Latest / Wellness, Actually with Emily Oster & Perry Wilson, MD / Racial Disparity in C-Section Rates: Unpacking bias in the medical system

Transcript

Racial Disparity in C-Section Rates: Unpacking bias in the medical system · Wellness, Actually with Emily Oster & Perry Wilson, MD

• 0:01
  Speaker 1: This is parent data. I'm Emily Oster. When we talk
• 0:06
  Speaker 1: about sea sections, it's often prefaced with unplanned or emergency.
• 0:11
  Speaker 1: About a third of all the deliveries in the US
• 0:14
  Speaker 1: are cesarean sections, and only about sixteen percent of those
• 0:17
  Speaker 1: are planned, and that leaves a lot of mothers in
• 0:21
  Speaker 1: a position where they're delivering differently than they planned or
• 0:25
  Speaker 1: intended to. To be clear, for many women, sea sections
• 0:30
  Speaker 1: are incredibly important our life saving and the World Health
• 0:34
  Speaker 1: Organization says about ten to fifteen percent of birth should
• 0:38
  Speaker 1: be sea sections to protect the health of the mother
• 0:40
  Speaker 1: and the baby. But ten to fifteen percent isn't thirty percent,
• 0:44
  Speaker 1: and abdominal surgery is never without risks. When we look
• 0:48
  Speaker 1: at the difference between the share of sea sections we
• 0:51
  Speaker 1: think should happen and the share that do happen, it
• 0:54
  Speaker 1: seems like sometimes there are too many sea sections being performed,
• 0:59
  Speaker 1: and in the US, a disproportionate number of those are
• 1:02
  Speaker 1: being performed on Black women. There are a lot of
• 1:08
  Speaker 1: possible reasons for the racial discrepancy, none of which are
• 1:11
  Speaker 1: easily dismissible on their face.
• 1:13
  Speaker 2: Black women may be at higher baseline health.
• 1:15
  Speaker 1: Risk, They may be delivering in hospitals, where C sections
• 1:19
  Speaker 1: are more frequent, they may request se sections more.
• 1:23
  Speaker 2: None of those reasons seem to.
• 1:25
  Speaker 1: Fit perfectly with the data, and understanding which of them
• 1:29
  Speaker 1: is more important is core to understanding how we might
• 1:33
  Speaker 1: change sea section rates.
• 1:35
  Speaker 2: So how are we going to get to the root
• 1:37
  Speaker 2: of what's going on?
• 1:38
  Speaker 1: That's what my guest, Molly Schanell, is looking at in
• 1:40
  Speaker 1: her paper, Drivers of Racial Differences in se Sections. Molly
• 1:45
  Speaker 1: is an assistant professor of economics at Northwestern University who
• 1:49
  Speaker 1: works on the causes and consequences of medical provider behavior
• 1:53
  Speaker 1: on populations. In her paper, she finds that black mothers
• 1:59
  Speaker 1: with unskeed sedule deliveries are twenty five percent more likely
• 2:03
  Speaker 1: to deliver by C section than white mothers, and she
• 2:06
  Speaker 1: argues that implicit racial bias among providers, or possibly even
• 2:11
  Speaker 1: a financial incentive in hospitals to fill their operating rooms,
• 2:14
  Speaker 1: may play a role in this racial gap. In this conversation,
• 2:19
  Speaker 1: we talk in great nerdy detail about her incredibly meticulous
• 2:24
  Speaker 1: methodology for separating out different explanations for trying to figure
• 2:28
  Speaker 1: out what is causality versus correlation, and for whether we
• 2:33
  Speaker 1: can actually figure out who's high risk and might need
• 2:36
  Speaker 1: this procedure versus who isn't. On a personal note, this
• 2:42
  Speaker 1: is an unsettling conversation about race and the medical system.
• 2:46
  Speaker 1: Molly is doing really important work here to unpack these
• 2:50
  Speaker 1: incredibly sensitive topics.
• 2:53
  Speaker 2: I hope that it's a little bit of.
• 2:54
  Speaker 1: Charting a path forward after the break, Professor.
• 2:58
  Speaker 2: Molly Schnail, Molly Chanelle, thank you so much for joining
• 3:15
  Speaker 2: me on parent Data.
• 3:17
  Speaker 3: Yeah, thanks for having me.
• 3:19
  Speaker 1: We're going to spend today talking about your new paper
• 3:22
  Speaker 1: on race and C sections and inequality. But I would
• 3:26
  Speaker 1: love if you would start by just introducing yourself.
• 3:30
  Speaker 2: And saying what you do where you are. You can
• 3:33
  Speaker 2: tell us about your kids if you want to.
• 3:35
  Speaker 3: Yeah. So, I'm an assistant professor at of Economics at
• 3:38
  Speaker 3: Northwestern and so most of my work focuses on the
• 3:42
  Speaker 3: causes and consequences of provider behavior. So thinking about how
• 3:45
  Speaker 3: individ visual clinicians make decisions in the presence of incentives
• 3:49
  Speaker 3: and constraints and see sections is one of those decisions.
• 3:52
  Speaker 3: So an interested in digiving to that into the data.
• 3:55
  Speaker 2: Awesome?
• 3:55
  Speaker 1: All right, So we're going to talk about this paper
• 3:58
  Speaker 1: of yours, which is about racial differences in C section rates.
• 4:03
  Speaker 2: But I want to sort of start at the.
• 4:04
  Speaker 1: Beginning and set the stage both about what are those
• 4:10
  Speaker 1: racial differences if you just sort of look out at
• 4:13
  Speaker 1: the world, and the question of why this matters. So
• 4:16
  Speaker 1: let's start actually with the second question. So why are
• 4:20
  Speaker 1: you interested in C section rates as an important outcome
• 4:24
  Speaker 1: to study?
• 4:26
  Speaker 3: Yeah, so c sections are a procedure that, of course
• 4:30
  Speaker 3: can be life saving for mother and baby if it's necessary.
• 4:34
  Speaker 3: But we have very high rates of c sections in
• 4:36
  Speaker 3: the US, rates that are so high that many would
• 4:39
  Speaker 3: say are too high. And of course it's a major
• 4:41
  Speaker 3: abdominal surgery that comes with the potential for a lot
• 4:44
  Speaker 3: of risks and complications, both for mom and for baby.
• 4:48
  Speaker 3: And so when we see really pronounced differences in rates
• 4:51
  Speaker 3: of c sections between black and white moms, it leads
• 4:54
  Speaker 3: to questions of whether or not that might be contributing
• 4:57
  Speaker 3: to sort of persistent disparities in health outcomes between those
• 5:00
  Speaker 3: two groups.
• 5:01
  Speaker 2: So, what does the C section rate in the US
• 5:03
  Speaker 2: look like now? On average?
• 5:06
  Speaker 3: So it's in the low thirties, so somewhere between thirty
• 5:09
  Speaker 3: two and thirty three percent. For white moms, it's going
• 5:12
  Speaker 3: to be just below thirty percent, and for black moms
• 5:15
  Speaker 3: it's closer to thirty five percent. And actually a lot
• 5:18
  Speaker 3: of the data that we're going to be using for
• 5:20
  Speaker 3: the study is going to come from New Jersey, and
• 5:22
  Speaker 3: New Jersey has a really high C section rate, So
• 5:24
  Speaker 3: it's going to be about forty five percent for black
• 5:27
  Speaker 3: moms and about forty percent for white moms.
• 5:30
  Speaker 1: Well, what is the correct SEA section rate and why?
