Transcript

SPEAKER_01
0:04

Hey Denise, how are you today? Hello, ginger. I think I always start the same way, but that's what we do. How are you?

SPEAKER_00
0:13

Yeah, what's next is the weather, man?

SPEAKER_01
0:15

The weather. We always talk about the weather. I'm just really glad that it's finding warm up. Yeah, no more snow in Madison. No, no. It's it's it we're done hibernating. So that's it. That's good. Bring up the flowers.

SPEAKER_00
0:30

About every Thursday, Friday, we go through these tornado experiences in Kansas and Kansas City. It's been a it's been a crazy spring for us, uh, but I think that's true for a lot of the a lot of the Midwest and the East.

SPEAKER_01
0:42

So Oh yeah, we got pelted really hard with Hale. I have stories, I have pictures about covering wrapping up the cars.

SPEAKER_00
0:48

So all right. So we're gonna jump right into new news, which a lot of people are familiar with now. And I really try hard to think about not only how can I stump Denise, but how can I tie this into our guest? And we're very excited that Neil Shaw is going to be with us today, which I would say 99.9% of our listeners uh know who this incredible guy is. But um I was up late last night getting prep done for some presentations. I'm overloaded by the end of May. And guess what popped up? The Vital Statistics Rapid Release report number 43, um, April 2026. And I actually had not seen this yet, Denise, but a good friend of mine, Kathleen Rice Simpson, had sort of hinted that something was floating around out there, but I hadn't I hadn't found it yet. And it came up. So I'm gonna I'm gonna tell you some things that I think are amazing and quite frankly, astoundingly positive. This is great. Yeah, and then something I'm gonna just say, what the heck is going on here? All right, tell us what it is. Are you ready? Okay, so I'm just gonna sort of look at the graphs. The first one is the number of live births and general fertility rate, this is provisional data for 25, has all dropped. We're hearing a lot about that nationwide. Um in a variety of conversations, which we won't go into, but quite honestly, the drop from 20 to 25 is pretty significant. The next graph I want to just applaud because back in the day, you know, when I was in active practice, we had a lot of grants for teen pregnancy. In fact, we had one at St. Luke's Hospital, Denise, when we remember that had a teen pregnancy clinic. The rates are at an all-time low. And yes, that's for every category: 18 to 19, 15 to 19, and 15 to 17. It's in fact the lowest it's been, like, I think ever. Something's working. Something's working. I think we know what's working.

SPEAKER_03
2:58

Right.

SPEAKER_00
2:59

Now I'm gonna tell you what I'm really concerned about. Because when I, you know, before I even graduated and was an RN, I was teaching childbirth education. I was a certified Lamas instructor, and I distinctly remember sitting on the floor in a room with 10 couples going, one of you is gonna have a C-section. You know, the rate is one in 10. These are some of the things we like to just help you be aware of and coping techniques to maybe reduce your chances, but it's it's just the way the odds are. We uh we have not stopped going up since 2018. And the overall rate right now for cesarean delivery again went up from 32.5 to 32.4 uh to 32.7. So our numbers are rising. And then we look at the NS uh NSVD. Yeah, yeah. And it's the highest V. Right. It's it's the highest that it's ever been at 27.2.

SPEAKER_01
4:11

Okay. So we're gonna start getting near Brazil rates here pretty soon.

SPEAKER_00
4:17

Well, those we don't even want to talk about. No, we don't they don't they don't think about vaginal birth much over there. No. But you know, I think it's important. We're getting all kinds of listeners now, and and even some global folks are starting to join us. What do you think? I mean, you work in the hospital, Denise, in a very high volume practice. You've got like what almost 1920 midwives, you work with residents. What's your rate?

SPEAKER_01
4:42

Um, well, that's interesting. Um, I think I have to look. We're still um, you know, I it has it has slightly increased um over the years, but we're still um in the range of like 12%. Whoa. So with our with our midwifery group, I'm not talking about, you know, the whole hospital rate. Yeah. But I do think if I remember correctly, it's in the like 20, maybe 27 to 28 percent. Yeah. So still a little bit lower than that number. Yeah. Um, but I, you know, I don't do the data as much as I used to. I gave that to some of the younger midwives so that they could be, you know, well aware of how to collect that and the importance of doing that, because I do think it's always very important um to really be aware of what your your practice is doing so that you can look at what things could be sh changing or shifting. Um so I actually that will be a really good thing to go back and make the comparison from 2020. But I yeah, I I I do think some of those good stats that are coming out, you know, come as a result of you know, our famous little COVID and and other efforts, right?

SPEAKER_00
5:53

Yeah.

SPEAKER_01
5:55

So wow. Well, um, thanks for bringing that to light again. I think that is important to always keep in front of our mind.

SPEAKER_00
6:02

Yeah. And and it does intersect with a couple things that I came to know uh Dr. Shaw for, and and now I'm gonna call you Neil from this point forward. Um, when I was leaving the presidency of ACM, a good friend of mine, Kara Osborne, uh, was sort of tapping on my shoulder and I was trying to figure out who I could really think about as a keynote in my last year, and it happened to be someone I had never heard of. And yet I understood that that this person really um as a young obstetrician was was beginning to research and talk about things like cesarean birth and costs of care that nobody really in my mind had been bold enough to talk about before, particularly in OBGYN. And so when Neil um agreed and came to that, I I think Neil, you had an overwhelming like standing ovation and applause, and you know, it it was all thematic through really this idea of the cesarean section dilemma. And over those years, we've worked a lot together uh and are sort of circling back again on another new project that maybe we'll get to before the end of the call. But we're so we're so honored to have you, Neil, um, because the mid-wifery world, as you know, not just domestically but globally, um, is under a lot of stress. The barriers in some ways seem to be rising, at least with our clients and what we're hearing. Um, costs of care have some implication for that, but so does this inability to truly mainstream this professional career track with the team. It's like you either know how to do it or you do it poorly. So um uh Neil, I want Denise to say a few things, and then we'd love for you to sort of talk to us about your journey into like where did this voice come from? You know, this this advocacy come from. Denise, any thoughts? Anything you want to say?

