean rates since the late 60s/early 70s
  • Why the #1 risk may be what hospital you walk into
  • Labor floors: providing the most intense medical protocols for the healthiest patients
  • Why the problem is not WHERE you deliver (hospital/birth center/home), but HOW the system is set up
  • How it could work: the successful U.K. system that actually offers choices
  • How you can better your chances of avoiding an unnecessary cesarean surgery
  • Asserting your voice, individually and collectively


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Cesarean Risk: What’s Your Place of Birth Got to Do With It?


Adriana Lozada: Welcome to Birthful, Mighty Parent or Parent-to-Be. I’m Adriana Lozada.

Neel Shah: 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. Like your #1 risk factor should not be the hospital that you show up at.

Adriana: That’s OB/GYN and ACOG Fellow Dr. Neel Shah, who is a globally recognized expert in designing solutions that improve health with a focus on building equitable and trustworthy systems of care. Dr. Shah is also Assistant Professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School and co-founder of the March for Moms Association.

Today he and I will be talking about the reasons why cesarean rates have mind-blowingly increased 500% in one generation, how we got there, and what you can do about it. 

This, of course, is an incredibly relevant conversation within our Models and Places of Birth series, since most births in the U.S. happen at hospitals.

Birthing at a hospital can provide you with access to many lifesaving technologies and procedures, but that access comes with other increased risks, so it’s important for you to have this information, to know that all hospitals are not created equal, and to do a bit of research and preparation so that you can minimize those risks as best as you can. Remember, you are the consumer.

You’re listening to Birthful. Here you inform your intuition. 

Welcome, Neel. It’s so great to have you here today.

Neel: Thank you so much for having me, Adriana. 

Adriana: 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.

Neel: 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 it turned out that I liked it, ’cause you kinda get to do everything: you get to deliver babies, you get to do some primary care, you get 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 spend my time thinking about how we develop solutions to improving care in childbirth and other domains of healthcare.

Adriana: Which definitely brings us to this— this, I don’t want to say pet project, but this— this not obsession… What’s the word I’m looking for?

Neel: You can call it an obsession and/or a pet project. I think all of that is accurate!

Adriana: “Inspiration,” like your muse about cesarean rates. What… How did you end up there?

Neel: 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 y’know, 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 I 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, y’know, 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 and much more productive ways.

Adriana: Those are big numbers. 

Neel: Yeah. 

Adriana: I mean a 500% increase over two generations, did you say?

Neel: Yeah, so… 500%, that’s right. And it’s happened so quickly that, y’know… I was speaking to a room of obstetricians where there’ve been people in practice for a few decades. And you can ask people to raise their hand, “If you’ve been in practice for 10 years, 20 years, 30 years”— people who’ve been around for the last 30 to 40 years have seen that entire 500% increase just in their time.

So it’s been relatively recent and we’re now at a point where C-sections are the most common major surgery performed on human beings. It’s the most common major surgery performed on Americans and it’s the most common major surgery performed on any group of people in any room that you walk into, even a room that has a lot of men in it, it’s still the most common major surgery.

And even as a surgeon myself, it’s hard for me to believe that 1 in 3 human beings needs a major surgery to be born, y’know?

Adriana: Indeed. And especially when you consider it, absolutely, when you consider with specifically towards y’know… we’re dealing with birth, which is not an illness. It’s not. Y’know, it’s a physiological process! You’re not coming in with a situation that requires surgery, in theory. Right? And I think it matches perfectly with your thoughts about the “too much” problem and these numbers and how it skyrocketed.

Like, how did we get here? What happened? 

Neel: 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 where people don’t have access to help, y’know, as many as 1 in 10 women can die in childbirth, y’know?

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). 

Adriana: Oh, no. Absolutely. And we have, I mean… we love that we’ve gotten to this place where I think part of that and— correct me if I’m wrong— but the part of the reason while we’re doing more cesareans now is because they become safer and safer and safer, o the risk of a cesarean seems to be less.

Neel: That’s right. The first C-sections y’know, you… basically, you’d do a C-section as a last-ditch thing. You’d plan on the mom not making it through because they were so dangerous. But y’know, we… 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. Like, 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 they come out looking blue, you think, “Well, man, it’s a good thing I did a C-section!” So it’s pretty good to be me, ’cause I’m always right— that’s the, sort of, the optics problem. But when you step back, as we talked about, we’re doing a lot of harm and y’know, the reasons why we’ve seen that 500% increase are mysterious, but a lot of the conventional wisdom doesn’t bear out.

So, y’know, it’s not well explained by the fact that moms in the seventies looked different from moms. Now y’know, 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 and 35 year olds out there having babies, y’know, 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 a 500% increase either.

Adriana: So then what explains it, or what have you found?