• 5:35
  Speaker 1: Is that a hard question?
• 5:37
  Speaker 3: So it depends on who you ask, right, the who
• 5:41
  Speaker 3: is going to say somewhere between ten and fifteen percent.
• 5:44
  Speaker 3: That's a very difficult question to answer because it's going
• 5:47
  Speaker 3: to depend on a mother's appropriateness for the procedure, right,
• 5:50
  Speaker 3: So that's going to differ across populations, that's going to
• 5:53
  Speaker 3: differ across countries. That could differ for a given mom
• 5:56
  Speaker 3: throughout her life cycle. She might be a good candidate
• 5:58
  Speaker 3: for one for a C section for one of her
• 6:01
  Speaker 3: births and not for another based on her underlying conditions.
• 6:05
  Speaker 3: And so it's ultimately, you know, closely tied to medical
• 6:08
  Speaker 3: risk and that's something that changes. And so one of
• 6:11
  Speaker 3: the goals that we're going to really look at, and
• 6:13
  Speaker 3: one of the goals of this study is to use
• 6:16
  Speaker 3: a lot of information on medical risk to see whether
• 6:18
  Speaker 3: or not that's one of the reasons why we see
• 6:20
  Speaker 3: these big differences in C section rates.
• 6:22
  Speaker 1: Yeah, so when we see these, if we sort of
• 6:27
  Speaker 1: establish that a C section, while safe and can be
• 6:29
  Speaker 1: life saving, that the rates may be too high, and
• 6:32
  Speaker 1: that it is, at least in the short term, a
• 6:34
  Speaker 1: much more complicated recovery and may have contributions to morbidity.
• 6:39
  Speaker 1: The way I'd often like to say this is like,
• 6:40
  Speaker 1: this can be a great option if you need it,
• 6:43
  Speaker 1: but it's not likely to be the first choice for
• 6:46
  Speaker 1: delivery method. Yes, So when we look out at the
• 6:50
  Speaker 1: world and we see differences in C section rates, either
• 6:55
  Speaker 1: a cross space or across racial groups, what are the
• 6:59
  Speaker 1: possible set.
• 7:00
  Speaker 2: Of reasons we could see that.
• 7:01
  Speaker 1: So I would say, you know, you said New Jersey
• 7:02
  Speaker 1: is very high and that there are big differences across
• 7:05
  Speaker 1: racial groups.
• 7:06
  Speaker 2: So as a researcher, as a person who says that,
• 7:08
  Speaker 2: what are the set of things that might be going on.
• 7:11
  Speaker 3: Yeah, that's a that's a great question. So the the
• 7:15
  Speaker 3: high sea section rates in general and the disparities by
• 7:18
  Speaker 3: race are really well documented and quite persistent, and so
• 7:21
  Speaker 3: that's led a lot of people to hypothesize about what
• 7:24
  Speaker 3: could be driving that. It's going to be important to
• 7:26
  Speaker 3: know that to be posible point to different policy solutions.
• 7:30
  Speaker 3: So what if people thought, well, people have argued that
• 7:32
  Speaker 3: it could be differences in what we would call maternal preferences.
• 7:35
  Speaker 3: So it could be, for example, if we see that
• 7:38
  Speaker 3: black moms are much more likely to have a sea
• 7:40
  Speaker 3: section than white mothers, maybe it's that black mothers prefer
• 7:43
  Speaker 3: to have sea sections, So maybe they're requesting them from
• 7:45
  Speaker 3: their providers and that's why they're higher up rates. That,
• 7:48
  Speaker 3: of course, would go against a lot of other things
• 7:51
  Speaker 3: we know about how Black Americans tend to interact with
• 7:53
  Speaker 3: the healthcare system. Given a history of racism within the
• 7:57
  Speaker 3: healthcare system in the US, we tend to see that
• 7:59
  Speaker 3: Black America want less intensive treatment as opposed to more
• 8:02
  Speaker 3: intensive treatment, and so it would be surprising if c
• 8:05
  Speaker 3: sections sort of when in the opposite direction. But that's
• 8:08
  Speaker 3: one of the hypotheses that you'll hear of. Maybe it's
• 8:10
  Speaker 3: differences in maternal demand. Another potential that explanation that we've
• 8:15
  Speaker 3: already sort of touched on, would be differences in health
• 8:18
  Speaker 3: risks at the point of delivery, right, So it could
• 8:21
  Speaker 3: be that when black moms show up at hospitals ready
• 8:24
  Speaker 3: to deliver that they are just much better candidates for
• 8:27
  Speaker 3: the procedure. Right, envision that all black moms show up
• 8:30
  Speaker 3: with babies in a breach presentation and they have justtational
• 8:33
  Speaker 3: diabetes and a lot of other risk factors that would
• 8:36
  Speaker 3: make them better candidates for the procedure. Well, then that
• 8:38
  Speaker 3: could be what's driving the higher rates and more black
• 8:41
  Speaker 3: moms than white moms. It could also be differences in
• 8:44
  Speaker 3: the hospitals or the providers that mothers of different races
• 8:48
  Speaker 3: go to. So we know that there are very large
• 8:51
  Speaker 3: differences in C section rates across different hospitals, and given
• 8:55
  Speaker 3: segregation by race, we tend to see that different populations
• 8:59
  Speaker 3: go to different hospitals, and perhaps black women are just
• 9:02
  Speaker 3: more likely to be going to hospitals that have higher
• 9:05
  Speaker 3: C section rates.
• 9:06
  Speaker 1: I think that would be the question, why does that
• 9:08
  Speaker 1: hospital have let exactly, I was Alina, but I.
• 9:12
  Speaker 3: Yeah, this is just going to kick the can a
• 9:14
  Speaker 3: little bit, and that you know, we'd still have to
• 9:16
  Speaker 3: figure out why those rates are different within those hospitals.
• 9:18
  Speaker 3: But maybe once you look in the same hospital or
• 9:21
  Speaker 3: within the same provider, you see no racial differences between
• 9:24
  Speaker 3: C section rates, and it's really just selection into different hospitals.
• 9:28
  Speaker 3: Of course, it could also be something about provider discretion,
• 9:31
  Speaker 3: either that providers are more likely to do C sections
• 9:35
  Speaker 3: for black moms because they're more worried about something going wrong,
• 9:38
  Speaker 3: or maybe there are just general biases in the healthcare
• 9:40
  Speaker 3: system that we observe in a lot of other settings
• 9:43
  Speaker 3: in the US.
• 9:44
  Speaker 1: I think the reason that thinking about these explanations and
• 9:47
  Speaker 1: trying to distinguish them between them is so important is
• 9:49
  Speaker 1: that we can't really think about solutions without understanding the problem.
• 9:55
  Speaker 1: So if you said, you know, I'd like to lower
• 9:57
  Speaker 1: this disparity, I'd like to lower the rates, I'd like
• 9:59
  Speaker 1: to lower it. In general, just observing this very robust
• 10:03
  Speaker 1: correlation or differences across groups is actually going to tell
• 10:06
  Speaker 1: you nothing about how to fix it. And those explanations
• 10:09
  Speaker 1: you just gave me all suggest pretty different approaches to
• 10:13
  Speaker 1: whether this is a fixable problem or something we could
• 10:16
  Speaker 1: affect and how we would do it. I mean, you're
• 10:18
  Speaker 1: going to approach us pretty differently if it's something about
• 10:20
  Speaker 1: differences across hospitals versus something about differences across provider discretion,
• 10:24
  Speaker 1: and certainly if it's something about differences in risk factors.