SPEAKER_01
8:02

Well, I just want to say also thank you, Dr. Shaw. Um, I'll call you Neil too, if you don't mind. Um, whenever you join our Pospa's um podcast, I mean, actually you're you become such a friend. So um I'm taking the liberty of calling you that. Um, I've heard your name for many, many years, and it's always been a pleasure to hear you speak. Um, but Ginger, you bring up some, you know, some really big stressors uh about cost. And I think we see that in the work that we do all the time with our clients, and we we this is something that needs to be really brought to light. So thank you for being here. And uh let's just delve into the problems.

SPEAKER_02
8:45

Let's do it. I mean, can I also say that um I as a rule do anything that Ginger asks me to do?

SPEAKER_01
8:52

Wow. Yeah, I also I'm I'm in your club.

SPEAKER_02
8:56

I know, and I'm aware, I'm aware how dangerous that is because Ginger's not a person who takes no for an answer in general. Um, and uh, but I also to the extent Ginger that I'm known, it's largely because of uh you. And um I think uh I I've been deeply honored over the years to uh work alongside you, learn from you, and I have found Denise fast friends in almost every midwife I've ever met in my whole career. Um, almost like a lost tribe.

SPEAKER_01
9:25

Yeah. Oh, that's amazing.

SPEAKER_02
9:27

Um, I don't know where the voice came from, Ginger. I mean, I don't I don't even know, I don't think I was aware that it was a unique voice until I was in that room at ACNM a little over a decade ago.

SPEAKER_00
9:37

Interesting.

SPEAKER_02
9:38

Um, in that really odd mashup in Albuquerque where there was a um, you know, a rally for the president, right? The current informer and and also midwives in the same space.

SPEAKER_03
9:49

Yeah.

SPEAKER_02
9:49

Um, but I I think I had a sense that it was maybe in that kind of clastic perspective a little bit, but I also um, you know, I don't think I was aware of the history of the tension in our country between these really um divergent and often opposing views of what childbirth should ideally look like. I don't think I knew. What I knew was I mean, I grew up as a son of Indian immigrants who came over on an H1B visa in the late 1970s. Nobody knew what an H1B visa was until recently, but I'm proud of that fact. And they were straight-laced immigrants, and so I very predictably went to medical school as an Indian kid from New Jersey, you know? But then everything after that was less predictable for me. Um and uh it might be because my grandparents they were part of decolonizing India, so they helped raise me and gave me, I think, a healthy respect for radical thought, even though uh I had very rule following, pragmatic parents. Um, and I think maybe that's what like drew me to midwifery because I think at least the modern version of midwifery requires working against the grain, and it requires being the kind of person, right, who sees that and does it anyway. Like Kara Osborne. She could have gone to medical school, she looked at that and she was like, No, I want to be a midwife. Who I am as a person is a midwife.

SPEAKER_03
11:14

Yeah.

SPEAKER_02
11:15

Um, and I think of the book The Giver by Lois Lowry a lot, where you know the book is about a society that sees everything in black and white, but there's one person who sees things in color.

SPEAKER_03
11:25

Yeah.

SPEAKER_02
11:26

And every time I'm with a midwife, I think they see in color, and I'm not crazy.

SPEAKER_00
11:32

So well, you know, what's interesting too, Neil, is is you know, when you're there in in Albuquerque, Liz Howard was like on the front row, right, right up there. And you know, we we we um but maternalistically argue over who's your midwife mother. It's Liz or Ginger, but you know, you had some great medical education training. I was at Brown.

SPEAKER_02
11:55

Yeah, I um I was at Brown where there was one in infants hospital who that has midwives and is one of the highest volume places in the country. And that was my introduction to medicine. I signed up for Obi Joanne first in medical school to get it over with. Ah, that's one I can get it. I'm clearly never gonna do that. Let's let's get it done. That'll be my way of like, you know, getting used to the hospital. And um, you know, that place is so busy, they do 10,000 deliveries a year. And um, my first week I was on night float, which meant like I was on the overnight shift. Um and uh what an introduction to medicine. Uh and and you know, Liz like taught me a lot, but she, you know, she taught me how to sew and you know, do you know, suture, but she also just was uh like my my shepherd into the whole profession. So it left a really lasting impression on me. Yeah. Got very lucky that way.

SPEAKER_00
12:50

So tell us a little bit about when costs of care evolved in your educational pathway, because I I sort of see it coming back now, Neil.

SPEAKER_02
12:59

Yeah, I see. Yep. So um right in the middle of medical school, there was um a freshman senator from Illinois who decided he wanted to run for president and he had no chance of winning. Uh, because Hillary Clinton was clearly going to be the nominee in 2008. But then it turns out uh she wasn't. And um, this candidate I think inspired a lot of people. But um one of the things that was really core to the presidential debate that year was affordability of healthcare. Yeah. And I was taking care of people before the ACA, before Obamacare, in a post-industrial New England city where very few people had deep pockets. Yeah. And I was seeing that we were making decisions on behalf of our patients without any idea what it cost them. Um in hindsight, I realized that I spent hundreds of thousands of dollars as a student and as a first-year doctor. But it was almost like, you know, I was a conductor leading an orchestra that I couldn't hear because I couldn't see any of that. And meanwhile, you know, I had patients who were choosing between rent and medical recommendations. So it just seemed wild to me that nobody had that insight. And um I ended up starting a nonprofit that was focused on trying to get clinicians to think about affordability of healthcare and how their decisions can make a difference. Yeah.

