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Skip to 0 minutes and 18 secondsDR NEEL SHAH: Inequity in maternal health in high-income countries at its core is very similar to inequity in every country, which is that there is a challenge in balancing the problem of delivering too much care, too soon with delivering too little care, too late. In high-income countries, the balance tends to be a little bit more shifted towards doing too much. And we see that in terms of really high- rates of interventions in childbirth, particularly in terms of C-section rates.

Skip to 0 minutes and 51 secondsThere are a lot of potential drivers of inequities in high-income countries that look different from low- or even middle-income countries. Because there is more wealth in high-income countries, we see a lot more infrastructure. So for example, we see a lot more births taking place in facilities like hospitals, in particular. Demographically, high-income countries look a little bit different. Moms tend to be a little bit older, there are more chronic medical conditions among moms that are recognised, such as hypertension, diabetes, obesity.

Skip to 1 minute and 26 secondsI'd say one of the key differences in terms of what care looks like in high-income countries is that a lot of the facilities, it's not just that birth takes place in hospitals more often, it's that the hospitals themselves have a lot more kind of wrap-around services and what I think of as just in case resources. So, things like access to really high tech interventional radiology or access to really sophisticated blood banks. I think one of the challenges is because high-income countries have more access to these kinds of resources, they are much more likely to use them. And sometimes they use them more than they strictly should in ways that could also be harmful.

Skip to 2 minutes and 10 secondsYou know, as we discussed, one of the primary sources of inequity in high-income countries is that we take our ample resources and we deploy them more often than we should and sometimes people get hurt. So, in the United States about one-in-three births are done by C-section. We think about half of them are unnecessary, and cumulatively, just in the US alone, this is billions of dollars that are spent that could otherwise be reinvested in better care. There's also hundreds of thousands of women who suffer needlessly from incisions that they didn't have to have. Tens of thousands who end up getting major surgical complications.

Skip to 2 minutes and 52 secondsAnd, you know, on the sort of over-intervention end, what we're now seeing in high-income countries, particularly countries have been over-intervening for long periods of time, for decades, is that a lot of our bottom line metrics not only are not getting better, but they're actually getting worse. So for example, maternal mortality in the US has been getting worse for about 20 years. And we think that, we don't know exactly what's driving it and it's probably complex, but one of the smoking guns is that we see higher and higher rates of haemorrhage in the US.

Skip to 3 minutes and 24 secondsAnd one of the most common reasons for life threatening haemorrhage among American moms is placenta accreta, which is a condition caused by C-sections that has become much more common, just as C-sections have become more common. Now at the same time, because we deliver care in these really highly intense, highly resourced facilities, it's very difficult to put those facilities everywhere in the US. And so we see these disparities. We see in 50% of US counties, there is no qualified OB, obstetrician, no midwife, no family medicine doctor. Women often have to drive hours to access one of these facilities. So we end up seeing disparity at both ends.

Skip to 4 minutes and 13 secondsWe have a lot of systems in healthcare to think about the problem of too little. A lot of patient safety revolves around trying to make sure that we more consistently do things that we consider to be best practices and fundamentally is often about doing more things. When we look at a big source of inequity in high-income countries, it's that we're actually harming people from doing too much, too soon and we don't yet have great systems figuring out how to dial it down.

Skip to 4 minutes and 40 secondsOne of the things that my team has started to believe is that often when we do too much - and by we, I mean clinicians in particular - it's not from lack of knowledge about what we ought to be doing. And it's not just intentional. For example, like, we're not doing it because we get paid more or we're worried about medical malpractice or it's not just about misaligned incentives. You know, often we err on the side of doing too much just because we're human and we're making mistakes.

Skip to 5 minutes and 10 secondsSo we've been thinking about what a solution could look like that makes it easier to do the right thing that sort of takes all the complexity of the labour and delivery unit environment and tries to create some decision support and some intentional areas of simplicity.

Features of maternal health & care in high-income settings

What is the role of inequity in maternal health in high-income settings, and in what ways does this differ from low- and middle- income settings?

In this step Dr Neel Shah (Harvard; Ariadne Labs) outlines key features of maternal health in high-income settings, with examples from the United States, emphasising the challenge balancing care that is “too much, too soon” with “too little, too late”. The relationship between over-medicalisation of childbirth and poorer health outcomes among women is discussed, and how this relates to the health care system.

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This video is from the free online course:

The Lancet Maternal Health Series: Global Research and Evidence

London School of Hygiene & Tropical Medicine