• 10:29
  Speaker 3: Yeah, absolutely, I think it. Also, you know, when you
• 10:31
  Speaker 3: hear about this disparity, you sort of naturally think that
• 10:34
  Speaker 3: that's probably a bad thing. But if it's differences in risk,
• 10:37
  Speaker 3: or if it's differences in preferences, well then maybe we
• 10:39
  Speaker 3: shouldn't be so worried about it. We should want to
• 10:41
  Speaker 3: address those differences in medical risk. But at the point
• 10:44
  Speaker 3: that a mother shows up to deliver, we don't want
• 10:46
  Speaker 3: clinicians to reduce C sections among black moms if they
• 10:49
  Speaker 3: really just are more appropriate for the procedure.
• 10:52
  Speaker 1: So your goal in this research paper, which is entitled
• 10:56
  Speaker 1: Drivers of Racial Differences in C sections, is to try
• 10:58
  Speaker 1: to unpack a bit but what in fact.
• 11:01
  Speaker 2: Is going on?
• 11:03
  Speaker 1: So you're going to start this paper by trying to
• 11:05
  Speaker 1: understand whether the differences across racial groups are about differences
• 11:10
  Speaker 1: in pre existing risk, whether there's something that we could
• 11:15
  Speaker 1: point to and say people more likely I have this
• 11:17
  Speaker 1: complication that makes the C section more likely? And so
• 11:21
  Speaker 1: do you do this in a very specific way using
• 11:24
  Speaker 1: very fancy methods? So could you talk me through a
• 11:27
  Speaker 1: little bit, you know, what you do and why it
• 11:30
  Speaker 1: was important to approach it in this like quite comprehensive,
• 11:33
  Speaker 1: complicated way.
• 11:35
  Speaker 3: Yeah. Absolutely. So Basically, when people have looked at this
• 11:39
  Speaker 3: in the past or you know, where do we get
• 11:41
  Speaker 3: these statistics on sea section rates by race and over time?
• 11:44
  Speaker 3: Those tend to come from birth certificate data, right, so
• 11:47
  Speaker 3: you can get really good information on when you're at
• 11:50
  Speaker 3: the hospital and you fill out that birth certificate. After
• 11:52
  Speaker 3: your child's born, those are digitized and researchers get access
• 11:55
  Speaker 3: to those and you can track things like whether or
• 11:58
  Speaker 3: not people at sea sections.
• 11:59
  Speaker 1: Just to be people, this doesn't have your name on it,
• 12:03
  Speaker 1: so yes, people would not be able to find you
• 12:05
  Speaker 1: with this, but the information from the firth certificate so
• 12:07
  Speaker 1: still whatever that would like comic and go remove themselves from.
• 12:11
  Speaker 3: Yes, these are anonymized, but they're very useful for researchers
• 12:14
  Speaker 3: in order to track these trends over time. Now that's useful,
• 12:18
  Speaker 3: and that it has a lot of information, it's not
• 12:20
  Speaker 3: very useful, and that it doesn't have a lot of
• 12:21
  Speaker 3: information about whether or not we think them or what
• 12:24
  Speaker 3: the mother was presenting with that would cause her to
• 12:26
  Speaker 3: either need to see section or not. So what we're
• 12:29
  Speaker 3: going to do is we're going to get really detailed
• 12:31
  Speaker 3: administrative data from the state of New Jersey. So again
• 12:34
  Speaker 3: this isn't going to have individuals names, so this will
• 12:36
  Speaker 3: be anonymized on the patient's side, But we're basically going
• 12:39
  Speaker 3: to see everything that would be in the mother's record,
• 12:42
  Speaker 3: and so we'll know sort of all of our health
• 12:43
  Speaker 3: conditions leading up to birth. Will actually also be able
• 12:46
  Speaker 3: to follow mothers and babies following the delivery in order
• 12:49
  Speaker 3: to look at how this might influence their health later on.
• 12:52
  Speaker 3: But with that, we're just presented with essentially a wealth
• 12:55
  Speaker 3: of information about, you know, what the clinician would have
• 12:57
  Speaker 3: known about the mom at the point of making that decision,
• 13:01
  Speaker 3: that decision about how to deliver the baby. And so
• 13:04
  Speaker 3: we're in an age of big data and machine learning,
• 13:07
  Speaker 3: and so basically what we do is we give the
• 13:09
  Speaker 3: computer all of this information and we have it help
• 13:12
  Speaker 3: us figure out how to predict whether or not the
• 13:15
  Speaker 3: mother was going to get a sea section. And so
• 13:17
  Speaker 3: what you can think of this as doing is it's
• 13:19
  Speaker 3: basically figuring out over a decade worth of data of
• 13:24
  Speaker 3: which characteristics are going to be most likely to be
• 13:27
  Speaker 3: observed among mothers who end up having a C section.
• 13:30
  Speaker 3: So you can think of this as basically capturing medical consensus,
• 13:33
  Speaker 3: and so if a mom has a breach presentation, it's
• 13:36
  Speaker 3: very likely that she's going to have a sea section,
• 13:38
  Speaker 3: and so the model's going to tell us that that's
• 13:40
  Speaker 3: an important characteristic that predicts whether or not that mother
• 13:43
  Speaker 3: is going to need a sea section. We're also going
• 13:45
  Speaker 3: to see things like diabetes, obesity, putting on a lot
• 13:48
  Speaker 3: of weight during pregnancy, maternal age, all of these are
• 13:51
  Speaker 3: going to strongly predict whether or not a mom is
• 13:54
  Speaker 3: going to have a C section. And so what that's
• 13:56
  Speaker 3: going to allow us to do then is for each mother,
• 13:59
  Speaker 3: once we've asked maated this model using all of this data,
• 14:02
  Speaker 3: we can then basically predict for each mother what her
• 14:05
  Speaker 3: appropriateness is for a C section given medical consensus. So
• 14:09
  Speaker 3: on average, would she had gotten one from these other
• 14:11
  Speaker 3: clinicians throughout the time period.
• 14:14
  Speaker 1: And so I mean this this approach it shares some
• 14:17
  Speaker 1: features with a regression approach of sort of trying to
• 14:19
  Speaker 1: think about basically holding constant characteristics across people, but doing
• 14:27
  Speaker 1: it in a way where the thing you're holding constant
• 14:30
  Speaker 1: is in some ways way way richer and much closer
• 14:33
  Speaker 1: to holding constant the actual thing you care about, which
• 14:36
  Speaker 1: is when this person showed up, what was the likelihood
• 14:40
  Speaker 1: based on everything you would see about them when they arrived,
• 14:42
  Speaker 1: what was the likelihood they could have the sea section,
• 14:44
  Speaker 1: they would have a C section?
• 14:45
  Speaker 2: And you sort of have that number produced by this.
• 14:48
  Speaker 2: You guys use a random forest.
• 14:50
  Speaker 3: We use a random forest exactly, and so it's exactly
• 14:52
  Speaker 3: as you describe it. You know, we can think of
• 14:54
  Speaker 3: it similar to our regression. It's just going to have
• 14:57
  Speaker 3: a lot of nice properties that we tend to like
• 15:00
  Speaker 3: in research, and that's going to do a very good
• 15:02
  Speaker 3: job of predicting whether or not you actually are going
• 15:04
  Speaker 3: to have a C section.
• 15:06
  Speaker 1: Do you have a sense of how good these these
• 15:09
  Speaker 1: random forest models have sort of metrics of how how
• 15:12
  Speaker 1: predictive they are.