SPEAKER_00
14:19

Yeah. And so let's go forward however many decades now, and we see this whole new AMA ACOG issue rolling out about unbundling and what that does for normal healthy birth versus this potential risk of what we started with, the increased C-section rate. And and where do where does money go? You know, and how do patients even begin to understand what any of this truly means? I I mean it's so complex. Um but but when you think about costs of care now over this time, the costs are going up for the patients and the cost of services is going up for everyone, supply the cost of supplies, I mean, all of that. Malpractice insurance rates are skyrocketing, especially in in maternity care. What's your forecast?

SPEAKER_02
15:09

I mean, I mean, listen, for the next nine months, the entire public discourse is going to be about affordability in general, affordability of life, everything, affordability of gas, affordability of groceries. But healthcare will be the tip of the sphere, running right up to the midterm elections. And we've seen this movie a lot, right? Like this happens every 10, 15 years where it boils over. And um, you know, I was um in the trenches during the lead up to the affordable care book air act, but now we're um I don't know how many years later, decade and a half-ish, right? Later, and so it's happening again, um, because lo and behold, the problem isn't solved. Um and um so my prediction is that uh that will become the catalyst for whatever follows. And there were very particular things that followed from the Obamacare era, but the things that will follow from this era are um you know consumerism, I think is related to affordability. The idea that like, you know, I would have certainly not have predicted that a couple years ago that uh direct-to-consumer healthcare companies would have enough money in the bank to uh have Super Bowl ads. But like once you're that big, you're probably gonna stick around, you know? Yeah. Uh I don't think it's a fad. I think it's a trend. GLP ones are not um a fad.

SPEAKER_00
16:38

Oh no.

SPEAKER_02
16:39

Probably they probably are to metabolic health, what penicillin was to infectious disease. There you go. And they're they're revolutionizing everything about healthcare services.

SPEAKER_03
16:46

Yeah.

SPEAKER_02
16:47

Um not to mention the AI of it all and all that. So I mean, I think a lot of what we're finding is that normal people don't want gatekeepers between them and their own health information and health services. And I think gatekeepers and middlemen are not gonna have an easy time uh in the years to come. And for good reason.

SPEAKER_03
17:07

Yeah, great. Yeah.

SPEAKER_01
17:13

What do you think, Indonese? I'm just like, I I I want to know what that's gonna look like. So I think um, you know, I I you can't it's not always easy to project, but I I think I mean I think middlemen are always let's just say middle persons, they're always a problem, right? Um is it gonna be a case of asking more accountability from the consumer um to insurance companies, or what is what is that gonna look like?

SPEAKER_02
17:43

I mean, I think part of what's disconcerting about the world we're entering into is that it feels like we're all standing on quicksand. Like nobody really knows, right? Like we had um a generation of relative stability, and then we've changed how we're paying for maternity services for the first time in a generation, and it will change things for the next generation, right? Right, there are all these things like that happening. Um, so I don't know, but I do think that um you know, we always shift responsibility in healthcare onto consumers, and and that impact will be inequitable. Yeah. And also, I think my hope, or that's the pessimistic view. My my optimistic view is that uh the primary purchasers of healthcare services these days are millennials and elder millennials. And that's my generation, and we invented wellness as a concept, and our expectations for what we want from our healthcare system are a little bit different than the prior generation. They're higher. Uh, that made us very annoying to the higher, the, you know, the generation in front of us. But I think it's leading to things like um menopause being like an employer benefit that wasn't a thing before. Yeah. Or even the fact that it's even in the zeitgeist.

SPEAKER_00
19:02

Yeah.

SPEAKER_02
19:02

Yeah. So I'm hoping there'll be more consumer empowerment that might come with this too. Yeah.

SPEAKER_00
19:06

You know, one of the things I'm seeing happen right now, um, from two perspectives, physicians are moving to concierge care. We we have some clients out in California, um, midwives, but also physician practices who have just said, I give up. You know, Medi-Cal isn't paying enough, and I need money, and and this is what we're gonna do. And, you know, those who can afford that, hooray. Um, but that leaves behind a lot of people. Um and then we see in the social media, but also in midwives we're working with who want to start home birth practices, those numbers are rapidly rising. You know, Jean De Klerk has talked about that a little bit in terms of the home birth percentages rising significantly. Um not I mean, it's not just COVID anymore. I think it's distrust, it's fear, it's it's cost, it's a lot of things. Um and do we have a society prepared for those kinds of things happening without systems in place to be a safety net or whatever we want to call that? Like when these decisions are made, people are impacted.

SPEAKER_02
20:18

I agree. I think part of the uncertainty that we're all feeling also is that um people objectively feel like their lives are getting harder and that opportunity is getting smaller. Yeah. And they not only feel that, but they it's just objectively true by a lot of measures, including some of the ones that you led off with from the CDC. Like c-section rates are going up, paternal mortality is going up, like and um that's leading to this like strong populism in the US and across the world. And populism doesn't align with the traditional parties in the same way. And so everything seems mixed up. Nobody knows, like, on one hand, we're so divided. On the other hand, like the line between being a Republican and a Democrat seems thinner than ever, or at least confusing or gerrymandered or something. And um, yeah, to your point, like there are a lot of things happening that are not good for like people as a whole, populations as a whole. Um, and that's that's fueling this sort of populist uprising. Um and that's gonna lead to massive generational change, hopefully for the better, but I don't know. And that's part of what's so disconcerting about this moment.

SPEAKER_00
21:28

Yeah. Well, as people try to understand, like I have four sons, as they try to better understand the healthcare system they're navigating, those that have kids and even those who don't, I mean, they're coming to me with questions that I mean, they just they have no understanding of of oh and they're pretty smart, you know, educated guys who are just trying to do the right thing. And um when you can't get a healthcare visit for nine months to a year, it's sort of like, what the heck is going on here?

