First of all, thanks. Thanks Joe to you and the board for for putting this apps in this topic that's so important in women's health on the agenda and Arianna thanks to you and the staff. This has just been amazing. Thank you and Thank you Kristen You folks will get to meet her in just a bit. She'll be on the panel. I Think everybody who hears Kristen's story cannot help but be touched by the near-death experience in the agonizing course of her second pregnancy For months. She was denied her role as a new mother and wife Hospitalized not at home with her husband and her newborn child and her first child and then came that faithful day of That emergency surgery where she was facing the menace of a retained placenta attached to her vital organs and being taken to the room filled with all those special surgeons and nurses and She faced the real challenge that she may not ever wake up again and see her loved ones Unfortunately when you practice as long as I have You realize that the you have the burden of seeing similar stories and tragedies and What makes Kristen's story so moving is that in a sense Kristen is a victim of modern medicine not something such as cancer or hypertension or infections things that it plagued human childbirth for Millennium's Unfortunately on our current modern medicine path Stories such as Kristen will increase in frequency Just 20 years ago if I had asked a room full of obstetrician gynecologist if they had seen a placenta credo or a per credo Occasional hand would have would have risen most in the room would be scratching their head going down a credo That's that's where it eats through They had never faced one in their practice and there were really had just heard about it in their their training So today when I give lectures on cesarean section in similar rooms I asked that same question and Nearly half of the room will raise their hand that they've seen such an event in the last year in their institution We even have specialized medical centers that treat and manage these conditions Statistical analysis has documented the epidemic rise in cesarean Historectomy and the overwhelming indication for the surgery is these placental abnormalities Now maternal mortality has always been a tragic event Because in every case it happens to someone's mother Someone's spouse or partner Someone's daughter or someone's granddaughter But it's also a mortal event for the family unit and the scars that leaves last lifetimes of note as many have Raised we as caregivers are also changed often leading to depression suicide and Oftentimes ending people's career Sadly maternal mortality is one of the metrics we used to trumpet in our specialty For decades it had declined as the improvements in our tools and techniques had Reduced such deaths in fact between 1900 and 2000 the rate of maternal mortality fell from 850 per hundred thousand to less than ten per hundred thousand By the year 2000 the focus of our safety and outcomes in Develop nations had really moved to fetal and neonatal outcomes and in underdeveloped countries were nutritional or sanitation Problems or medical infrastructure prevented it We were working hard to increase appropriate time C sections Now in fact in in my home in Orange County We turned our debate to important things like Waterbursts and working with patients who were too posh to push who were requesting elective cesarean deliveries Now in the meantime Insidiously the rates of maternal mortality in developed nations began to nadir and slowly rise in the most recent data in the United States we even have states that have now Risen some four to five times back up to 30 to 40 per hundred thousand And by the way to give you an idea of what risk that is if you compare that to the general population and Look at things that Harm or kill folks That would trail only behind cancer and heart disease as a cause of death So what was so different in developed nations to explain this rise and death technology medical support Things such as anesthesia and intensive care those of all continue to improve There are basically three differences about our patients in 2018 compared to 1998 First they're more mature That's the proper way to say they're older And that's a result of socioeconomic lifestyle changes With delayed childbearing and improvements in infertility therapy that have allowed Women to extend their reproductive careers Second they weigh more in obstetrics were not immune from the obesity epidemic and Thirdly like Kristen They're more likely to arrive at labor and delivery with the history of a prior cesarean section The last factor is a result of rising rates of cesarean section secondary occasionally to medical factors Such as age and obesity But mostly by concerns from patients and providers to worry more about things such as timing the delivery or medical legal concerns Now don't misunderstand my message when necessary cesarean section can be Absolutely life-saving for the mother and the baby however, when not necessary or avoidable because of our management these results increased short-term morbidity and mortality numerically small but more important such as Kristen's case Exemplifies there's this exponential rise in risk and subsequent pregnancies Indeed avoidable cesarean section in the first pregnancy Deprives women of the safest delivery there is that is a woman delivering with a prior vaginal delivery Now fortunately, there's hope for this epidemic First we have the ability to follow our outcome data much much better now And we can look at the trends and we can highlight this and is as was mentioned in the video It's clearly become a safety issue Second we have real success stories and we can point to simple techniques which can lower rates in My mode in my own experience We we achieve success in one of the highest rates area the country in orange County in In 1988 at Saddleback women's hospital we had a