Ep 94 Elise Erickson on how oxytocin shapes our birth experience and trying to predict birth

Ep 94 (http://ibit.ly/Re5V) Ep 94 Elise Erickson on how oxytocin shapes our birth experience and trying to predict birth

@PhDMidwives #research #midwifery  @uarizona #epigenticaging #hormones #pph

research link -t.ly/ea0x1

MuMH lab -https://www.mumhlab.com/

From witnessing her first birth as an undergraduate to pioneering research on the biology of childbirth, Elise Erickson takes us on a compelling journey through her evolution from midwife to maternal health researcher.

Elise, associate professor at the University of Arizona and certified nurse midwife of nearly 20 years, shares the moment that changed everything—a women's health course that aligned her interests in biology, healthcare, and feminist theory. Her subsequent path through midwifery education revealed the power of community-based care, particularly in group prenatal settings where women support each other through pregnancy and beyond.

What truly stands out is Elise's ground breaking research at her MUM Lab (Mechanisms Underpinning Maternal Health). She's challenging conventional wisdom about maternal age, investigating biological aging markers that may better predict pregnancy outcomes than simply counting birthdays. Perhaps most exciting is her innovative work using smart rings to track body temperature patterns that could predict labour onset—potentially transforming how we approach inductions and birth timing.

The conversation delves into the complex relationship between synthetic oxytocin (commonly used in labour) and postpartum outcomes. Through meticulous research, Elise explores how this medication might affect everything from postpartum haemorrhage risk to breastfeeding success by altering oxytocin receptor function. Her work exemplifies the vital connection between clinical observation and scientific inquiry.

Looking forward, Elise envisions truly personalized maternal care that integrates biological markers, personal preferences, and social contexts—moving beyond one-size-fits-all approaches while maintaining safety standards. Her story reminds us how curiosity and compassion can drive scientific discovery that transforms lives.

Want to learn more about the cutting-edge research happening in maternal health? Follow Elise's MUM Lab and join us in reimagining what's possible in pregnancy and birth care.

Transcript

Speaker 1 0:27

Thank you very much for joining me, as per usual. Can you introduce yourself, please?

Speaker 2 0:32

Yeah, absolutely Hi. I'm Elise Erickson. I'm an associate professor at the University of Arizona in Tucson, arizona, and I'm in the Department of Physiology, and I'm a certified nurse, midwife and a clinical researcher. Scientist and been a midwife for almost 20 years and been doing research in different capacities, but formally after finishing a PhD in 2018, I've been mostly focused on research since then.

Speaker 1 1:04

Let's go back. How did you get into midwifery?

Speaker 2 1:08

How did I get into midwifery? That's a great question. I knew nothing about midwifery. How did I get into midwifery? That's a great question. I knew nothing about midwifery before.

Speaker 2 1:15

I was probably a sophomore in my undergraduate program at the University of Michigan and kind of drifting from one major to another, not really sure what the right calling was. Knew that I loved the concepts of you know anatomy, physiology, biology, healthcare in general, but didn't really feel a physician pathway calling to me. Also really liked the idea of you know sociology and biological anthropology lots of interests but not really finding the right thing that put it all together. And I had a class taught by a nurse midwife who was also finishing a PhD at that time and it was a women's studies you know, feminist theory in women's health course. That was recommended to me by another person who had taken it.

Speaker 2 2:12

And it's one of those moments in life where you know the bells and whistles and the light bulbs all go off at once and you're like this is, this is amazing, this is what I I feel like aligns all of these interests all at the same time. And so I learned about midwifery. I learned about the path through nursing. I switched into nursing as a major, got involved in research like almost instantaneously, with mentors who were doing like women's health mostly research topics and just immersed myself in, you know, midwifery led research, pregnancy related research, and I through that process I got to attend some births. I saw my first birth and I ran across campus from the hospital into my mentor's office and I said I know what I want to do with my life and that's what I've done. So that was I don't know, I was that's what I've done.