SPEAKER_02
21:59

Yeah. People deserve, I mean, of course, of course they're mad. Yeah. Right. And like I it's it's so hard because, you know, um all of us have worked within what I now refer to as the incumbent system.

SPEAKER_03
22:11

Okay.

SPEAKER_02
22:12

Right. And and like we sometimes feel defensive of its constructs because we are we understand the reason for them in many cases, and the reasons can be complicated and hard to explain.

SPEAKER_03
22:25

Yeah.

SPEAKER_02
22:25

Um, you know, whatever. Like the FDA is really slow, but also they make sure that things are safe, you know. And so, but it's the same energy why, like, you know, people are going online and getting compounded peptides and stuff because the FDA is too slow. And you understand that too, right?

SPEAKER_00
22:42

I mean, yeah, I mean, I'm looking into that right now myself, to be honest with you. Yeah, I mean, I get it. Um, well, let's let's sort of, you know, you and I talk about this a lot with maternal mortality. How do we bring hope and and and and action outside of the fear and the uncertainty? If if you had some thoughts, and we asked Dr. Wickstrom this, a maternal fetal medicine doc that was a consultant for us in St. Luke's for years, and Denise and her have done a lot of work in Haiti together. When when we think about how to help midwives improve their opportunities to engage in practice, you know, how the fragmented system that exists, for many, they're barely holding on. Um and they're and they're probably holding on because they need an income and there's nowhere else to go. Do you have any thoughts or ideas about how we can change that? Or what kind of steps could people take, maybe um to feel empowered to take action? It's a big question.

SPEAKER_02
23:50

Well, I mean, this this podcast is about what's possible. And there's right, and so like I that my instinct is to lean into that because I think at this moment where the whole board seems scrambled, it is more challenging. Uh there's more weight on our shoulders now than before in terms of people's well-being and in terms of structural changes and payment that are gonna make things harder, and I'm sure we'll talk about.

SPEAKER_03
24:16

Yeah.

SPEAKER_02
24:17

But there's more that's possible also. One, what a time to be alive technologically. Like, oh my gosh. Like, you know, it just within the last year, there are things that I never thought would be possible. Do you know that this aura ring can predict when people go into labor?

SPEAKER_01
24:34

No.

SPEAKER_02
24:35

Yeah. I used to think if there was a full people go into labor. But yeah, we're we're like getting close to that being the reality. It can already predict ovulation pretty regularly. Um, we didn't know what preoclampsia was for you know our whole existence. And now we can find a molecular signature and predict it in someone with no apparent risk factors months in advance. Um, we can uh type a complicated question into Chat GPT or Claude and get back something pretty reasonable. Yeah. Um, you know, most of us who work in maternity would have to document our notes late into the night after a day in the clinic, and that's medieval now. Now we have ambient listening. Yeah, uh up-to-date is going away and being replaced by something called open evidence. There's so much that's changing. So I mean, midwives have always been people who see in color when everyone else sees in black and white, and this is a moment to lean into that capability because there's more that is possible from that standpoint. Um, I I I also think structurally the unbundling of the maternity code is going to lead to more volatility. But it means like, you know, I think actually there could be more leaning into innovation as a result. If that makes sense. I mean, that might seem overly optimistic, but the old bundle to me very clearly stifled innovation. Sure. I regret that we threw the baby out with the bathwater, you know. Like I I wish we would have replaced it with a better bundle instead of just unbundling, getting rid of it, and just waiting to see what happens. Yeah. You know? Yeah.

unknown
26:16

Yeah.

SPEAKER_02
26:17

But part of what'll happen is that we'll see new ways of caring for people that I hope that midwives can lead.

SPEAKER_00
26:22

Yeah, I mean, I'm really glad to hear you say that because we we have become avid possibilist advocates uh for midwives who are just like we don't we can't afford to lose them, you know.

SPEAKER_03
26:35

Yeah.

SPEAKER_00
26:35

Certainly doesn't take as long to train them, but we can't afford to lose them because the workforce shortage is in such a crisis right now. Um, but I think sometimes when you're that beaten down, you know, as an oppressed profession, it's hard to feel like anybody believes anymore. So the easiest path is to exit and you know, go do something else.

SPEAKER_02
26:57

But well, you spend a lot of time helping people who are feeling that.

SPEAKER_00
27:00

Yeah, we do.

SPEAKER_02
27:01

Right. But I, you know, okay, here here's here's a tip that I'm certain of. It in the AI of it all, I actually think that human connection is gonna have a premium. It's a weird thing, but from a pure like market forces perspective, people are starved for human relationship right now. And like the the building blocks of midwifery care are the most valuable service to society now and going into the future, especially when we have asynchronous care and virtual care and all that stuff. Yeah, I think.

SPEAKER_01
27:35

I think I I just have to interject. I think that piece of that statement is the truest statement that I've heard all day, all week, all year. Um, I really, really like on every level to my core, believe that there's so much isolation. And so that I do think that is so critical. Um, I mean, I might just have to write that down a few times, but I already feel it. Um, I just want it to be on a t-shirt or something.

SPEAKER_02
28:02

I mean, we see it in everything, right? Like even if we're all drowning in AI slop.

SPEAKER_01
28:06

Yeah.

SPEAKER_02
28:06

But if you see something that was authentically written by a human, you can tell it's better. Oh yeah. We hold on to it, right? It's like um even more so in something so intimate as childbirth um and healthcare.