Neel: Well, this is going to 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, y’know, it’s interesting to me that in pretty much every other domain of our lives, science is simplified, y’know— from how we get around, to how we communicate, to how we put food on the table— 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, it actually looks very different from the way it did in the seventies. A labor and delivery unit that a normal healthy mom might walk into has all the functionality of a cardiac ICU.

Y’know, 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.

Adriana: Mhm. And for my listeners— because I know that’s something I didn’t learn until recently— what does ti-, titr-, (I can’t even say it!) “titrating” medicines mean?

Neel: “Titrating.” Yeah. So basically, y’know, uh, it’s very common to be hooked up to an IV where, y’know, you might get fluids, you might get a medication called Pitocin or oxytocin that helps with your labor or can make your contractions stronger.

And with all of these medicines y’know, they usually come in through a drip, so the rate at which these medicines go into your body can be controlled on a minute-to-minute basis, and that’s what the nurse is often adjusting on that pole that’s that’s next to you on the bed. 

Adriana: And which that in itself was a huge development, in terms of shifting maternity care in general, for sure.

Neel: Well, yeah, I mean, if you think about it, 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, y’know, life’s only two certainties and treating them as pathologies. 

Adriana: You’ve got so many good soundbites, like, “Oh, I gotta write that down.” Like I want a shirt of that!

Neel: Well, it’s a 45-minute podcast, so I can’t use them all up. 

Adriana: No, no. So going back to it, so… it’s very complex how the, y’know, 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?

Neel: Well, 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 tenfold. The lowest C-section rate 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 you, then you account for that. And it turns out you see 15-fold variation— you see more variation, not less. And what that means, 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. Like your #1 risk factor should not be the hospital that you show up at. And a lot of, in that we found was probably the clue to figuring out, y’know, what’s going on with C-section rates, why we overdo it, and more importantly, what we can do about it.

Adriana: Mhm. Huge! So answer for me those questions: what did you find out and what can moms do about it?

Neel: Well, those are a couple of 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 the restaurants based on who their waiter is going to be. But in healthcare, most people pick which hospital they’re going to deliver at based on who their obstetrician is going to be. Now, I’m not saying that waiters and obstetricians are the same, but y’know, 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 system-ness, that the whole thing has to kinda 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, y’know, 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, um, 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? Y’know, if you’re the one that’s figuring out how to staff your labor floor, you have no idea when your customers are going to 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, y’know, take safe care of their patients, both in terms of the “too little” and the “too much” problem. 

Adriana: So, what are some of these conditions that you saw that are more supportive of a lower cesarean rate? Like what constitutes a better management of their complexities?

Neel: Well, one of the biggest, which I’m guessing your audience knows very well, is just being able to provide birth support. We’re one of the only areas of healthcare where we’ve had to professionalize caregiving beyond what the clinicians can do by, y’know, there’s a whole profession of doulas that act as, essentially, y’know, coaches and support people.

And one of the big differences, I think, is 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. Y’know, usually the way labor floors work, they’re not the cash cow for the hospital, they don’t make a lot of money— the cardiac ICU, even though it’s set up very similarly, makes them much more money.

And as a result, most labor floors are a little bit strapped. They usually don’t have all the nurses they need or all the rooms that they need. And so they’re really, really tight on resources and have to figure out how to manage them dynamically and shuffle the deck when things get busy, ’cause you can get these unexpected surges and patient volume or acuity. All that sort of deep in the weeds and kind of complicated, but the stepped 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.

Adriana: Right. Because if the hospital… if the floor just got full and there’s no rooms— and I’m just thinking of one of our local health hospitals here that is a small hospital, that is now in very high demand— and more often than not, I see it more and more, it’s busy, it’s busy, it’s busy. And I’m hearing more— y’know, I’ve been doing this for 10 years, so I do have my own anecdotal comparison— but then they start overflowing labor rooms into the maternity area, right? Empty maternity rooms, then become labor rooms, staging, and trying to manage all that because you, as you said, you don’t know how many people are going to walk in the door. And what do you do with them?

Neel: You got it. 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— not that a cesarean is a bad outcome in and of itself, but your risk of hemorrhage, your risk of infection, all of that just dependent on what’s going on around you. And yeah, I mean, being on a busy labor floor, it can be the equivalent of aging, like 6-7 years, which in childbirth matters.

Adriana: Right, because you then can jump into that “Advanced Maternal Age,” that lovely, lovely phrase.

Neel: Right. But I mean, like when we think about risk as clinicians, that’s a really powerful framing because, y’know, we think about age as a risk for diabetes, hypertension, all kinds of things, y’know, 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, y’know, and not only thinking about tort reform, y’know?

Adriana: Right. So I know that in your studies, you looked… it included the birth centers as well, right?

Neel: Yeah. We’ve, I’ve spent a— it’s been such an education for me to spend some time in birth centers. That’s right.