Pathways to Midwifery in America

Speaker 1 3:15

So that was. I don't know. I was 19, 20 maybe I don't remember. So there are two different pathways to become a midwife in.

Speaker 2 3:19

America at least, uh, state by state, has slightly different, um, legal paths. There are some that are still considered unregulated paths, or ones that are maybe what might be called a more traditional midwife, where it's like kind of within a religious community or a cultural community that does not engage with a regulatory pathway. But by and large, yes, there is the the, let's say, the majority of the path is it through a nursing curriculum that is conjoined with midwifery. So you become a nurse midwife and there's different degrees that you can receive. Now there's a doctoral program, doctorate of nursing practice, and there's also a master's degree path, which is the one that I had there really weren't doctoral programs at the time a master's degree path, which is the one that I had there really weren't doctoral programs at the time, and so that's probably the dominant path from you know just, there's more information about it, there's a lot more programs for it, there's funding for it. When you become a certified nurse midwife you can, you know, bill insurance companies for your services. You can be caring for people in the hospital or at home or in a birth center. So there's a little more flexibility and that's probably why it's the more majority path.

Speaker 2 4:37

But the other way would be through a certified professional midwifery path where there is a accredited curriculum exam that's taken for a certification. Become a certified professional midwife. You can become licensed as a midwife that is not a nurse in a lot of states and I don't know the exact number off the top of my head of which one's licensure is available, but it's not every state. Um, I would say the majority, though now do. And um, the vast majority of licensed midwives are caring for people in the home, in the birth center on occasion, can follow a patient to the hospital if they need transport, but then they're serving more in a doula role. They don't have hospital privileges necessarily. Those are the majority paths. There's a few other variants in there, depending on where you're at.

Speaker 1 5:29

It's confusing, it causes a lot of confusion, and especially with the state regulation as well, because it's and we could very easily spend a lot of time talking about current changes in women's health in america across the states at the moment, but we won't. We'll talk about happier stuff, um, but it is, yeah, as especially those working on the border and kind of women were seeking and having access to healthcare as well. Those different levels could make it confusing for some of the women seeking assistance and who they go to.

Speaker 2 6:05

I think it can. I think there's a lot of activity online and in. You know social media and other you know web groups that are helping to provide education around the differences and um. But I still get asked like what's a midwife? Like what are you capable of doing? Um, a lot of people still don't really understand. So it's in some states where midwifery is much more prevalent, there's fewer of those conversations, but the states where it's less common, you, you sometimes still have to answer for yourself quite a bit from an international point of perspective, that there's still the assumption that um there's no midwives, it's obstetric nursing yeah, yeah, and that's a point of confusion as well, right, um, because that is, you know, a whole other line, a professional line, that is, is also contributing.

Speaker 2 6:59

So I agree it's very confusing and it's all been a reaction to like trying to provide options for people and trying to develop these other pathways for, um, you know, for people, and trying to develop these other pathways for, you know, prenatal and birth care, to kind of navigate the dominance of the medical model, and so there's all these different like streams that get created and pushed through because that's what works in that place, and so then it spreads from there and I don't know. It's nice that people have choices and they can pick the path that works for them professionally and also as a patient. You can decide what works for you. But it sometimes I wish we were all just one big group of midwives and there was one licensing body and there was one certified, you know, certifying body and there was one you know, exam that we all take and call it a day yeah but I don't see that happening yeah, no, no, sadly no.

Speaker 1 7:58

You find with the. We found it before covid, but covid increased it. But it's also been increasing because of women's poor experiences in the healthcare, that increasing an increasing amount of women are birthing outside of the system and not necessarily free birthing, though that is increasing but they're not trusting the profession and the institutions, um, and if they can't get access to home birth, they are actually kind of free birthing. Is that trend happening as well?