SPEAKER_01
28:20

So I mean, I think there's this whole new thought about like that. I've been stewing about about third spaces, you know, where the the need to create third spaces is just because, you know, you need that extra space to connect with people. So I wonder how that could translate into, you know, this innovation concept, um, creating healthy third spaces, which you know, people do like for birth centers or whatever, but I think on a bigger, uh bigger scale.

SPEAKER_02
28:50

Okay, that's my my best metaphor for the moment we're living in is that uh there was a time that the three of us remember where you you know blockbuster existed, and we would go there and we would like rent VHS cat cassettes or DVDs.

SPEAKER_00
29:04

Come on, you're you're that old, Neil. Come on.

SPEAKER_02
29:07

Oh, I am, I am, and then in fact, uh I'm old enough to have been married during that era and driven my wife nuts because I used to love like browsing. Yeah, and like she's supposed to pick something already, you know? Um and and we make a whole trip of it. Yeah, yeah, yeah, yeah. But but now it goes it's gone because we're in the streaming era, and people forget this, but for like two seconds before streaming, Netflix would mail you the DVD.

SPEAKER_01
29:33

Right. Yes, yes.

SPEAKER_02
29:34

And when it comes to whatever we're headed to, uh we're not in the streaming era, but we're in the equivalent of Netflix mailing you the DVD. Like we're seeing the glimmer of something transformative about to happen.

SPEAKER_03
29:48

Yeah.

SPEAKER_02
29:48

Um, and it's kind of clear that like Blockbuster as a construct is crumbling, yeah, but it's still there.

SPEAKER_01
29:54

Yeah. Right. Yeah. Right. Oh. Okay, that's food for thought.

SPEAKER_00
30:01

You know what we believe is is is an opportunity. Um, and I think Leslie Rathman, who you know, would would talk about this much more eloquently than me, is how do we how do we bridge, if you listen to William Urey enough, how do how do you sort of find the compromise or the win-win for the for the individual and for the institution, where what still 97% of US people give birth in a hospital, is the alongside midwifer unit, which has been in the UK for a while. Now, I'm not saying they're perfect, I'm not saying that the majority of people deliver in an AMU, but it, you know, Women and Infants has created one. I haven't been there to see it yet. I think I'm going out there in the fall to do some grand rounds, but um it's it is an exciting time to try to find a bridge. Uh, and I think that's I know, I don't know if you've seen any. There aren't a lot that are actually accredited in the US. There are some that exist that that don't get accreditation from CABC, but it's an idea I think we should percolate on. Low cost, midwifery led, separate hallway.

SPEAKER_02
31:09

I agree. I want me to visit a few of them.

SPEAKER_01
31:15

Just about places to be.

SPEAKER_02
31:18

It's amazing how the setting changes people's whole frame of mind.

SPEAKER_00
31:22

Yeah.

SPEAKER_02
31:23

Um, you know.

SPEAKER_00
31:24

Yeah.

SPEAKER_02
31:25

Yeah.

SPEAKER_00
31:27

Um and you can bill a hospital fee for it versus the birth centers that are falling day by day by day because they can't afford to keep them open.

SPEAKER_02
31:38

I mean, I think that's among the kinds of ideas that an enterprising midwife could go make happen in this world and honestly feels more possible today than 10 years ago to me.

SPEAKER_00
31:47

And another one that we talked about with Dr. Wickstrom um is this hub and spoke model for rural health care, rural maternity care, which, you know, I think you you all are doing to some degree at Maven, but taking it to the level of let's give Denise an iPad, send her out to rural Kansas with a portable ultrasound and an NST machine and stuff to draw labs, be able to connect to the home base if needed, as needed, and and and provide the care remotely, but in person. Um, I I think there's so much potential to do that with midwives with the workforce shortage the way it is and these hospitals closing, with people driving 92 hours anyway, 90 minutes, two hours anyway to get care is just unsafe.

SPEAKER_02
32:38

Yeah, I agree. I agree. There's no replacement for the need for actual infrastructure. And there's a lot of reasons why people have to drive that far that I think are addressable if we cared enough to address it. But I also think that um, you know, the other like even more approximate than predicting labor on our wearable devices is taking a real reasonable blood pressure. And like, boy, is that going to be game changing. We're literally six months away from like a ring on your finger taking your blood pressure, you know, and that would change pregnancy management forever for the better. You know, yeah.

SPEAKER_00
33:10

Yeah. It's just amazing how that technology can interplay with how the care model is actuated, you know.

SPEAKER_01
33:18

Um I mean, it yeah, it's just like the continuous glucose monitors for gestational diabetes or diabetes. Like it's so the biofeedback information and the way to transfer that information, similar to the blood pressures. Like we should use all of these things that would be much less costly, you know, I agree.

SPEAKER_02
33:39

And I think like if I had a call to action for your listeners, which I'm imagining are obviously people who are probably largely midwives or care about midwives, they're nerdy enough to talk about it or listen to it for you know 50 minutes to an hour and um are really thoughtful people. I think that there's been this false narrative or false dichotomy at least between technology and nature in childbirth. I think that sometimes we think and it's because there are specific uses of technology that we've over-rotated on, like the C-section or the electronic phenomena, but it seems like it's either all natural and you're reading like the horror stories about the free birth or whatever, right in the extreme, or it's like let's go deliver in the ICU surrounded by surgeons. Right. And there's gotta be a way for midwives to um, you know, lead with their ability to care with humanity, yeah, but also embrace technologies and maybe even lead the way on how to deploy technology more responsibly.

SPEAKER_00
34:51

Yeah. We don't make money, Neil.

SPEAKER_02
34:57

I mean say more about that.