Adriana: So I want to get your insights as to how did birth centers compare, with their cesarean rates— and of course that would involve a transfer. Was there any difference between a hospital and a birth center, in terms of generalizing of cesarean rates?

Neel: Yes, of course. I think, y’know, there’s very different contexts there, but I think there is a lot to be learned from looking at birth centers and comparing them to hospitals. Even though that, y’know, birth centers are fundamentally set up to take care of a different patient population, and y’know, 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, y’know, 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, y’know, the hospital, the bed is in the center of the room. And like we think of patients and beds almost in synonymous terms when we do facility planning. Y’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 mind when you talk to people who are not in the childbirth world.

So that’s one big difference. Y’know, 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, y’know, upstream interventions before they need to happen.

Y’know, 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.

Adriana: And I think that is a huge point because in a lot of places, 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, rural area. And yeah, if the place you walk into to give birth has such an enormous weight on your risk for cesarean, then not having options and choices and variations of that, and being able to choose different restaurants, right, different hospitals, then that plays a very important role in that.

Neel: That’s right. I mean, I think there’s room to leverage the… 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, y’know, there’s room to improve the way that people are able to pick the best place to have a baby for them. And, y’know, we can talk about that separately, but it isn’t a big issue that basically there’s only one model here, which is the ICU (whether you’re low-risk or high-risk).

Whereas, y’know, 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 a… what they call a freestanding 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. 

Adriana: And I know you have studied how the U.K. does their models. And I read an article that you said, y’know— I paraphrase 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 close enough?

Neel: That was more or less it.

Adriana: That close enough?

Neel: Yeah. I mean, so what happened was in the U.K. 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. 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, y’know, for the baby, it’s basically equivalently safe (in terms of the outcomes for the baby), but at 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 like, y’know, 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 something 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, y’know, which seemed radical to… within my profession that, y’know, there could be a reason to want to have a baby at home, and that there could be an opportunity to make home safer, and maybe that’s where we ought to focus, as opposed to just, y’know, having a very dichotomous debate about what’s inherently safer. 

Adriana: 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. 

Neel: Right. I mean, it’s all about expectations, but y’know, for first-time moms who try to have babies at home— the data in the U.K. and in Canada and the Netherlands and y’know, 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.” Like, why would they set moms up so that half of them end up needing to be transferred to the hospital? And the reason I felt like it was crazy is because I imagined what would happen here in the U.S. where you’d end up at a 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?

Like they send a midwife to you and you get, like, one-to-one support from a qualified midwife, which is amazing. And then 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 looks and works very different. 

Adriana: Yeah. And not all needing transfers of going to the hospital are because something bad is happening, either. It could also be like, mom decides that says, “Y’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.”

Neel: Which is totally cool. Right? And that’s actually… that was the big insight that I tried to convey in that article was that, y’know, 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, y’know, 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 a 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 babies is because you believe it’s safer. Right? But if that’s not the case, like why wouldn’t you want the intimacy and privacy and comfort of your home? 

[00:25:46] Adriana: Right?! This is so fascinating. So let’s bring it back to that individual mom, faced with this new information, what can she do to try to have, y’know, not fall into that increased cesarean risk?

Neel: there’s probably a few things that moms can do both individually and collectively— and I want to talk about both. So I think, y’know, 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.

And they support you through what is a really y’know, remarkable process where your whole body goes through these radical transformations in a really short period of time. But on average, you’ll see them like a dozen times in nine months. 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. So I think sort of paying attention to the quality of the facility that you’re going to be going to, where C-section rates are a measure of quality, is important. I think the other thing is going in mentally prepared for what labor is.

I mean, I think, y’know, 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 to coach there? Y’know would I run a marathon without practicing, like..? Y’know, and sort of going in prepared for that is important.

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 can 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, y’know, among the things 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, y’know, do you want the baby on your chest right away? All of these things are important. 

Collectively, I think there’s a huge opportunity for moms to assert their voice, in order to get what I think that they deserve. I mean, I think moms are used to putting themselves last in order to put their families first, and it’s high time that they get the support investment that they deserve. When you look, when you step back and look at our country, we have the highest rates of maternal death and injury in the entire developed world.

We have the highest prematurity rates. We have the widest disparities. We have the worst access to care. And then just to throw salt into the wound after all of that, we have the worst paid family leave policies in the entire developed world. And my colleagues and I think the United States can do a lot better than that.

Maybe, maybe the thing is that I think that there’s something about being a mom that makes you inherently resilient. And so like when things are less, like moms don’t generally complain, right? They just move on. Moms are busy. 

I’ve spent a lot of time thinking about why it is that moms are not as well-organized (I mean, politically-organized) for themselves? Actually, moms are very politically-organized for others, right? There’s Moms Against Gun Violence. There’s Moms Rising. There’s all these powerful groups of moms. There’s Mothers Against Drunk Driving. But when it comes to themselves in their own homes, moms are used to putting themselves last.