total cesarean section rate of 31.8% at the time that was five to ten percent higher than the national Average within four years we cut that rate in half and this was five to ten percent below the national average The outcome was we avoided hundreds of cesarean sections per year We had absolutely no Quantifiable harm to the mothers and babies Our story even made the NBC today show When dr. Art you lean their medical reporter at the time proclaimed if you are going to have a baby This is the kind of people and the kind of hospital you want taking care of you and your baby Trust me. You could not buy That PR for any amount of money Combined with other folks story we clearly showed that we could lower cesarean section rates But unfortunately for a variety of reasons such efforts in the 90s did not last and And and really Unfortunately began to rise again Now I just checked our California data in the last six months. We're down to having Only one-third of our hospitals Above the 23.9 low risk cesarean section rate national goal and the reason that's amazing is is that if you looked at the 2014 data in a similar time period two-thirds of California hospitals Would have been above that rate. So that means given our size 240 hospitals in California 80 to 90 institutions have lowered their cesarean section rate over that time period So success is is clearly possible today and given the other factors that have happened. We can overcome those now we know that most If you analyze Most avoidable cesarean sections are performed by well-meaning and compassionate providers Unfortunately, they practice in a manner Which seems the easiest thing to do at the time is to do a C section And that's the best for the mother and the baby But what we have have done however by recognizing the big picture is developed Methods Which less than the likelihood of cesarean section and still afford safe and memorable Deliveries This afternoon our panel is going to describe an apps with common-sense solutions Preventing and responding to the most frequent problems that can encounter we can Encounter and lead to cesarean sections. These are multidisciplinary practice standards and changes outlined by provider organizations such as the ACOG the Royal College of OB-GYN the nurses association midwife associations, etc and Published toolkits like the one the California maternal quality care collaborative Published that was assembled by thoughtful experts as you'll see in our apps success requires involvement of patients families delivering providers Supporting nursing personnel doulas and educators who sincerely want to improve the lives of mothers and babies and prevent the terrible complications of unnecessary cesarean section So like you I was touched when I first heard Kristen's story Believe it or not, we physicians sometimes can be human But let me confess my other feelings as an obstetrician fear and anger Fear because it brought back the memories when it was my turn to be standing next to that operating table with the Patient laying there with the placenta previa Knowing that all my skills and all my knowledge and all my prayers May not be enough to save that young mother's life and anger Because as you see upon further discussion Kristen could have had a procedure called breached breached version in the first pregnancy Unfortunately, however, Breach version is not readily available in many hospitals like so many useful practices that are unevenly available in medicine due to the variability of training and expertise About 50% of the time in patients like Kristen The cesarean section would have been avoided by safely turning the baby From the outside before labor had begun and giving a high chance of successful vaginal delivery The story you heard in all likelihood would not have happened at all At least not to Kristen and her precious family Ladies and gentlemen, we are here today to describe measures and methods of avoiding unnecessary cesarean delivery and Asked everyone in every setting Performing deliveries adopt such practices So let me bring out an amazing group of experts that can explain and describe our apps That we believe if adopted could prevent these tragedies Please listen and engage with these caring folks about this critical part of the patient safety movement. Thank you Welcome and I'm gonna have everybody Introduce themselves and Jill. Why don't why don't you start off? Hi, I'm Jill Arnold and I'm a patient advocate and the co-founder of the National Likrida Foundation Hi, I'm Siddharth Satish. I'm an engineer by training. I founded a company called Gauss Surgical We're focused on using AI to help make delivery and surgery safer My name is Bob Silver and I'm an obstetrician at the University of Utah in Salt Lake City I'm Kristen Tbilisi co-founder of the National Likrida Foundation and Dr. Legreau did a great job Augmenting my video about my story In my second pregnancy my son's placenta attached over the prior cesarean scar in my uterus And that's what caused me to develop placenta percrita And I am so grateful for the incredible medical team that delivered my son safely and saved my life twice actually And I'm honored to be here today to help illustrate the downstream risks of a cesarean Now now we may look very American to you But let me just reassure you this is an international panel. There's a couple of us are from the Republic of California So Let's let's start things off though to look at that with you Bob And and I know you've worked with colleagues Throughout the world and in your studies and your travels and in your research What's your international? perspective on The variance between different cesarean section rates Obviously today we're seeing a problem of two higher rates in developed nations and then still and underdeveloped nations to lower rates Is there a just right rate or what is where are we? Well, that's certainly a great question