SPEAKER_00
35:00

If you if you look at the if you look at the performas that we've done for hospitals, FQHCs, midwives who want to start their own practices. If they're only doing maternity care, even if they're getting comparable physician reimbursement rates, which not all are, but many are, it's not enough revenue. They're not doing surgery, they're not doing a lot of you know, high acuity patients, procedures, GYN, and and it's very difficult to stay above water if that's the only thing you're doing, unless you have such high volume that then you have many midwives. Let's I'm I mean, let's take the needs as practice. If there's 19 midwives, you know. On the other hand, we know that midwives typically have accounts charged over a million dollars a year. Most APPs do. Doesn't mean it's accounts received. And it becomes even lower as you factor in reimbursement, overhead, costs, malpractice.

SPEAKER_03
36:01

Yeah.

SPEAKER_00
36:02

So there's a very, very thin margin. And the question becomes: is it better to employ one physician surgeon than two midwives? What's what's the goal? Is it money or is it patient experience?

unknown
36:14

Right.

SPEAKER_00
36:15

It seems to be the battle.

SPEAKER_02
36:16

I mean, I think that uh yeah, it's very unfortunate that those things are intentional. It's like that and it's really in the consumer movement, right? But I also think that um it should it should be the case, ideally, that um we pay more for the services we value. That has to happen.

SPEAKER_00
36:42

Yeah.

SPEAKER_02
36:42

Like, you know, we we we should not reimburse maternity services at a rate where you need really high volume to even break even. Right. Um meanwhile the cardiac ICU is like crushing it or like the infusion center. Like it doesn't, it's all backwards, right? We're talking about childbirth here.

SPEAKER_03
37:02

Right.

SPEAKER_02
37:02

And also um we should be able to find ways to like maybe lean into the the overhead is a big part of what kills us. Yes. Right. And that like that also seems like an innovation opportunity. It seems like boast to me, I guess is what I'm trying to say.

SPEAKER_03
37:24

Yeah.

SPEAKER_02
37:25

Um I am really worried about midwives in this new world of January 1st, 2027. Sorry. And I'm I'm curious how you're thinking about it too. But the I mean the way I see it, you know, the incentives will clearly be towards the kinds of services that you described, the higher reimbursing services. That's right. And uh midwives seem to be attracted to helping people first and then figuring out how to get paid later.

SPEAKER_00
37:52

Right. Oh, that's for sure. They have no idea how they get paid, Neil. I I shouldn't make such a broad statement. Many, many don't. By far the most.

SPEAKER_02
38:01

Most dogs don't either, but I think like midwives midwives are uniquely driven by the help part first.

SPEAKER_00
38:06

Yeah. Oh, sure.

SPEAKER_02
38:08

Sure.

SPEAKER_00
38:09

Yeah, Arden Schwinker, who's our CFO, was on many discussions. She wasn't on the panel, although you may know Sue Kindig. She's a she's a WHMP JD that's done a lot of stuff with the WHMP world. Sue's a good friend of mine from Missouri. Sue was on the panel. And when she realized there was not a midwife there, she makes a call to ACNM and ANA and says, look, we need a midwife perspective here. So Arden and I were invited to some of those calls with the full panel. And then Arden continued on into some of the final decisions. She's now free to talk about it and can do a much better job than I can, probably, but everything we're forecasting of it of it lowering our reimbursement rates is likely true if you're caring for low-risk normal patients, which many midwives do not do.

SPEAKER_02
39:03

Yeah, fair enough. I also wonder, though, if we could use this as an opportunity to like get really smart about how billing works, you know, and like because I mean before all we had is four codes, and so we have to think about it. And now we we don't have a choice but to think about it at a much more granular level. Right. You know, and um there will be things that feel not ideal in terms of more like the the AMA has to tell CMS this will be budget neutral, and so there's gotta be cost shifting. That's the only way that's possible. And so the money has to go from one place to another.

SPEAKER_00
39:43

That's right.

SPEAKER_02
39:43

And bottom line, you know, I've been talking to actuaries and all kinds of folks who wanted to look at the details of case mix and market-by-market geographies and all this stuff. And like at the end of the day, like money is gonna go from low risk care to high risk care. That's what's gonna be. It has to. And like on the low risk care in our country, we're not doing great. We're not doing great. We've got uh uh real challenges around access. Why? Because they were not making enough money to begin with, right? To your point. And that is gonna get worse, and that's gonna make access worse, particularly in certain parts of the country.

SPEAKER_00
40:16

Well, what I found really interesting in in some of the discussions I was on was qualifying social determinants of health as a high-risk condition.

SPEAKER_02
40:26

There we go.

SPEAKER_00
40:28

I mean, I I I will I mean, I haven't I haven't seen it to the detail that Arden has, and I haven't asked her yet, but that was intentional. That was clearly intentional. And I'm I'm sitting there even saying, wait a minute, there are very, very healthy people who may have qualifiers of social determinants of health that do not make them high risk from a medical perspective, but may end up with an obstetrician because now they've been classified as high risk.

SPEAKER_02
40:55

Oh, interesting. I was actually thinking that maybe um the midwife at the federally qualified health center uh might benefit from that. But I I I hear what you're saying too. I mean, there's also plenty of people who are 35 and perfect perfectly healthy and are also gonna be labeled that way.

SPEAKER_00
41:11

So yeah, that would have been me with Isaac. Yeah, exactly. I I I don't think we know yet, but we'll know more. We've we've we just posted Arden's doing a webinar early June, and um in one day we had like 40 people sign up. So we have a lot of interest that's growing uh very rapidly because people are concerned and they don't know where to get the information.

SPEAKER_02
41:33

Yeah.

SPEAKER_00
41:34

So being innovative and smart um and having billers who understand the new codes versus holding up, you know, payouts for months because you've coded something wrong.