Speaker 2 8:39

I think in places, yes, there definitely was an uptick in community, at least starting in a community birth setting or with intention to birth in a community setting during the pandemic. You know, fear of getting sick, fear of going to the hospital when everyone is, you know, got to wear, you know, a mask and a gown, is, you know, got to wear, you know, a mask and a gown and you know, wouldn't it be nice just to have your family around.

Speaker 2 8:58

They were limiting visitors, limiting the number of attendants like you couldn't bring a doula, you could only bring, you know, you couldn't only bring one family member. There were a lot of limitations so a lot of people did make that switch. So there was definitely a statistically significant uptick Now, whole number wise. It's still a significant minority of people that are choosing a community birth path, but with more access to reimbursement. I think that's really a big piece of it. Until it's readily accessible to anyone and not just people who have extra pocket change, then it's still going to be a privilege instead of a right and I see trends and things of that changing. We're now seeing states reimburse for doula support. Oh cool, yeah, in certain states not all of them where a doula can actually make a reasonable living and actually make a reasonable living, you know, being able to bill to the you know public payer or private insurance a little bit here and there, mostly the Medicaid plans. So that's a nice option. But yeah, access to birth center care or home birth reimbursement is still an issue.

Speaker 1 10:10

Yeah, I think that research shows that the majority of women who home birth, reimbursement is still an issue. Yeah, I think the research shows that the majority of women who home birth are older women and professional qualifications and income, because once again, it is that kind of that cost factor, especially for those that have private practising midwives for themselves.

Speaker 2 10:29

Yeah, I agree.

Speaker 1 10:30

Whilst it's technically open to everyone. It is the and I know that you're very big into social determinants of health in a lot of your research and that kind of compounds on everything.

Speaker 2 10:43

It entirely does. There have been some initiatives to try to provide Medicaid support for birth center oriented prenatal care. There's been a couple of really important studies the strong start study, which was looking at a Medicaid population so a public payer, so not a not a wealthy private paying or out of pocket paying population and even just showing that there's evidence to support better outcomes, even if your prenatal care is in a birth center setting, and even if you don't birth in the birth center but you're birthing elsewhere, that the benefits are able to justify making policy changes.

Speaker 2 11:20

But, because each state regulates Medicaid. It's not a national program in the sense of everyone gets access to the same stuff. It's really bizarre, you know you can cross the border from state to state and have completely different laws and access to things. So with that, you know we have a lot of work to do policy-wise in each state to make sure that it's equitable and people can get access, even if it's just for the prenatal experience and then move to a hospital if that's the best up and to have less prematurity, less underweight kind of better nutrition to have that healthier journey, which means the fetus has got a better chance and also then they're in a better place for postnatal as well.

Speaker 1 12:23

So, yeah, very important to kind of link those things together yeah, absolutely.

Speaker 2 12:30

Um, I think that's. Uh, I think drilling down what some of those elements are is going to be important, because all of those components are probably valuable in and of themselves. Are they more valuable when they're all provided together? Are there other aspects about longer visits? Or you know more or, let's say, a less stressful environment when you're not going to a major hospital center and having to navigate. You know parking structures and you know all of those sorts of things. You know it's trying to figure out what it is sometimes is the tough part, because then you can really validate your existence or prove that your, your services, have worth, if you can really show that. It's these pieces that pull that thread through. And that's tricky research to do because you'd have to randomize people to different options and you know ethics of doing that might not be the best.

Speaker 1 13:25

And it is for business. It's about that return on investment, which is why it's really important that we have midwives who are at those tables where those decisions are made and can argue for the policies, and we need the midwives who are looking at governance and policy that are there to give the voice of. This is what we need. It's not just about this, it's about this is the actual whole context of it, but be able to talk about it in the language of everyone else at the table and not just about what somebody says, the fluffy feelings of midwifery.