and I don't think there's a one-size-fits-all answer firstly Let me just say especially if there are any young women in the crowd who are planning on having a baby Pregnancy is a normal physiologic event. It's not a disease And most people live and don't have to be hospitalized. So don't be afraid to get pregnant and and Cesarean delivery is is really a great thing in many cases and it can save lives of mothers and babies and It has had a tremendously favorable impact on on Childbirth for the last hundred years. So all cesareans are not bad And in fact, it can be really life-saving But unnecessary cesareans are bad and that's the message that that we want to deliver and It's hard to say exactly what those should be now Placenta acreta is the the major risk of cesareans and subsequent pregnancies But like any unnecessary operation and that's what what this is is unnecessary Operations, there are risks and and if you do enough of them, you'll have anesthesia complications You'll have blood clots. You'll have hemorrhage. You'll have infections and if you do enough of them, you'll have unnecessary deaths and Unnecessary seriously ill people. So what we want to do is eliminate unnecessary cesareans There's really no one-size-fits-all Optimal number of cesareans and people have asked this question And and sometimes we'll just kind of make up a number But it's it's hard to say exactly and in many low resource settings Where it's hard to get to a hospital and you don't have the resources of a surgeon or anesthesia Caesarean rates are way too low and if we did more of them you would really save mothers lives and babies lives But in high resource countries The rates are too high. So on balance a Number that's considered reasonable is somewhere between 15 to 25 percent and probably 15 to 20 percent and That's a little bit made up, but it's based on Modeling if you model the best outcomes for moms and the best outcomes for babies in high resource settings That's the number you'd expect. There's incredible variation in the actual numbers in the United States the Rate of cesarean is about 32 percent But if you go state by state and I'm proud of this because I'm in Utah, which has the lowest rate It's 22 percent, but in the highest state, it's 38 percent here in the UK The rate is about 26 percent But in Europe it ranges from a low of 17 percent in Sweden to a high of 50 percent in Cyprus So that range is due to individual practice patterns. So Really great question the best answer I can give you is 15 to 20 percent Recognizing that that's an estimate Thanks What let's focus on on the view of the problem Kristen I'm gonna start with you.  Do you think the message is getting through? I think there's really two different camps of providers I think there's providers like dr. Silver who are treating the acridas who are acutely aware of the patient safety Impact of our cesarean epidemic But I think that there's also providers who aren't seeing it and who think that the cesarean reduction measures are more of a cost Savings are a nice to have and they just don't see the urgency there And that's where my story can make a big difference We know that data is what brings improvement in health care But it's really the patient stories that help show what the reality of that data is to the patients and the families that are affected by these issues and While telling my story I I want to make clear that a cesarean can be a life-saving intervention But it is also a trade-off of current risk for future risk Yeah, I think that's one thing different about this safety aspect is that the the time difference between the event that Actually caused it and the actual bad outcome and I think a lot of clinicians do not make that that time Bob you've you've Obviously you're in the midst of a lot of the national work and research the recent arrived trial that talked about elective inductions and and how that's going to be How that could impact or lower C-section rates That's balanced against our number of our current recommendations Including those in the apps that limit Inductions and things of that nature How do you see that being reconciled? How do you compare those the recommendations sort of non intervention versus? versus elective induction You bet so this is a this is a really exciting exciting study. That's just been completed The results have been presented, but they haven't been published yet, so I can only talk a little bit about the results Just for for the audience in the big picture Because there's such a range in cesarean delivery rates It's clearly due to behavior of Obstetricians of practitioners and so how to change that behavior to lower the cesarean rate and to have there be fewer Unnecessary cesareans is really the challenge and and that's what we're going to talk about So the arrived trial is the study that compared elective induction Of low-risk women people who who were very healthy Otherwise having their first pregnancies at 39 weeks gestation So induction of labor versus just normal care, which would be to continue the pregnancy and the derivation for the trial Was two-fold we know that the later you go in pregnancy if you go past 39 weeks There's a very slight but real Increasing the risk of bad things happening to moms and babies the further out you get the more likely are to have a stillbirth The more likely are to have a sick baby the more likely are to have a sick mom Those risks are low, but but they're they're there and the reason that people didn't want to just deliver everybody at 39 weeks is Because we thought that that would really increase the cesarean rate and we've known for a long time That if you induce someone's labor and you compare the rate of cesarean compared to somebody who goes into spawn tiniest labor that the induction will increase their chances of a cesarean by about two-fold and In fact when I was training a long time ago