SPEAKER_02
41:49

Yeah, yeah. You know, one of my predictions also though, like my ideal is that we would start with the best care model and then we'd figure out how to pay for that. That would be the rational approach. What usually happens in American public policy is we decide the payment and then we hope that the right care model follows. But you know, it in this unbundling, there's gonna be winners and losers for sure, but there's also gonna be higher and lower performers. And one of the things that I'm hopeful about is that somebody with purchasing power will lean in, maybe in Arkansas, maybe we know people there, I don't know, somewhere, somewhere in the country, and just say, like, if you're you're willing to take risk, I'll pay you for it. So if you're willing to prove to me that by take caring of taking care of low-risk people in the quote unquote right way, you're gonna create better outcomes. And that means less babies in the NICU and less cesareans. I will pay you to deliver that.

SPEAKER_00
42:42

So your performance measure you're talking about is outcomes, not money.

SPEAKER_02
42:46

Well, I think ideally we would pay money for outcomes. Right, right, right. Maybe that's more possible in a world where uh, you know, you have visibility into every service that's being built.

SPEAKER_03
42:58

Yeah.

SPEAKER_02
42:59

And you see that some people are billing for lots of high-risk care, quote unquote, but uh the outcomes aren't following. Or, you know, and there there are like health plans that have vantage over all of that where you can say, well, my patients are higher risk, and you can say, well, no, they're not, actually.

SPEAKER_00
43:15

Yeah.

SPEAKER_02
43:16

Right.

SPEAKER_00
43:16

Yeah. Well, we have a little bit of time left before we go to that call to action. But one of the things, if if you feel comfortable talking about it, you and I have circled back together now working on a project out of Arkansas. Um, do you want to talk about that for a minute? And and what's your what's your thoughts about reducing the maternal mortality rate by half in five years?

SPEAKER_02
43:41

Yeah, I'm I'm uh very excited that uh the effort to address maternal health in the United States of America continues to have a lot of momentum.

SPEAKER_03
43:52

Yeah.

SPEAKER_02
43:53

We have a world that is so crazy right now, and the news cycle is so bonkers. Um And in spite all of that, you know, the issue that you both have long championed continues to have a lot of momentum. And so um Olivia Walton, um, who um is in the Walton family, uh, which started Walmart, um, and is a philanthropist and an investor, um uh is working closely with our mutual friend Kara Osborne, who introduced us uh on an initiative to do exactly what you just said. Uh and she's gonna commit philanthropic dollars, she's gonna raise philanthropic dollars. I think there might be an announcement around Mother's Day that quantifies some of this, but it'll be big.

SPEAKER_03
44:35

Yeah.

SPEAKER_02
44:35

And it has this audacious goal. Yeah. And, you know, like you can't do anything unless you set big audacious goals. And so why not? Like, we absolutely should be able to cut our maternal mortality rate in half uh on any time scale, especially when you look at our peer countries.

SPEAKER_03
44:52

Yeah.

SPEAKER_02
44:52

Um so I'm really grateful for them and their leadership and stepping up. And uh, I'm really honored that you and I and other friends of ours are going to be around the table to help them think through how they're gonna do that. But a big part of that, Ginger, which you you both are uniquely qualified to lean into, is one of their three pillars is making the business incentives better aligned.

SPEAKER_00
45:12

Right. Right, right. Well, and and I think they have taken a spin, if I if I understand all of this correctly, to engage in with intention businesses to sort of step up to the plate.

SPEAKER_02
45:28

Yeah, I mean, Walmart has a baby every eight minutes. Oh my god, I didn't know that. Like think about that for a second.

SPEAKER_00
45:34

Is that global or US?

SPEAKER_02
45:36

I that's across our whole employed population. Amazon has a baby every 12 minutes.

SPEAKER_00
45:40

Oh my God.

SPEAKER_02
45:41

You know, and so we have not traditionally thought this way, though.

SPEAKER_00
45:44

No, we haven't. I mean, which is what's so damn exciting, to be honest with you.

SPEAKER_02
45:48

Yeah, and by the way, with everything that we've talked about, their costs are gonna go up like five to ten percent year over year just because of the unbundling. You know, that's a lot of money uh for those businesses that are also dealing with supply chain issues and gas prices and all that, right? So they have a stake in this.

SPEAKER_00
46:05

Yeah.

SPEAKER_02
46:06

Um, so yeah.

SPEAKER_00
46:07

Yeah, it's exciting. More to come. I think on our Buzz Sprout website, Denise, I'll put what we can about um the the initiative that that is available on the website, but also um some other stuff Neil's talked about. We can share.

SPEAKER_01
46:23

I really appreciate this. Is like a little bit of glimmer of hope. I'm sitting here in the seat as a like a very clinically focused midwife, you know, and we have we work many, many hours and taking the time to sit and think of innovative strategies is it's not there's no time to do that, you know. Um, so we keep plugging along, um, trying to just do the work that we do really well. But when we do hear of some of these potential new projects, it does, it does provide the hope that we need. Um, and it does really encourage people to really bring up the dialogue and to be connected to push forward on some of these things. So I think I think the the people out in the workforce need this hope for real. Yeah, I absolutely agree.

SPEAKER_02
47:14

I understand that. I mean, my personal litmus test for character has always been if you come to a fork into the road and there's like the right way and the easy way, which way do you go? And uh, you know, again, that's the whole against the grain thing that midwives do so well, but we really need you. And I have so much empathy for so how how hard it is, but we're like all counting on you to keep going. Uh and um, you know, we're we're we're collectively, I really do think on the cusp of figuring out some important things because even though things seem very, very hard right now, they always get harder before they get easier.

SPEAKER_00
47:53

I absolutely believe that.

SPEAKER_02
47:54

And something transformative is gonna happen, hopefully for the better.

SPEAKER_00
47:57

Yes. And I want to live to see it, so let's get going. We want you to live to see it, Ginger. We uh we're gonna end with a call to action. We usually start with our with our guests. Is there is there one thing that you would sort of like to leave with the midwives, especially the midwives that are listening, that maybe I don't know, could motivate them, incentivize them, lift them up. I don't know. What do you think?