Speaker 2 13:56

It's the business side, but still addressing everything that it encompasses oh, entirely, yeah, I mean you I don't know the saying, who said it? Was it elizabeth warren? Like, if you, if you're not at the table, you're on the menu. Oh, I like that it's. I think it feels very, very much true in that regard for midwifery or any sort of women's health policy. Really, you know, if, if you're not part of that conversation, setting, setting the tone, setting the agenda, or at least being a part of it, then no one's going to understand what you're doing. And so you really have to do, you do have to learn the language of, you have to translate what you know and what you believe and what is truth in your setting to what others understand. And that sometimes is a hard stretch for people because they don't know how to communicate in those, whether it's scientific or economic terms.

Birth Center Care and Social Determinants

Speaker 2 14:50

Policy is difficult and tricky. You know those are all things that require some some specialized skill. Yes, so it's. It's really important for midwives to find those champions and help and help push them forward. You know whether they're students who have a policy. You know, yeah, bug, that they need to. You know work on, so anything, anything like that is very helpful okay, let's go back to some nicer memories.

Speaker 1 15:20

What sticks with you about your midwifery education? What did you, kind of like, enjoy the most?

Speaker 2 15:28

Oh, what did I enjoy the most? I loved everything. One of the benefits of the program I attended was in the. It was in the University of Illinois in Chicago, so I had moved from Michigan Ann Arbor, michigan to Chicago and the program was situated within, so that, sorry, the faculty who were teaching courses were also part of the service and they were running the prenatal clinics around town in most of like the public health centers. So we were working in.

Speaker 2 16:07

Chicago is an interesting place. There's a lot of like, there's a lot of small communities in a very big city, and so each community health center was serving the population that surrounded it and it all has each one has its own flavor and and style and the patients that it serves and the languages spoken and the. You know the cultural context and all of that, and so you could go from place to place around the city and learn about a completely different, you know, subculture of of our town, of our city, learn about the distinctions and the similarities of things people were facing, challenges and and social determinants, and also, just, you know, the other aspects that contribute to the life of a, of someone who's pregnant in in Chicago, which is, you know, multifaceted, you know, trying to take three buses to get to your prenatal visit on time in a city where nothing runs on time, you know is is a challenge, um, just as one example, so, uh, so that was that was a real privilege to be able to be embedded in all these different clinics with your faculty, who then teach you in the classroom and then, you know, you get to be with them at the hospital too. So that made it feel like a really close knit community and, um, a really safe environment to develop and to ask questions and to challenge things. Um, I also got the opportunity to help do centering pregnancy or group prenatal care.

Speaker 2 17:36

Are you familiar with centering?

Speaker 1 17:38

No.

Speaker 2 17:39

You're familiar with centering. So Sharon Schindler-Rising was the kind of the I don't know inventor starter of the centering movement centering pregnancy. So it's a specific model of care that is based on like a group orientation for prenatal visits. So you're coming together eight to 10 people and maybe it's about a two hour session and you spend time doing, you know, take your own blood pressure, check your weight. If you need to check a urine dip, you do a urine dip, but then you get a few minutes with the midwife in the corner on the mat to check belly. You know, listen to baby and. But then most of the time you're sitting together in a group doing, you know, a facilitated leadership, trying to pull on the strengths of the community, the members of the group, to lead and teach one another, to share stories. If you have a multi who's done this three times, they can share their experiences and it's so amazing to see how people change and evolve through that process. People who were very scared and nervous gain strength from hearing the stories of those who have been there, done that. You know you got this, you can handle this. You know you got this, you can handle this. You know this is this is how you get through it or, you know, whatever challenges there may be.

Speaker 2 18:58

And there was one group that we were caring for. It was towards the end of my of my time as a student and they were all. There was like three young women who were all you know doing the same couple of weeks and they bonded so tightly. They spent the same couple of weeks and they bonded so tightly. They spent the last couple of weeks like going to museums together, walking around town, like visiting you know, just keeping themselves busy and active.