• 15:12
  Speaker 2: How good is your random forest?
• 15:14
  Speaker 3: So what we can do is we can, you know,
• 15:16
  Speaker 3: sort mothers in the testing sample into groups based on
• 15:21
  Speaker 3: whether or not they need one, and we're going to
• 15:22
  Speaker 3: basically be able to predict it for you. So the
• 15:24
  Speaker 3: women who are not in our sample that we're using
• 15:26
  Speaker 3: to train the model, we can kick out this number
• 15:29
  Speaker 3: of whether or not we think you're going to have
• 15:31
  Speaker 3: a C section. We can group you into different groups
• 15:34
  Speaker 3: based on that average risk, and then we can compute
• 15:36
  Speaker 3: the true chance that mothers in that group actually have
• 15:39
  Speaker 3: a C section, and they're going to line up, they're
• 15:41
  Speaker 3: going to match almost perfectly. So I think this also
• 15:44
  Speaker 3: tells you there's a lot of discretion in the decision
• 15:46
  Speaker 3: of whether or not to have a C section that
• 15:48
  Speaker 3: I'm sure we'll get into it and in just a bit,
• 15:50
  Speaker 3: and you know, we'll see some patterns in the data
• 15:52
  Speaker 3: that are going to really highlight the role of discretion.
• 15:55
  Speaker 3: But at the same time, there are a lot of
• 15:57
  Speaker 3: characteristics that are gonna, you know, really predict whether or
• 16:00
  Speaker 3: not you're a good candidate for the procedure or not.
• 16:02
  Speaker 1: Yeah, okay, so let's start. Let's get into what you
• 16:06
  Speaker 1: what you find. So I want to start with the
• 16:09
  Speaker 1: sort of baseline difference. So there's a racial difference in
• 16:14
  Speaker 1: C section rates, and you're focusing here, it's really useful to.
• 16:17
  Speaker 2: Say on unscheduled c sections.
• 16:20
  Speaker 1: So we're already kind of taking out the possibility, although
• 16:23
  Speaker 1: I agree it's remote and not true, but the possibility
• 16:27
  Speaker 1: that there are differences in kind of what people request
• 16:31
  Speaker 1: or even what is sort of happening at the doctor
• 16:34
  Speaker 1: beforehand in terms of how how you negotiate your things.
• 16:36
  Speaker 1: These are people who come in with an expectation of
• 16:40
  Speaker 1: laboring and having a vaginal birth and then there is
• 16:43
  Speaker 1: a C section or not afterwards. So with that sample,
• 16:47
  Speaker 1: what's the kind of headline racial difference in C section risk?
• 16:51
  Speaker 3: Yes, so we're going to see that above mothers with
• 16:53
  Speaker 3: unscheduled deliveries in New Jersey, Black mothers are going to
• 16:57
  Speaker 3: be twenty five percent more likely to have a C
• 17:00
  Speaker 3: section than white mother's And I think that's already quite striking.
• 17:04
  Speaker 3: Why I agree with you that I didn't think this
• 17:07
  Speaker 3: was going to be differences in maternal demand. I don't
• 17:09
  Speaker 3: often hear a lot of moms sort of begging to
• 17:11
  Speaker 3: have a sea section. But if you really want to
• 17:13
  Speaker 3: have a C section, you can certainly find a provider
• 17:15
  Speaker 3: who's willing to schedule one for you. And so that's
• 17:18
  Speaker 3: the reason we're focusing on unscheduled deliveries and is also
• 17:21
  Speaker 3: something that we people haven't been able to do in
• 17:23
  Speaker 3: previous data. So again going back to that birth certificate
• 17:26
  Speaker 3: data that again is anonymized, it will just say whether
• 17:28
  Speaker 3: you had a C section or not. It's not going
• 17:31
  Speaker 3: to say whether that c section happened after a trial
• 17:33
  Speaker 3: of labor, whereas in our data we can see that
• 17:36
  Speaker 3: mom shows up in labor, has a trial of labor,
• 17:39
  Speaker 3: and that ultimately ends in a C section. Those are
• 17:42
  Speaker 3: the cases that we're going to look at to sort
• 17:43
  Speaker 3: of exclude these women who already scheduled the C section
• 17:46
  Speaker 3: in advance, they knew they were coming in to have
• 17:48
  Speaker 3: a C section. Why we think if you show up,
• 17:51
  Speaker 3: you didn't schedule a CE section, you show up to
• 17:54
  Speaker 3: have a baby and it ends in a C section.
• 17:56
  Speaker 3: Those are the mothers who have signaled that their preferred
• 17:59
  Speaker 3: method would have been a bat delivery and then ultimately
• 18:01
  Speaker 3: proceeded to a C section.
• 18:03
  Speaker 1: So you see an increase, and we should say it's
• 18:06
  Speaker 1: twenty five it's about twenty five percent, not twenty five
• 18:08
  Speaker 1: percentage points.
• 18:09
  Speaker 2: It's twenty five.
• 18:10
  Speaker 3: So it's four point two percentage points over the base
• 18:14
  Speaker 3: for white moms is twenty five percent.
• 18:16
  Speaker 1: So I think the thing that's really striking for me,
• 18:19
  Speaker 1: even the baseline statistics, is that this difference is in
• 18:23
  Speaker 1: percentage terms, much larger for people who's like ex Ante,
• 18:28
  Speaker 1: coming in risk of a C section is lower. So
• 18:32
  Speaker 1: there's a set of people you have like kind of
• 18:34
  Speaker 1: they came in, you thought maybe they were unlikely to
• 18:37
  Speaker 1: have a sea section, and then for black moms, that
• 18:40
  Speaker 1: group is just way elevated and their risk relative to
• 18:42
  Speaker 1: the group that came in and it seemed likely they
• 18:46
  Speaker 1: have a C section where there's an elevation but it's smaller.
• 18:49
  Speaker 3: Yeah, I think this is one of the most striking
• 18:51
  Speaker 3: findings that just comes out of the data that if
• 18:53
  Speaker 3: you we talked about how we get that measure of
• 18:56
  Speaker 3: risk for moms, and if we group moms into risks,
• 18:59
  Speaker 3: so we have very low risk moms, so think in
• 19:01
  Speaker 3: the lowest quintile and then moms you know, all the
• 19:03
  Speaker 3: way up to the highest risk. There there is a disparity,
• 19:06
  Speaker 3: but it's very small for mothers in you know, once
• 19:09
  Speaker 3: you get to the highest risk quintile. Why most moms
• 19:12
  Speaker 3: that are getting sea sections right as they should and
• 19:14
  Speaker 3: so there's not much of a disparity. What is driving
• 19:17
  Speaker 3: the underlying racial disparity? We see it's low risk moms.
• 19:21
  Speaker 3: So if you show up to the hospital, these low
• 19:23
  Speaker 3: risk moms essentially have nothing in their record that would
• 19:25
  Speaker 3: suggest that they're going to need a sea section. We
• 19:28
  Speaker 3: see that black moms are going to be almost one
• 19:30
  Speaker 3: hundred and fifty percent more likely to have an unscheduled
• 19:33
  Speaker 3: sea section, so one point five times more likely, and
• 19:36
  Speaker 3: that's what's driving that overall disparity.
• 19:38
  Speaker 1: I mean, this paper is really really good, but it's
• 19:41
  Speaker 1: also very upsetting, and we haven't actually gotten to the
• 19:43
  Speaker 1: most upsetting part leading into it. The next thing you
• 19:48
  Speaker 1: do in the paper is you talk about these controls.