We were taught it's really bad to induce people that you're causing harm that you're going to increase the Cesarean rate and that's what we've we've taught historically But it turns out that's really a flawed comparison Because when someone comes in to see you in your office, you can't will them into spontaneous labor That's not a choice that you have your choice is to induce labor or to wait to do what we'd call expectant management and see what happens and some of those patients will go into labor in a week But some of those patients will never go into labor and you'll have to induce them two weeks later And maybe the placenta won't work as well and maybe the baby will be bigger and you'll actually have an increased rate of cesarean So in in poorly designed studies when we tried to look backwards and compare induction of labor to Expectant management induction of labor didn't seem to increase the cesarean rate and it actually seemed to decrease it So the study that was done was to to randomize three thousand patients to induction versus expected management And it turned out there was a a small but real reduction in adverse events for mom and baby and a Meaningful reduction in the cesarean rate and the people who were induced So we're really excited about that and it really is a paradigm shift It really causes us to have to unlearn a lot of the things that we learn It's only one study. It was a very very Selected group of women By no means doesn't mean that we should induce everybody at 39 weeks But it gives us another tool in the toolbox and something that we ought to study that may help us to lower the cesarean rate Great now. I think it's an exciting development and it just shows the need for further research Jill I'm gonna switch to you now. You've worked with Kristen and Heard a lot of stories about a creed is you know through your work Our Providers and patients aligned on this are patients asking the right questions and getting educated Well, I think that as always certain patients with higher health literacy are probably asking We're always asking the questions, you know who we are And I do think that with you know, all of the campaigns that we've done in recent years to You know raise awareness for high c-section rates I think people are I would posit that they probably are asking more questions about, you know asking directly What is your c-section rate? But I do think there are people that are more comfortable in a healthcare setting and I do want to take the time to Say that you know in any discussion of childbirth. I think it's important to point out that in the US Black women are three to four times more likely to die of pregnancy related complications than their white counterparts And so I just like to bring that up that you know when we talk about comfort in a medical setting and feeling safe That's an important issue to address But you know one of the challenges as far as you know, I think you can have the most you know an incredibly robust conversation in your prenatal visits with your doctor, but You know, we have in among hospitals We have tenfold variation in c-section rates and it goes so far beyond just like a you know Strategic regionalization of care where you have certain hospitals picking up, you know, like the complicated cases that they have a higher rate It's just all over the map and it's actually you know it The hospital itself and the way that labor is managed is an independent risk factor for cesarean birth Which is you know pretty significant. So You know if you're gonna have an uphill battle at hospital a that you wouldn't have at hospital b Does it really matter what questions you asked your doctor? But you know now that I've actually I've painted a pretty bleak peaks picture I think one of the things we're working on at In my day job as a consultant at Consumer Reports with CNQCC the organization You mentioned in California healthcare foundation is creating a suite of patient education materials based on qualitative research that really do So that alignment is possible like I'm not being totally negative the I think that alignment between provider and patient And the questions asked is possible and there are steps that patients can take Yeah, and I just want to pile on a little bit because you talked about the variation hospital to hospital part of my work has led me to look at literally Hundreds of hospitals and drill down and what you see is actually that same variance within the hospital Between the different providers now some of that you can explain by attribution and different things But there's clearly not only variants with hospital to hospital, but variants from provider To provider so it's it's something that's a real challenge for us Sid now you've done most of your work on using AI and big data on on blood loss as as part of your day job But Pretty much as the world of obstetrics through the EMR through our data in the fetal heart rate Ultrasound etc. It becomes digitized We're being Now having access to huge amounts of data. How can we use AI and and big data to help us? Reduce unnecessary C sections. Yeah, that's a that's a great question. I Accidentally I would say discovered this problem We were mentioned in the same article around maternal mortality and placenta crita One of the things that really stuck out to me is is our organization started to look at postpartum hemorrhage as the area We were focusing on was this incredible variance in C-section rates Across the country in different states different hospitals being the the key difference the key, you know decision point for whether or not a rate was high or low and I think the first thing that it really ought to be called out is the data itself just having the data as openly as it's been in California specifically with the CM QCC's maternal data center that itself. I know has triggered a change You know physicians certainly You know