Speaker 2 19:24

And then they I think at least two of them ended up in the hospital at the same time giving birth, and so then postpartum they would share each other's rooms and come and like sit together and feed the babies and and it was like growing a sisterhood that hopefully continues after. So, because of how our communities sometimes have gone and to be very isolated, and that like notion of of a women's group or a women's society, like really helping foster that, that knowledge and helping one another and growing their families, that has become much more dissipated. This really felt like a really organic replacement for that or just something that some people really needed. Yeah, so that taught me a lot about the value of that type of social connection and social environment to grow and develop, hopefully, a healthier pregnancy and hopefully, a better future for you know what, you feel more empowered to be able to go and get what you need.

Speaker 1 20:27

Well, that's what it was. It was the before, I'm going to say, industrial revolution and I'm going back a few hundred years now, but it was the very much that it was the community and it was the women in the community that your extended family and we still see that in a lot of communities and a lot of nationalities that is the extended family that are there to help, that share that advice. That it's not. Not, it wasn't as isolatory as it very much is now, and a lot of that's economic, because you've had to have kids that have moved away because they weren't able to stay in the area to do, to have employment or jobs and things like that. So they are kind of disenfranchised from those social networks to be able to exist because of cost of living and changes in a more industrial world.

Speaker 2 21:19

Yeah, I agree, I think building healthcare from the community or creating a community like structure to provide care, it's the benefit of reaching people in a more, I would say, effective way, instead of like sitting in a waiting room for 45 minutes to see a provider for 10 minutes and then driving, you know, like, if you're going to be here for an hour and a half or two hours, let's just all do it together, and I don't want to say the same thing nine times. Let's say it once and hear all of your stories. You know that's it was fun, it was super fun and it just it was very eye-opening in a lot of ways. So, yeah, so those were the.

From Midwifery to Research

Speaker 2 22:05

You asked, like, what do I about my midwifery education? But those are the things that really stand out, aside from you know all the other things. Like you, those, those are the things that really stand out, aside from you know all the other things. Like you know, getting to attend births and learning so much about the process. But it was really about the, the instructors, the faculty and, um, the women we were privileged to care for. You know, like it would not have. It was just really meaningful.

Speaker 1 22:28

Did that help drive you into research Did?

Speaker 2 22:31

that help drive you into research? I well. So, yes, that was a. I was part of a research project that was implementing this group prenatal care, so I was like helping to assist the program, so that was a piece of it. Um, I had been interested in research prior wanting, you know, having had some experiences in undergraduate doing um birth related research and research on doula programs and fatigue during labor, I mean there were a number of things that I had gotten involved with. So and then, yeah, I think, having witnessed the power of the social bond and the social connection really helped stimulate some of the next steps and, you know, developing a line of inquiry or a hopeful research program Because it comes from our observations. You know, I mean nurses and midwives are, I think, are very natural scientists in that way, because you're always collecting data. Yes, and hopefully we're updating our priors. You know we're updating our biases or our prior beliefs based on our new data and what we're seeing, and some people probably do that better than others and some people don't update their priors.

Speaker 2 23:40

But it is something that we have to challenge ourselves to do and I think most of the time you know we do that pretty well.

Speaker 1 23:48

So what was your pathway into a PhD then? Was it a natural progression from a master's or was it something that came about, that you were already looking at something and it was suggested to do it as a PhD?