• 19:49
  Speaker 1: You talk about like basically trying to rule out some
• 19:53
  Speaker 1: of the differences that might be driving this and what
• 19:57
  Speaker 1: happens when you use your fancy system that.
• 20:00
  Speaker 3: Yeah, so we're going to start with that baseline disparity
• 20:03
  Speaker 3: that we talked about that if we just look at
• 20:05
  Speaker 3: women showing up with an unscheduled delivery, that we see
• 20:08
  Speaker 3: that black moms are twenty five percent more likely to
• 20:11
  Speaker 3: deliver by sea section. We're then going to basically control
• 20:14
  Speaker 3: for things that are closely related to that you have
• 20:17
  Speaker 3: said that people have thought might be driving this disparity
• 20:20
  Speaker 3: to see how it changes that disparity. So we can
• 20:23
  Speaker 3: control for medical risk. So say, think of two moms
• 20:26
  Speaker 3: with the same medical risk, one who's black and one
• 20:29
  Speaker 3: who's white. We're actually going to see that if anything,
• 20:32
  Speaker 3: the disparity is then larger. Now that seems a little
• 20:35
  Speaker 3: surprising because you might, as I said that, you know,
• 20:38
  Speaker 3: black moms are going to have on average, some health
• 20:40
  Speaker 3: conditions that would make them better candidates for sea sections. However,
• 20:44
  Speaker 3: in New Jersey, we're going to see that black moms
• 20:46
  Speaker 3: are significantly younger on average, and that's going to be
• 20:49
  Speaker 3: a very important predictor of whether or not you have
• 20:52
  Speaker 3: a sea section. And so the average black mom is
• 20:54
  Speaker 3: actually going to be a less appropriate candidate for the
• 20:56
  Speaker 3: procedure than the average white mom. But again, there's going
• 20:59
  Speaker 3: to be that spectrum. We'll be able to look across
• 21:01
  Speaker 3: the whole risk spectrum. But if we just control for risk,
• 21:04
  Speaker 3: we're actually going to see the disparity go up slightly.
• 21:07
  Speaker 3: What can we then do We can control for other
• 21:09
  Speaker 3: socioeconomic characteristics of the mother, So think of the type
• 21:12
  Speaker 3: of insurance that she has, or education level, so on
• 21:15
  Speaker 3: and so forth. It's not clear why those things should
• 21:18
  Speaker 3: affect whether or not you have a C section, but
• 21:20
  Speaker 3: I'd put that in those candidate explanation bins of that
• 21:23
  Speaker 3: maybe it's something else observable about the mom other than
• 21:26
  Speaker 3: race that's affecting this decision. That's not going to wipe
• 21:29
  Speaker 3: out that disparity. We can then even control for the
• 21:32
  Speaker 3: hospital that you go to. So think of two moms,
• 21:35
  Speaker 3: similar health risk, same insurance, same education level, delivering in
• 21:39
  Speaker 3: exactly the same hospital. We're still going to see that
• 21:42
  Speaker 3: if the mom's black, she's going to be twenty one
• 21:44
  Speaker 3: percent more likely to deliver by sea section. So twenty
• 21:48
  Speaker 3: one percent is lower than twenty five percent, but it's
• 21:50
  Speaker 3: not much lower, right, which is suggesting that those candidate
• 21:53
  Speaker 3: explanations aren't explaining much of the gap. And what I
• 21:56
  Speaker 3: find very striking is since we know in the data
• 21:59
  Speaker 3: who actually the delivering physician was, we can control for
• 22:02
  Speaker 3: the physician who delivers the baby. So a mom with
• 22:06
  Speaker 3: the same medical risk delivering in the same hospital, delivered
• 22:09
  Speaker 3: by exactly the same physician, we're going to see that
• 22:12
  Speaker 3: black moms are still twenty percent more likely to get
• 22:14
  Speaker 3: a sea section. And so it's certainly not something about
• 22:17
  Speaker 3: the providers that they're going to the differences in their
• 22:19
  Speaker 3: health risk, their preferences, so on and so forth.
• 22:27
  Speaker 1: More parent data, including how Molly addresses her skeptics, the
• 22:32
  Speaker 1: thought processes and pressures of clinicians who choose to perform
• 22:35
  Speaker 1: sea sections and the implications of this paper on black
• 22:38
  Speaker 1: mothers and sea section policy after the break. So in
• 22:55
  Speaker 1: this you've controlled for quite a lot of stuff and
• 22:59
  Speaker 1: I think it still shows up, and it's very striking
• 23:02
  Speaker 1: way that there's this difference. But a skeptic coming to
• 23:06
  Speaker 1: this is going to say, well, it's still.
• 23:11
  Speaker 2: Could be unobserved differences.
• 23:13
  Speaker 1: You know, you yes, you see everything about their vistatus,
• 23:16
  Speaker 1: but you know you don't see you know, you didn't
• 23:19
  Speaker 1: you weren't there, so they didn't talk. You know, you'd
• 23:22
  Speaker 1: hear them talk about what they wanted. You know, there's
• 23:24
  Speaker 1: like something that you're that you're missing. And this is
• 23:28
  Speaker 1: in some ways for me why this sort of last
• 23:31
  Speaker 1: part of the paper is so crucial where you try
• 23:35
  Speaker 1: to you show us kind of one more piece of
• 23:37
  Speaker 1: evidence that I think really suggests that what is going
• 23:41
  Speaker 1: on is not difference, is an unmeasured risk. And so
• 23:45
  Speaker 1: can you just talk us through this part of the
• 23:49
  Speaker 1: paper about surgical resources.
• 23:52
  Speaker 3: Yeah, absolutely, So, as you said, you know, we're we're
• 23:55
  Speaker 3: not there, and there are certainly things that clinicians on
• 23:58
  Speaker 3: the ground observe that we as researchers, even if we
• 24:01
  Speaker 3: have the best data possible. Not everything is written down
• 24:04
  Speaker 3: in the medical record, right, and so what we were
• 24:06
  Speaker 3: thinking when, you know, when this disparity still persisted, conditional
• 24:09
  Speaker 3: on everything that we saw, is that there could be
• 24:12
  Speaker 3: differences in what we would call unobserved health rists. So
• 24:14
  Speaker 3: maybe black mothers are unobservably unobservably to us, to the researchers,
• 24:19
  Speaker 3: but not unobservably to the clinician, just more appropriate candidates
• 24:22
  Speaker 3: for the procedure. And so that's why they're getting additional
• 24:25
  Speaker 3: sea sections. And so what we what we do in
• 24:27
  Speaker 3: order to look at that is we leverage variation throughout
• 24:31
  Speaker 3: the day in terms of whether or not there's a
• 24:33
  Speaker 3: scheduled sea section at the same time. So why is
• 24:36
  Speaker 3: that useful for us? Well, one thing that you see
• 24:39
  Speaker 3: in the data is that when there's a scheduled sea
• 24:42
  Speaker 3: section at the same hour that a mother with an
• 24:44
  Speaker 3: unscheduled delivery is delivery, she's going to be significantly less
• 24:49
  Speaker 3: likely to have an unscheduled sea section.
• 24:51
  Speaker 2: And that's true for and that's true across races. That's true, that's.
