Combatting Maternal Mortality through Trustworthiness and Advocacy: A Conversation with Dr. Neel Shah

Interview by Suheila Mukhtar

HHPR Associate Editor Suheila Mukhtar interviewed Dr. Neel Shah, MD, MPP, FACOG, who is Chief Medical Officer of the world’s largest virtual clinic, Maven Clinic. Alongside being an Assistant Professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School, he is also an obstetrician-gynecologist at Beth Israel Deaconess Medical Center and Senior Advisor to the Delivery Decisions Initiative at Ariadne Labs. Dr. Shah is Co-Founder of nonprofit March for Moms and Founder and Executive Director of Costs of Care, a global NGO focusing on clinician insights that propel better and lower-cost care. Listed among the “40 smartest people in healthcare” by Becker’s Hospital Review, Dr. Shah has conducted extensive research on maternal health and the design/testing of healthcare solutions. Dr. Shah is a senior author of “Understanding Value-Based Healthcare” (McGraw-Hill) and is also featured in the films “Aftershock” and “The Color of Care.”

Suheila Mukhtar (SM): Thank you for taking the time to speak with me today, I’m really grateful for your time! To start, could you explain what propelled your interest in the field of OB-GYN?

Dr. Neel Shah (NS): I went to medical school, and I was a man in my early 20s. OB-GYN was the last thing I ever thought I was going to do. I did it first in medical school to get it over with. And then it turns out that everything about taking care of people's reproductive health is very compelling because first of all, delivering a baby is pretty cool, right? There's no existential crisis in the middle of the night when you're delivering a baby. You know that you're doing something that's helpful to people. Also, the people that go into OB-GYN care deeply about social justice. It's not that general surgeons don't, but when you're operating on a gallbladder, it's different than taking care of people's reproductive health because their rights are so deeply tied to it. I think that I was really compelled by, of course, the people and the needs that you get to take care of but I was equally I compelled by my colleagues. I wanted to be more like them and I wanted to spend more time with them. So I ended up in women's health, and as a clinician, I then developed my career into public health where you see the needs of people one-on-one as a clinician And then you see the huge gaps and unmet needs when it comes to gender equity and racial equity, all of which intersect when it comes to reproductive justice.

SM: What is the main fragment or shortcoming in our healthcare system that you believe exacerbates maternal mortality the most?

NS: I mean, the way I think about it, the well-being of moms is sort of a bellwether for the well-being of society as a whole. So if moms are unwell, it means society is unwell, which is why every injustice in our society shows up in maternal health. One of the leading indicators of structural racism in the country, is maternal mortality. The fact that if you're Black, you're four times more likely to die. So if I were to pick a single factor, at the end of the day it's misogyny and racism. It's a choice. I'd like to think that, you know, a bad system will beat a good person every time. I don't like solutions that castigate individuals or institutions at the same time. Every system is perfectly designed to get the results that it gets. So if you have a system that's producing equitable care and big disparities in maternal mortality, it was designed that way.

SM: Maternal mortality is a multifaceted issue that is ultimately correlated with the race, socioeconomic background, and geographic location of pregnant mothers. Is there a single, prime solution that you believe would combat each caveat of this issue?

NS: I think honestly what we need to do is realize that everybody has an important role to play in addressing maternal mortality, but they've got to do it with an awareness of their positionality. Academia has a role, government has a role, and the private sector has a role. It’s okay for people to take different strategies and tactics, and even to some extent have different goals. But what we need is a shared framework and vision for what a better world looks like, and a shared set of values. I think that fundamentally what it comes down to is trustworthiness. We've got to make sure that we're developing a system that helps the people that, right now, have been made the most vulnerable. You mentioned geography, and I think the most vulnerable person in America right now is probably a pregnant woman of color somewhere in the South, probably in a rural part like the Mississippi Delta region of Arkansas. For that person, it's not her job to be more trusting of the system. It's the system's job to be more trustworthy. What that means is that we've got to build the system in a way that is competent at taking good care of her—which is not where we are today—and is good at affirming her and is reliable at showing up when she needs to and how she needs it.

SM: That's a really interesting point you bring up. How exactly can we measure trustworthiness? How can we measure whether we're making progress or not in terms of combating maternal mortality?

NS: I think trustworthiness is measurable because I think trustworthiness is the right problem frame. You can't fix what you don't see, and you can't see what you don't measure. Trustworthiness has to be looked at as more than a virtue. Trustworthiness has to be looked at—in order to operationalize it—as an output of a system that's either working or not working, and you've got to decompose it into different dimensions. So, you cannot be trustworthy unless you improve outcomes. What's interesting, though, is that it's not sufficient to improve outcomes because a lot of the things I think have undermined the trustworthiness of other public health institutions like the CDC, is inconsistency. And it's okay for messages to evolve with new information, but when the motives don't seem consistent, that undermines trust. So, you can measure trust. For example, I'm on the faculty at Harvard and am the Chief Medical Officer of a digital health company for women’s health, and a big part of how we measure the trustworthiness of our service is reliability in being accessible to people when they ask. So we've set a goal, for example, that whenever somebody needs help from a lactation consultant who's struggling to breastfeed, we should be able to get to them in 30 minutes. You have to say what you mean and mean what you say, so you have got to show up in 30 minutes. That is a very quantifiable way of knowing whether or not we're trustworthy. We also have to make sure to affirm people well. You earn the opportunity to make people healthy if they trust you and engage you in the right ways.

The other ways we try to quantify trustworthiness is to make sure that we're not only connecting them to a lactation consultant, but we're aiming to connect them to a person who shares some lived experience with them. You can quantify that too because you need to have a healthcare workforce that looks like the people you're trying to serve.

SM: You are also a Co-Founder of March for Moms, an organization that aims to better maternal and family health through activism and awareness. Overall, what specific role do you believe that activism plays in combating maternal mortality?

NS: I think activism is almost all of it. As a professor and a clinician, at the end of the day your job is to be a scientist. That requires precision around what science does for you and what it doesn't. What science can and should do is give you confidence that what you think you're observing is true. That's it. Having the answer is not good enough to accomplish the solution. I think that sometimes in academia, we draw these bright lines between science and advocacy. But the truth is, you need both. You have got to keep the science pure and make sure that what you think you're observing is true. Then, once you have the “truth”, you need to do the rest of the work. You have to build coalitions and you have to frame messages. You've got to build trustworthy channels to deliver the messages, and you need to have calls to action. It's not magic.