SPEAKER_02
48:22

I mean, I think it's what we've been talking about, but I like maybe to restate midwives hold on to deep truths that are timeless. Hold on to them steadfastly. Yeah. Also loosen some of your ideas too, because we're all standing on quicksand right now and we have to be nimble, right? And that means like if you're a younger midwife that's uh entering into practice, if you have a choice between maintaining in a legacy system and joining the tidal wave of what's coming next, lean into the tidal wave. And if you're a really seasoned midwife and you've been around for a while, um do your best to think flexibly about some of the stuff that's coming. Um that includes AI, that includes direct-to-consumer platforms. I know it's scary, a lot of it seems like the Wild West. A lot of it you may vehemently disagree with, I certainly do, but uh we should we should really try to understand like why they're happening uh and make some space for them because ultimately these these disruptions are what we need to get to a better system, I think.

SPEAKER_00
49:22

Yeah. Great advice. Uh Denise, I'm gonna go last. So why don't you go next?

SPEAKER_01
49:29

You know, I just I I have to say one thing about the to your call to action, which I've I'm fighting with. There's a lot of the newer midwives that are coming out, is they're very vehemently opposed to AI, not the older midwives, the newer midwives, because of because of the the cost, the use of water, all the things that I absolutely do not understand how that works. So I'm you know, as the older midwife, the oldest, you know, longest in our practice, they there's just big pushback against that. And even even the children are saying, like, don't use AI. So um anyway, that that's for a whole different discussion, but um, but I love that you give me permission to do that. I'm taking it as permission because I have really enjoyed what I say is like, thank you for giving us a chance to do more now with AI that we never could do before. Like, you know, it's the whole case of we worked so much harder, we walked 20 miles to school, and you, you know, you're doing online courses. It's that analogy a little bit. So um anyway, I I have to think a lot about what you just said and and um you know come to terms with it. But um, is it my call to action?

SPEAKER_03
50:45

Oh yeah.

SPEAKER_01
50:46

This one's a hard one because I I I feel a little bit like um, you know, it's it's frightful what I think is coming. So I have to always go back to what can small groups of people do together in my firm belief in connection and how important that is. So again, it comes down to what can I individually do as a midwife in a yeah, very much growing practice to keep my own practice colleagues, you know, aware um and interested and invested in looking at innovation, you know, just within our own practice, but really within our state. So I I think it's just my call to action is really like continue to do the work of the one-on-one, one-on-two, one-on-three. Yeah. Moving forward of awareness and then creativity going into that.

SPEAKER_00
51:41

One of the things you said, Neil, really resonates with me, and I I I think I heard it right, which is our profession is unique. There is a reason why our outcomes historically, globally, are what they are. There, there's a reason why we need, you know, a million more midwives in the world because we save lives. And there is something about the midwifery model of care that gets chipped away at but for a lot of reasons. And it's very, very difficult to defend how each of us might describe the midwifery model of care without appearing to accuse people that they're physician extenders. Denise, you and I have talked about this before, right? How do how do we how do we continue to believe in that model of care as we go forward? I think there are always compromises, right? You can't always sort of from myself and practices that I was in for 25 years, I couldn't always do everything I believed was evidence-based and should be done. But at least I held the banner of what midlife, mid midwife-led care was and the why, the evidence, which continues to be demonstrated in far more studies than we need. I'm so sick of studies. Give the money to the answers. But I would say for people to really don't be afraid to champion the midwifery model of care and continue to educate. We still have far too many people, including someone, real quick story. Joe and I were in DC for an ABA meeting. We went to probably the best restaurant in DC with his publications board that he's the chair of. And there's a attorney there, probably my age, excitedly telling us she was running for a s for US Congress, for Senate. And I'm I'm like, whoa, you know. And somewhere in the conversation with three black women sitting across from us, attorneys, I bring up maternal mortality. And she looks and says, I didn't think there was a problem. The one running for Senate. And and I just very respectfully lost it in the best way that I could to educate her. But we are a hidden secret. We still are a hidden component of what's possible. And um, you inspired me today, Neil. So I'm not gonna stop, you know, just not.

SPEAKER_01
54:10

We need we need a pit version of midwifery to be real and true. Like I really think we need a no Noah Wiley, but uh but maybe a midwife version.

SPEAKER_00
54:21

Ah, there's work on that. There's someone that you know, Neil, who worked with Christy Turlington as a journalist for years who became a midwife, uh-huh, who's working with people producing the pit on a midwife storyline.

SPEAKER_02
54:37

Ooh, that's very exciting.

SPEAKER_00
54:39

It's very exciting. Yeah. So things are happening. Things are, I can't I can't disclose a lot. I don't I don't want this person to sort of get in trouble, but you might know who I'm talking about, Neil. Yes. Um, very close friend of Christie's. In fact, they're hanging out together this weekend in California. But um thank you so very much for being on with us, Neil. We could not just be happier for your time. You're extraordinarily busy, but more of a lot of people. Anytime.

SPEAKER_02
55:04

Anytime. This fills me up too. I'm just as inspired. I I missed uh all the opportunities to connect. And and by the way, I heard that you're coming to Providence and we don't have 20 minutes away now. So I'm oh dude.

SPEAKER_01
55:21

All right. Thank you so much. I really enjoyed spending time with you.

SPEAKER_02
55:25

Likewise today.

SPEAKER_01
55:26

Picking your brain and being inspired, and yeah, we're in this together.

SPEAKER_02
55:30

So absolutely.

SPEAKER_01
55:32

All right, guys. Thanks again.

SPEAKER_00
55:34

Have a great day.

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