• 24:54
  Speaker 3: True across races. You just see that when the ore
• 24:57
  Speaker 3: they these hospitals in New Jersey typically only have one
• 25:00
  Speaker 3: or two operating suites sort of set up to do
• 25:02
  Speaker 3: sea sections, and you see that when one of them
• 25:05
  Speaker 3: is busy, mothers are significantly less likely to have an
• 25:08
  Speaker 3: unscheduled sea section, which already I think sort of highlights
• 25:12
  Speaker 3: the discretionary nature of a lot of these unscheduled sea sections.
• 25:15
  Speaker 3: That it doesn't drop to zero, right, It's not that
• 25:18
  Speaker 3: one there's a scheduled sea section, there's no unscheduled sea sections.
• 25:21
  Speaker 3: If mom and baby are going to die, they're absolutely
• 25:24
  Speaker 3: going to do that unscheduled sea section. And we still
• 25:26
  Speaker 3: see some unscheduled sea sections happening, but you see that
• 25:29
  Speaker 3: throughout the day. They just sort of trend inversely with
• 25:32
  Speaker 3: what's happening with scheduled se sections, so they're significantly less
• 25:35
  Speaker 3: likely when that takes place. Now, I will say, one
• 25:38
  Speaker 3: thing we had thought is maybe they're just shifting around
• 25:40
  Speaker 3: the timing, right. Maybe you shift the scheduled sea section
• 25:43
  Speaker 3: back when there's an unscheduled sea section or vice versa.
• 25:47
  Speaker 3: We can basically change the level of aggregation, and what
• 25:50
  Speaker 3: you'll see is that they're going to be significantly fewer
• 25:53
  Speaker 3: unscheduled se sections on days when there's more scheduled se
• 25:57
  Speaker 3: sections or even in weeks when they're scheduled se section,
• 26:00
  Speaker 3: and so this is actually preventing unscheduled sea sections from
• 26:03
  Speaker 3: happening as opposed to just shifting the timing. Okay, so
• 26:06
  Speaker 3: we have this variation in whether or not there is
• 26:09
  Speaker 3: a scheduled sea section at the time of delivery, and
• 26:12
  Speaker 3: why is this going to help us get at the
• 26:15
  Speaker 3: underlying causes of those persistent racial disparities and delivery method
• 26:20
  Speaker 3: you know, conditional on that rich set of controls. Well,
• 26:23
  Speaker 3: if it was, if that disparity was due to difference
• 26:26
  Speaker 3: as an unobserved health risk, that black moms are just
• 26:29
  Speaker 3: better candidates for the procedure in ways that we can't observe. Well,
• 26:33
  Speaker 3: then when there's a scheduled sea section at that time
• 26:36
  Speaker 3: and you have to cut back on your unscheduled sea sections,
• 26:39
  Speaker 3: who are you going to stop doing them among? First,
• 26:41
  Speaker 3: you're going to stop doing them among white moms? Why
• 26:43
  Speaker 3: white moms are going to be less appropriate for the procedure?
• 26:46
  Speaker 3: Black moms are more appropriate for the procedure, you cut
• 26:49
  Speaker 3: back on them for white moms, and so the disparity
• 26:51
  Speaker 3: should actually grow, Right if it's something about unobserved differences
• 26:55
  Speaker 3: in health risks, the disparity should get larger when the
• 26:58
  Speaker 3: birth occurs at the same time as a scale section.
• 27:01
  Speaker 3: On the other hand, if it's something about discretion, and
• 27:05
  Speaker 3: you know, we can talk through what we think is
• 27:06
  Speaker 3: kind of in that discretion. If it's something about doctors
• 27:09
  Speaker 3: just being more likely to do sort of these marginal
• 27:12
  Speaker 3: se sections on black moms, well then when the oar
• 27:16
  Speaker 3: is busy, who should you stop doing C sections among?
• 27:18
  Speaker 3: First black moms or white moms. You're going to stop
• 27:20
  Speaker 3: doing them among black moms because they're less good candidates
• 27:23
  Speaker 3: for the procedure and the white moms are going to
• 27:25
  Speaker 3: need them more. So if that was the underlying explanation, well,
• 27:28
  Speaker 3: then the disparity should fall when the birth occurs at
• 27:31
  Speaker 3: the same time as a scheduled see section. And what
• 27:33
  Speaker 3: we're going to see in the data is that when
• 27:35
  Speaker 3: the birth occurs at the same time as a scheduled
• 27:37
  Speaker 3: sea section, there's going to be no racial disparity in
• 27:40
  Speaker 3: unscheduled C section rates. So they're still going to do
• 27:43
  Speaker 3: some unscheduled see sections. It's not again that those fault
• 27:46
  Speaker 3: to zero, but it's going to be in a statistically
• 27:48
  Speaker 3: equivalent rate between black and white moms. You no longer
• 27:51
  Speaker 3: see that additional that additional rate among black mothers.
• 27:55
  Speaker 1: I think the uncharitable view of this discussion is we
• 28:01
  Speaker 1: have a free O R C sections pay a.
• 28:04
  Speaker 2: Lot, let's use it. Who should we use it on?
• 28:08
  Speaker 2: Maybe we'll use it on black moms.
• 28:10
  Speaker 1: I mean, is that, like, that is one thing that
• 28:13
  Speaker 1: would be consistent with your explanation.
• 28:15
  Speaker 3: Is it not? Yes, so that certainly would be consistent
• 28:18
  Speaker 3: with what we're seeing. And I've spoken to some clinicians
• 28:21
  Speaker 3: since the study came out who actually sort of thought
• 28:23
  Speaker 3: that that was the most likely explanation. But I think
• 28:26
  Speaker 3: there are also more charitable explanations that could be happening. Right.
• 28:30
  Speaker 3: It could be the case that, you know, clinicians are
• 28:33
  Speaker 3: certainly well aware of disparities and outcomes between black and
• 28:37
  Speaker 3: white moms, and maybe when there is additional capacity to
• 28:41
  Speaker 3: put additional resources towards the care of black mothers, maybe
• 28:44
  Speaker 3: they're more likely to want to just provide those extra
• 28:46
  Speaker 3: resources to black moms to try and mirrow those disparities. Now,
• 28:50
  Speaker 3: what we'll see in the last part of the paper,
• 28:52
  Speaker 3: and we can look at the health implications of that
• 28:54
  Speaker 3: is that you know, c sections aren't costless procedures for
• 28:57
  Speaker 3: mom or baby, and so if you're very low risk
• 29:00
  Speaker 3: and you get a C section, that can lead to
• 29:02
  Speaker 3: additional complications that you wouldn't have had in the absence
• 29:05
  Speaker 3: of that surgery. And so that's not necessarily a good
• 29:07
  Speaker 3: thing for clinicians to be doing, but you could envision
• 29:10
  Speaker 3: that would be part of the thought process, although it
• 29:12
  Speaker 3: could also be that you know, they need they want
• 29:14
  Speaker 3: to fill that room with the mom, and they're gonna
• 29:18
  Speaker 3: choose which moms to do that on.
• 29:21
  Speaker 1: Before we get to the last part about about health impacts,
• 29:24
  Speaker 1: I'm I'm curious if you have a.
• 29:26
  Speaker 2: Sense from talking to clinicians about.
• 29:30
  Speaker 1: In some ways, even putting aside the racial differences, like
• 29:33
  Speaker 1: this suggests a fair amount of discretion in whether I
• 29:37
  Speaker 1: go to a C section or not a reasonable amount
• 29:40
  Speaker 1: of the time.
• 29:40
  Speaker 2: I'm kind of like, we could do it, we could
• 29:42
  Speaker 2: not do it. If there's a space, we do it.
• 29:43
  Speaker 1: If there's do you have a sense from clinicians of like,
• 29:46
  Speaker 1: what are you doing instead? Is it just trying harder?