look at their experience and they know kind of what happened in the last 10 cases they did But but certainly, you know while we can talk about it at the population level A specific physician may not really know what their own C-section sort of rate is so having this data come out having physicians start Start looking at it Caused a big change it caused a big change because people don't want to be outliers But I think it goes a step further to your question about AI and data as we've thought about just the work We've done in the digital space and I think the answer really comes down to this reminds me a lot of a very parallel topic of Blood management and you know prevention of unnecessary blood transfusion It's it's really a diagnostic question with a lot of variability in in you know practice patterns the risk factors things like the time of labor being a determinate in In you know whether a C-section is performed or not And I think that the role data could play and the role that AI can play is Significant the reason being that we can employ data, which there's a lot of it There's a lot of data available We can then you know take algorithms that have been significantly developed to date And and attach them to that data and we can then I think essentially predict the appropriateness levels of Medical interventions in this case C-sections Do we really need to perform a C-section and does the data objectively with Interoperable data from many different devices really support the conclusion that a C-section is necessary And then we leave it up to the physician to communicate that to the patient and for the patient to make a choice Which I think is key, but I think AI look we have Self-driving cars and they're using deep learning Which is a very advanced form of machine learning and we're broadly AI Helping us do those types of things we use AI to predict what movies to watch Why can't we use AI to analyze medical data in real time and to have a self-learning system? That can make delivery safer and really help us understand if a C-section is necessary Before performing it great absolutely couldn't couldn't agree with you more Okay rapid rapid response time, okay I want to jump to the apps and I'm going to ask each of you. What's your favorite part of the apps, okay? Kristen First off, I love that the patient perspective was included in the creation of the apps I think that is so important to quality improvement to include those who have been personally affected by these problems and identifying the solutions But as for the text of the APSS my favorite part was the focus of educating patients on the long-term risks of a cesarean I think we do a very good job of educating on the short-term risks But in the acreta community, we have this saying that Placenta acreta is that future life-threatening risk of a cesarean that no one ever told you about and Too often the first time women hear the word acreta is in the doctor's office when they're diagnosed with it Myself included Thanks Bob I'm gonna say that that I'm not gonna choose a single part of it I think the most important thing is just trying to pay attention and just using it and trying to lower the cesarean rate And I think that there's no single Part of it. That's magical or a key ingredient I think the entire thing together and more the just just wanting to you know Just as a culture as clinicians as Institutions as nations deciding we're gonna lower the cesarean rate almost anything that we do is gonna result in a positive change So the entire package together and the effort is more important than any individual component Yeah, I think this is where it aligns with other safety measures. It's it's Just standardization and reducing the variance of What we do and working better as a team that can Agree said I think actually on that note standardization What really spoke to me was device interoperability and having the data All accessible and in the same place as sort of a universal source of truth And the reason that's important is that I think is ultimately what allows for more standardized decision-making and also then opens the potential for you know, these these aforementioned AIs that can effectively take that data and And and provide real-time clinical decision support But it we can't go anywhere without the data and having the data sort of in one form talking to each other Which I think is key Joe so I think overall I like that it was a You know, it's a low cost low burden solution I look at things and I think are they scalable and are they affordable because I know in Arkansas where I live We have a lot of critical access hospitals and rural hospitals that offer maternity services And this is something that a motivated QI team without you know They could leverage existing IT resources don't need to hire anyone don't need to you know get special fancy software or anything It's something that they could implement if they feel motivated to do so nurses could step up and do this. So That's my favorite part Great so Let let me go back a little bit because I think Bob our discussion early raised this tension between Interventionalists or In the old days it would have been active management of labor against patients patients patients or what today would be natural Childbirth and and more physiologic approaches What are your thoughts can we have both? I mean You know as a quality improvement specialist I'm all all about as we talked about Standardizing and reducing variation But I think it seems that certainly labor techniques and things that nature do have to be Individualized to what the patient wants what what are your thoughts on that? You bet I think that's that that's really well said and you know Pregnancy and having a baby is really a different Part of medicine, you know if you if you have a heart attack or cancer You just want to get better and if you break a bone you want to get