I think it might be… I guess it’s worth just saying that, whether moms are complaining or not, there’s an opportunity for us to recognize that moms deserve better and then to deliver on that

Adriana: Indeed. And we really focused on birth today, but if we look at a broader scope and into what we’re seeing in terms of postpartum mood disorders. And… moms are having a hard time becoming moms, and then going from that place that’s maybe not so happy, into being a mom. They’re resilient, but oh my goodness they do put— y’know, we do, I’ll include myself— put ourselves sort of last. Then I had a really interesting guest recently, Dr. Carrie Contey, and she was talking about how the best way you can take care of baby is to take care of yourself first. And to have that split 51% for you, 49% for baby, because if you start depleting yourself and you can’t last that— for the long haul, those weeks, also especially within the maternity leave spectrum that we have here in the U.S.— you’re going to burnout.

Neel: That’s really well said. And 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— y’know, working moms and have to balance all that with y’know, going to work and earning their livelihood.

And, y’know, one of the consequences of the uncertain times that we live in right now is that it’s stoked a fire of activism in this country, that we haven’t seen in decades— where people are standing up for all the things that they believe in.

And, y’know, the March for Moms, I’m not sure if it would’ve been possible a few years ago; y’know, we really just created a canvas and the wireframe 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.

Adriana: And I am so excited. I want it. Yes, please. Yes, Neel. Thank you so, so much for this wonderful talk! 

Neel: Thank you so much for having me. 

Adriana: That was doctor Neel Shah, who is also the co-founder of the March for Moms Association, which is a coalition of more than 20 leading organizations, that focuses on increasing public and private investment in the wellbeing of mothers. Go to marchformoms.org to find out about their annual family-friendly day of powerful storytelling, advocacy, community, and entertainment in Washington D.C., or to learn more about how you can become an effective advocate. 

You can find Neel on Twitter @Neel_Shah, and that’s spelled N-E-E-L underscore S-H-A-H.

And you can connect with us @birthfulpodcast on Instagram.

In fact, if you are not driving, it would be always lovely if you would take a screenshot of this episode right now and post it to Instagram sharing your biggest takeaway from the episode. Do make sure you tag @BirthfulPodcast so we can see it and amplify it.

You can find the in-depth show notes and transcript of this episode at Birthful.com, where you can also learn more about my birth and postpartum preparation classes, and download your free postpartum preparation plan.

Birthful is created and produced by me, Adriana Lozada, with production assistance from Aysia Platte. This episode was produced in part by LWC Studios and Paulina Velazco.

Thank you for listening and sharing Birthful. Be sure to follow us on Goodpods, Apple Podcasts, Spotify, Amazon Music, and everywhere you listen. 

Come back for more ways to inform your intuition.

CITATION: Lozada, Adriana, host. “Cesarean Risk: What’s Your Place of Birth Got to Do with It?” Birthful, Birthful. May 4, 2022. Birthful.com.


Neel Shah, a man with brown skin and black hair, smiles at the camera with his arms crossed over his chest, wearing a navy blue blazer, white button-down shirt, plaid bowtie, and a stethoscope around his neck.

Image description: Neel Shah, a man with brown skin and black hair, smiles at the camera with his arms crossed over his chest, wearing a navy blue blazer, white button-down shirt, plaid bowtie, and a stethoscope around his neck.

About Dr. Neel Shah

Dr. Neel Shah, MD, MPP, FACOG, is Chief Medical Officer of Maven Clinic, the largest virtual clinic for women’s and family health, and Assistant Professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School. He is a globally recognized expert in designing solutions that improve health care, and is listed among the “40 smartest people in health care” by the Becker’s Hospital Review. His work to build equitable, trustworthy systems of care has been profiled by the New York Times, Good Morning America, and other outlets, and is featured in a forthcoming documentary produced by Oprah Winfrey and Yance Ford.

Dr. Shah has written more than 50 peer-reviewed academic papers and contributed to four books, including as senior author of  Understanding Value-Based Healthcare (McGraw-Hill), which Don Berwick has called “an instant classic” and Atul Gawande called “a masterful primer for all clinicians.” Prior to joining the Harvard faculty, Dr. Shah founded Costs of Care, an NGO that curates insights from clinicians and patients to help delivery systems provide better care. In 2017, he co-founded the March for Moms Association, a coalition of more than 20 leading organizations, to increase public and private investment in the wellbeing of mothers. Dr. Shah serves on the advisory board of the National Institutes of Health, Office of Women’s Health Research.

You can connect with Neel on Twitter via @neel_shah or @mavenclinic, Instagram @neel_t_shah or @mavenclinic, or LinkedIn under Neel Shah or Maven Clinic.

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