• 29:50
  Speaker 1: Like what is happening that is that is allowing vaginal
• 29:56
  Speaker 1: bards in these cases? In which there's the oar is
• 29:59
  Speaker 1: busy and somehow we've given up when the or is
• 30:03
  Speaker 1: not busy.
• 30:04
  Speaker 3: Yeah, I guess so. What we've heard from clinicians is
• 30:07
  Speaker 3: that there's often a lot of pressure both internally externally
• 30:10
  Speaker 3: from peers from the system also from themselves of just
• 30:12
  Speaker 3: wanting to sort of keep your schedule in order, right,
• 30:15
  Speaker 3: and so if you know you have a lot of
• 30:16
  Speaker 3: births ahead of you for the day, you might want
• 30:19
  Speaker 3: to move some women through and so that you can
• 30:20
  Speaker 3: sort of clear up time for other mothers. There's also
• 30:24
  Speaker 3: evidence showing that towards the end of a shift, people
• 30:26
  Speaker 3: are more likely to do see sections, and so you know,
• 30:28
  Speaker 3: in addition to the financial considerations that are always going
• 30:31
  Speaker 3: to be present with these different types of delivery methods,
• 30:34
  Speaker 3: there is also just time constraints and just wanting to
• 30:38
  Speaker 3: keep things moving.
• 30:39
  Speaker 1: We did an interview a couple of episodes ago with
• 30:42
  Speaker 1: a midwife in which this sort of general discussion came up,
• 30:46
  Speaker 1: and I think one of the things that she would
• 30:49
  Speaker 1: articulate as being somewhat different about the Midwiffery model of
• 30:52
  Speaker 1: care is like you expect to be there for a while,
• 30:56
  Speaker 1: and that's like you're just like you're hanging out, there's
• 31:00
  Speaker 1: more waiting.
• 31:01
  Speaker 3: Yees wait, No, absolutely, I think that that it's just
• 31:04
  Speaker 3: a different approach to it with my With my first child,
• 31:07
  Speaker 3: I had an obstetrician tell me that if I didn't
• 31:09
  Speaker 3: want more potosa than I should go home because the
• 31:11
  Speaker 3: beds are reserved for women in labor. And so I think,
• 31:14
  Speaker 3: you know, he was really like, we gotta we gotta
• 31:16
  Speaker 3: move the salog or let's just get you out of here.
• 31:18
  Speaker 1: So please contract faster, Molly, thank you exactly, So right,
• 31:23
  Speaker 1: your pelvis is too strong and it's moving slow.
• 31:27
  Speaker 3: Yeah, he wanted things to just go faster. He seemed
• 31:30
  Speaker 3: really focused on kind of how long it had been
• 31:33
  Speaker 3: and that, you know, he wanted to get the show
• 31:35
  Speaker 3: moving and he wasn't willing to wait.
• 31:37
  Speaker 1: With my second kid, I waited too long to go
• 31:40
  Speaker 1: to the hospital, having been given a similar speech with
• 31:42
  Speaker 1: the first one, and we arrived at the hospital like
• 31:45
  Speaker 1: fifteen minutes before the baby came out.
• 31:47
  Speaker 2: So that was true.
• 31:49
  Speaker 3: I also got to look fast, exactly.
• 31:53
  Speaker 1: So let's talk about the last piece of this, which
• 31:55
  Speaker 1: is what is the what are the implications? So what
• 31:57
  Speaker 1: are you finding when you're able to look in the
• 31:59
  Speaker 1: data on health health impacts, what is the what is
• 32:04
  Speaker 1: the result of this.
• 32:05
  Speaker 3: Yeah, so we can use that same variation in terms
• 32:09
  Speaker 3: of the variation and whether or not there's space and
• 32:12
  Speaker 3: the o R to basically try and isolate these marginal
• 32:16
  Speaker 3: what we would call marginal or discretionary c sections. And
• 32:18
  Speaker 3: so you should think of this as a mom who
• 32:21
  Speaker 3: has a C section because the o R is empty,
• 32:24
  Speaker 3: but she wouldn't have had a C section if the
• 32:26
  Speaker 3: or was fult and so these are kind of those
• 32:28
  Speaker 3: those cases that are on the margin. And what we're
• 32:30
  Speaker 3: going to see is that when those c sections take place,
• 32:32
  Speaker 3: particularly for low risk mothers, we're going to see additional
• 32:36
  Speaker 3: complications both for mom and for baby. So for mom,
• 32:39
  Speaker 3: what we're seeing we're going to see additional complications basically
• 32:43
  Speaker 3: of the surgical wound, which makes sense, right, You're not
• 32:46
  Speaker 3: going to have complications of a surgical wound if you
• 32:48
  Speaker 3: didn't have surgery. And so you know, I'm not surprised
• 32:50
  Speaker 3: that c sections are leading to increases in complications involving
• 32:54
  Speaker 3: those wounds. But again, this really just emphasizes the fact
• 32:57
  Speaker 3: that you know, these procedures do come with risks, and
• 32:59
  Speaker 3: so that you really only want to be having one
• 33:02
  Speaker 3: if it's really necessary. Now for babies, we're also going
• 33:06
  Speaker 3: to see implications only when the mom was very low risk,
• 33:09
  Speaker 3: and so for the low risk moms, we're going to
• 33:12
  Speaker 3: see that there's additional additional complications or for health at
• 33:16
  Speaker 3: birth for the infants. So we're going to see increased
• 33:19
  Speaker 3: chances of being admitted to the NICKEU for those babies.
• 33:23
  Speaker 3: We're actually going to see the opposite for high risk bombs.
• 33:25
  Speaker 3: And so if you're a high risk mom and you
• 33:27
  Speaker 3: have a C section that's cut because of limited capacity,
• 33:30
  Speaker 3: we're going to see actually increased negative health outcomes among
• 33:34
  Speaker 3: those babies, which again I think really highlights the fact
• 33:36
  Speaker 3: that you know, with c sections, we really want to
• 33:40
  Speaker 3: be reducing them for low risk moms, not for high
• 33:42
  Speaker 3: risk moms, that they can be really necessary procedures, and
• 33:45
  Speaker 3: so the goal shouldn't be just to bring sea sections
• 33:47
  Speaker 3: down across the board. We want to be reducing them
• 33:50
  Speaker 3: for low risk moms and keeping them for high risk moms,
• 33:52
  Speaker 3: and if anything, and then increasing them in that end
• 33:54
  Speaker 3: of the distribution.
• 33:56
  Speaker 2: So what do you take away in terms of policies.
• 33:57
  Speaker 1: So we started by talking about, you know, understand the
• 34:00
  Speaker 1: problem being core to developing policy solutions. So what do
• 34:04
  Speaker 1: you take from your results about what should be done
• 34:07
  Speaker 1: to try to help fix this.
• 34:10
  Speaker 3: Yeah, so I think there's a couple of potential policies here,
• 34:13
  Speaker 3: So one or one set of policies I would sort
• 34:16
  Speaker 3: of group of the information bin. And so you could
• 34:18
  Speaker 3: envision giving moms more information about C section rates across
• 34:22
  Speaker 3: different hospitals, or even racial disparities and those sea section rates.
• 34:26
  Speaker 1: Right.
• 34:26
  Speaker 3: We know that patients tend to take this information in
• 34:29
  Speaker 3: account when choosing their provider, and that also hospitals and
• 34:33
  Speaker 3: hospital systems tend to respond to this sort of information
• 34:36
  Speaker 3: in terms of trying to provide the services that patients want.