better and you want to be able to use your your limb When you have a baby you want to have a really healthy mom you want a really healthy baby and you want to have this wonderful experience and Every family has a very different conception of what that wonderful experience is And and pretty much as as health care systems We ought to be willing to provide that experience as long as it doesn't cause harm and and so it's it's very different than some other areas of medicine and Also, there are certain things that that it's hard to make a mathematical formula for you know if Certain things are really harmful and you would recommend don't do that But if there are tiny differences or really small risk differences then patient preference is really important And so as we decide what to do number one It's not necessarily a one-size-fits-all and number two is more and more we have to have patient-centered outcomes And really work with families to see what they want. So I do think it's possible To to be natural and holistic and also Use interventions. I pride myself on doing that personally. I'm a high-risk obstetrician So I take care of a lot of very sick patients who need a lot of major interventions But I also am passionate about vaginal birth and I have a large group of families who see me because they really want to have a holistic non-interventional experience and so I've been nicknamed the perineal midwife because I do a lot of very Low-risk touchy feely kinds of things, but I also do some of the most high-risk interventions pregnancy is a normal physiologic event and Most patients would do just terrific if we if we didn't intervene or metal or or over utilize Interventions and if things are going well I think being hands-off and and natural is the best thing that we could do But if things aren't going well and we have really good and safe interventions that can help moms and babies We shouldn't be afraid to use them and I think where we fall down is sometimes Physicians especially are too quick to use interventions even when they're not needed and sometimes Families and and other clinicians are too resistant to those interventions even when they are needed And so I think we have to be Open-minded and honest about the data work with families to provide the experience that they want and and do both of those things Yeah, I think that's why involvement in of the patients in the decision process is such a big part of the apps Joe you've been around this debate You've watched the doctors and the nurses and the attention in the room. What's what say you? Well, pretty much what dr. Silver said all of that You know one of the things that I think pregnancy is a very preference sensitive condition and I think one of the things that I like about kind of what we're doing is it does find that middle ground I'm not sure if this is the popular answer But I you know among kind of like the natural birth crowd and stuff, but I think that allowing birth to happen Naturally or however as long as it's safe in a hospital is probably that middle ground and there You know, there's a term that you've probably heard midwives and doulas easy for holding the space You've heard this the idea is it's you're holding the space for the woman to have her birth happen the way she wants it to And I feel like the neat thing about this apps is that it uses data to kind of quantify is your hospital Holding the space for these women Kristen your view is a patient I was speaking to you in MFM recently about the recent surgeon acreta rates And he referred to it as mother nature's revenge for increased caesarean rights And I thought that was a really interesting way to think about it But one of the things that really fascinates me about my story is that a caesarean tried to kill me But then the only reason my son Leo and I survived to that pregnancy is because a caesarean was available to us If I had gone into labor without a caesarean available, we both would have died So I think that that shows very well the power of a caesarean and intervention in general on both sides Right, I think it gets back to the individualization that you raised Bob that we have to look You know, it's not one-size-fits-all Said so how do we balance we have folks that want natural childbirth non intervention How does that sync up with big data and AI and Devices and and all sorts of things. Yeah, I don't think it's actually as complicated as an AI for that purpose. I think it's just communication and and having the data at one's fingertips I think choice is a really important factor here on the patient's part And I think what better way it, you know for a patient to exercise You know their choice than to be super connected to the body of information the recommendations guidelines and best practices But also then to be able to communicate that with other patients or to read about other patients experiences So whether that's just media or social media or whether that's you know, the medical literature So I think having Recommendations as I think the apps do around, you know The use of handheld tools and mobile devices as a communication tool for that information That's a key part of really I think democratizing the information and and giving sort of choice, you know to the patient Great great Okay, very quick response What's the biggest barrier to getting this apps through Kristen? I Think that we tend to think of birth as this isolated event when in reality It's a moment across a woman's reproductive life and the culture change that I would like to see in Obstetrics is really a focus on that shared decision-making across that entire scope Bob, what's the biggest barrier? I Think the biggest problem we have is we haven't aligned the incentives for for Providers with the behaviors that we would like to have and People can make more money In less time with less fear If they do the behaviors that we don't want them