• 34:39
  Speaker 3: And so that could help mothers choose where they want
• 34:42
  Speaker 3: to deliver, and it could also put some pressure on
• 34:44
  Speaker 3: hospital systems to change these numbers. On the information side,
• 34:48
  Speaker 3: you could also envision giving doctors sort of these these
• 34:52
  Speaker 3: risk predictions that we're getting using all this data that
• 34:55
  Speaker 3: you have available in their healthcare systems. Right, So we
• 34:58
  Speaker 3: do this for a lot of other procedures where you
• 35:00
  Speaker 3: sort of get a measure of how successful this candidate
• 35:03
  Speaker 3: would be for this or how appropriate they are for
• 35:05
  Speaker 3: a certain procedure. We do this for VBAX, for example,
• 35:08
  Speaker 3: and you could envision having that score pop up on,
• 35:10
  Speaker 3: you know, on a clinician screen. You certainly don't want
• 35:12
  Speaker 3: to force clinicians to make decisions based off of that,
• 35:15
  Speaker 3: and that you know, again, clinicians will see more than
• 35:18
  Speaker 3: what we see just in the data. But if you
• 35:20
  Speaker 3: see if the number comes up and it shows that
• 35:22
  Speaker 3: a patient might be a particularly bad candidate for having
• 35:25
  Speaker 3: a C section, you might think twice about whether or
• 35:27
  Speaker 3: not that mother actually meets the procedure. So it could
• 35:29
  Speaker 3: least show you that given everything that we see in
• 35:32
  Speaker 3: the record, given how other clinicians would behave, they'd be
• 35:35
  Speaker 3: very unlikely to do a C section for that weather.
• 35:37
  Speaker 3: So I'd put that all on the information bin. I
• 35:39
  Speaker 3: also think it's sort of difficult to overstate the importance
• 35:42
  Speaker 3: of advocates. And so I know you've talked a lot
• 35:45
  Speaker 3: about and have people on your show talk about Doula's exactly.
• 35:48
  Speaker 2: What I was hoping you would get to do it.
• 35:49
  Speaker 2: Otherwise I was going to have to get to doulas.
• 35:52
  Speaker 3: Yeah, and I think you know to the extent that
• 35:54
  Speaker 3: there is a discretionary part of this making sure that
• 35:56
  Speaker 3: you have somebody in the room who can help advocate
• 35:59
  Speaker 3: for you. Right, there's great evidence showing that birth outcomes
• 36:01
  Speaker 3: are better when people have doulas, and there's many reasons
• 36:04
  Speaker 3: for that, but you know, part of it is probably
• 36:06
  Speaker 3: having somebody in the room who can who knows the process,
• 36:09
  Speaker 3: and who can advocate for you. And there's been changes
• 36:11
  Speaker 3: in reibursement policy to make sure that you know, women
• 36:14
  Speaker 3: from many different backgrounds can have duelas with them. In
• 36:17
  Speaker 3: New Jersey, it was added to Medicaid in twenty twenty one,
• 36:19
  Speaker 3: and so you know, our study ends in twenty eighteen.
• 36:22
  Speaker 3: I would love to go back into the data in
• 36:24
  Speaker 3: more recent years and see whether or not that's affected
• 36:27
  Speaker 3: these racial disparities, and whether it's changed whether or not
• 36:30
  Speaker 3: people have somebody with them, and whether it changes what
• 36:32
  Speaker 3: we're finding here, So advocates, I think is important. The
• 36:36
  Speaker 3: last thing I mean, and this will take longer, but
• 36:39
  Speaker 3: I think it sort of should be a big picture
• 36:40
  Speaker 3: goal of the healthcare system is just to increase diversity
• 36:43
  Speaker 3: among the healthcare workforce. So one thing we did in
• 36:47
  Speaker 3: the study is that it's actually quite difficult to know
• 36:50
  Speaker 3: the race of clinicians. We have a lot of information
• 36:53
  Speaker 3: on clinicians and data sets. One thing we tend to
• 36:55
  Speaker 3: not have is their race, and so we had a
• 36:58
  Speaker 3: wonderful ra google every clinician that was in our data,
• 37:02
  Speaker 3: because we do have we have clinicians names, even though
• 37:05
  Speaker 3: we don't have patients' names, and so we had a
• 37:07
  Speaker 3: research assistant google them to find pictures of them on
• 37:10
  Speaker 3: different websites so that we could try and code their race.
• 37:13
  Speaker 3: And unfortunately, there's not many black obstetricians in New Jersey,
• 37:16
  Speaker 3: and so we're somewhat limited in what we would call
• 37:18
  Speaker 3: statistical power for these analyzes, but we are going to
• 37:21
  Speaker 3: see suggestive evidence of a much smaller racial disparity among
• 37:25
  Speaker 3: black clinicians, and so if it's a black obstetrician delivered
• 37:29
  Speaker 3: for a black mom, you're going to see a much
• 37:31
  Speaker 3: lower additional rate of C sections for those women, and so,
• 37:35
  Speaker 3: you know, sort of promoting racial concordance in medicine. They
• 37:38
  Speaker 3: could also be potentially useful.
• 37:44
  Speaker 1: Thanks for doing this work, Molly, Yeah, thank you for
• 37:47
  Speaker 1: covering it, Thanks for.
• 37:48
  Speaker 2: Coming and talking about it. I think it's incredibly important.
• 37:52
  Speaker 1: And also really high quality, which doesn't always overlap.
• 37:56
  Speaker 2: So I'm glad you're doing it.
• 37:58
  Speaker 3: I'm glad you think so awesome. Thank you.
• 38:12
  Speaker 1: Parent Data is produced by Tamar Avishai with support from
• 38:16
  Speaker 1: the parent Data team and PI Rex. If you have
• 38:19
  Speaker 1: thoughts on this episode, please join the conversation on my
• 38:21
  Speaker 1: Instagram at Prof Emily Ostar, and if you want to
• 38:25
  Speaker 1: support the show, become a subscriber to the parent Data
• 38:28
  Speaker 1: newsletter at parentdata dot org, where I write weekly posts
• 38:32
  Speaker 1: on everything to do with parents and data to help
• 38:35
  Speaker 1: you make better, more informed parenting decisions. For example, doctor
• 38:39
  Speaker 1: quantrella Ard wrote a beautiful essay for us last year
• 38:42
  Speaker 1: title Black Maternal Health is Maternal Health, where she talks
• 38:46
  Speaker 1: about her own unplanned C section and how delivering as
• 38:49
  Speaker 1: a black mother in America opened her eyes to the
• 38:52
  Speaker 1: discrepancies in the system that Molly is researching.
• 38:54
  Speaker 2: It's well worth a read or a reread. Find it
• 38:58
  Speaker 2: at parentdata dot org.
• 39:00
  Speaker 1: There are a lot of ways you can help people
• 39:01
  Speaker 1: find out about us. Leave a rating or a review
• 39:04
  Speaker 1: on Apple Podcasts, Text your friend about something you learned
• 39:07
  Speaker 1: from this episode. Debate your mother in law about the
• 39:10
  Speaker 1: merits of something parents do now that is totally different
• 39:12
  Speaker 1: from what she did. Plot a story to your Instagram.
• 39:15
  Speaker 1: The monk in a panic headline of your own. Just
• 39:18
  Speaker 1: remember to mention the podcast too, write Penelope right, mom
• 39:23
  Speaker 3: We'll see you next time.