to do and I think if we want to push their behaviors We have to align their incentives to with the behaviors that we want Well put said so I'll give the the technology answer Which is that I think the two big barriers are you know One is having the data in the same place as we discussed earlier and being able to access it and do interesting things With the data to help you know create clinical decision support And I think the bigger more broad barrier is just clinical adoption of new technologies Especially when they go sort of head-to-head with conventional decision-making So at a point at which physicians can be very open to new technologies helping Them make better decisions I think that takes a while but it but it's the place to go jail Well, I think one of the barriers is not patience I think a lot of patients sometimes get blamed although i'm dr. Silvered um was uh, I think we're kind of aligned on this What's we can look at what's already worked as far as lowering c-section rates and that has been like in arkansas for example Arkansas medicaid implemented a pay-for performance They got away from fee-for-service and they dropped their rate over three years from 28 to their lowest rate from uh 28 to 24 Like and they knew no consumer engagement No patient engagement no special steps for patients to take and the same with your Pilots in southern california and the same and and so it's just um, I think it really is that provider re-education The data feedback and uh transparency Yeah, and i'm gonna go back to yesterday's discussion about leadership And tag on to that that clearly it takes from all the disciplines Good leaders, but I would add to it passionate leaders. I I think this is one area Of change that because of the time difference because it's not right in your face that harm occurred You really need to have a different type of leadership with that Now I I want to include everyone's question, but there's huge numbers Glad to see you're engaged. Thank you very much Um start off with multiple questions on v-back now and I should say that the apps like many of the national Focuses uh and international focuses have worked on first c-sections But uh, I'll ask the panel whoever wants to jump in is there a role for uh v-backs in in in preventing unnecessary c-sections Absolutely, um one of the data points that shocked me when I learned it is once a woman has a prior cesarean in the united states She has a 90 percent chance of having a repeat cesarean And it's these women with multiple cesareans who end up at significant risk of developing an acreta yet No one else has done that Bob You bet it's it's it's a really good example of of surgeries that are done um In large part because of a one in a thousand Risk and and we're probably causing more harm than good by not doing more more vaginal birth after cesarean and You know certainly the best way to prevent Cretas is to not do that first cesarean, but not doing the second or third one really helps as well jail said So we have a measurement gap if you don't we have a a gap so about 600,000 or I think it's 604,000 approximately Um, it's about 15 of all women who give birth annually Have a prior c-section and we have a gap like we don't look at parity Or we we only look at nullips first time moms for our c-section measures, but we do need to come up with some better um ob measures of safety That do take into account that you know women do have more than one baby and it would be interesting to see You know what what that looks like down the line I was just gonna add I think it's important to focus on preventing the first c-section to your point But that you know that that being said the rate of acreta goes up like this With a number of cesareans so one is still a lot better than two or three So so that way strongly Okay, here's one I think it came in from cedar sinai What's the panel think of regard regarding a maternal request for c-section maternal request c-sections? I'll handle this as the the act of obstetrician You know I get asked about this all the time and and I think we we do have an ethical obligation to offer that procedure And and you can get into Arguments you know in a society where you can have plastic surgery You you probably have an ethical obligation to do that But I can tell you that if if you sit down and talk to patients and ask them why they want to do that Almost always they'll have some information that may not be factually correct And if you just ask them what they're worried about and what their concerns are and ask their questions and educate them 99 of the time they won't want to do it anymore So this joe you get the last word. Oh, no Well, we had talked earlier and um you'd said that you thought that one of the reasons people choose natural childbirth Is to have more control over the process and uh, I think you're spot on And I think that's why I don't think that you know the whole maternal request c-section You know, I don't think it's a real debate Um because one of the stories, you know for my second birth I chose a birth center freestanding birth center and The stories that I actually related to more Were the women who had a vaginal birth in a hospital the first time thought I'm not going to do that again And had an elective c-section And I thought that speaks more to me than seeking some ideal birth It was more like I'm not going to do that again. And so I actually don't think I think there's room for that in our healthcare system So unfortunately, we don't have any more time and we need to wrap up. Thank you guys so much for your answers and There's still a ton of things here. These guys Had promised me they're sticking around so please grab us at the break and and talk to us And then I'll put a shameless plug for our workshop tomorrow in a necessary c-section Feel free to come in and fill up the room and and we'll talk more about these things. Thank you