Speaker 2 24:02

That's a good question. I had been inspired from, you know, the very first midwives I interacted with, who had PhDs, to think like, think like this. It could be a real path and, you know, maybe someday I could teach and I could do research, and wouldn't that be great. Um, but I wanted to practice and I wanted to, you know, build skills as a midwife, and I had. So I was working as a midwife in Chicago after graduation, um, for a very busy um clinic that was service serving mostly, um, spanish speaking, fairly recent immigrant population, not not exclusively, but but the neighborhood it was in was was a lot from Mexico, central America, south America, um, as an origin, but, um, so, you know, very busy, place lots of births in in a shift, um, and I started paying attention and, and like, observing some things around the social environment that births are unfolding in, and when the social environment was soothing, supporting, calm birth, went one way, Yep, and when it was not, when it was the opposite of that, things went a different way. Yeah, not exclusively right, like we know that there's our generalizations, but I did recognize that when I could be in the room spending time hands-on, providing massage, providing, you know, coaching with breath, uh, positive affirmations, all of those things that people need psychologically to cope and manage. Um, because our, our patient population by and large did not want to use pharmaceutical. You know it was their, you know cultural preference, personal preference, and so we try to support that as best we can. And if they change their mind, or someone wants an epidural, like, fine, go do it, let's. Let's get you set up. But when someone is coming with a non-pharmacologic plan, we try to do our best. But when you're running from room to room catching babies, you can't always do your best in that regard, because there weren't doulas at that time. Maybe there'd be a grandma or a mom or someone there to provide some of that. You know, motherly support or you know, but that not always. Sometimes people were very alone when we were able to provide more of that hands-on care. So it started making me think of, like, what's the biology of this? What's the physiology of labor unfolding in different ways based on psychology and based on, perhaps, the stress environment, or you know why does it go well for one person and not another? So I had all these questions and I stumbled onto literature around.

Speaker 2 26:54

Oxytocin function out, you know, not in the context of of contractions, but in the context of social biology and neurobiology. And lo and behold, the one of the you know, world famous oxytocin scientists happened to be in Chicago at UIC. Her name is Sue Carter, who has studied oxytocin in the setting of social bonds with the prairie vole as a model of social monogamy. And I showed up, you know, I emailed her, I showed up at her lab and I was like you know, I'm interested in this and I was also really interested in what were how the use of oxytocin in labor was potentially impacting some of that social biology and whether it could have an impact. And that was my question. So came to her she said, let's do it.

Oxytocin Function and Postpartum Hemorrhage

Speaker 2 27:48

Come work in my lab and so I started grad school there in a neuroscience program and through a circuitous path and course of events that didn't end the way I had hoped it would want it to and I wrote a actually I wrote a journal article about this. So it's available, it's out there. It's called a prolonged latent phase and early career in oxytocin. So that is available for someone who needs, like I don't know, bedtime story. So you know some ups and downs in that process. Ultimately I moved to Oregon, thinking well, maybe science isn't the direct path or isn't the path that's for me, so I went back into just being a midwife, but I quickly realized that no, I actually do have research questions. I have an impulse to study. So I entered another doctoral program several years later, in 2014, and finished a doctorate PhD there, and still focused on oxytocin, but wanting to stay more centered on human research and human outcomes and not the animal model. Research and human outcomes and not the animal model. Yeah, and I did a dissertation surrounding oxytocin use in labor and birth.

Speaker 1 28:59

Um implications for third stage, postpartum hemorrhage and lactation was what it was centered on, and I've kind of been in the postpartum hemorrhage world for ever since then because that's the, I think, the interesting conversations that I've been hearing is that with the increasing use of inductions and with oxytocin synthetic oxytocin is that, and if I get this wrong I'm happy to be corrected that the synthetic oxytocin is basically tiring out the receptors and therefore they're not as effective in their job, especially increasing in the postpartum hemorrhage but also because they are being the receptors are being tied out, then that's the link to the decreasing in breast milk production as well and the bonding and attachment that also comes afterwards. Is that in the right track or very simplistic view?

Speaker 2 29:54

I think it's the hypothesis that we're trying to test, right, well and so so, yes, I mean all of those things like it follows right. So, whether it's endogenously produced oxytocin or exogenously given synthetic oxytocin, the more you saturate a tissue with an agonist or that you know, peptide, the receptors will not be available forever. They will desensitize, they will internalize from the cell membrane and they may become available again. Or maybe they'll go away and stay away for many hours. And so if you're doing that throughout the body, because you're giving it peripherally for hours or days, what is the impact? And the the desensitization phenomenon is is real. We know that happens in the uterine tissue. What happens in the all the other tissues? That's a great question and that's something that we have a hard time directly studying, because it's hard to sample, like the myoepithelial that surrounds the milk ducts, to be able to say like, okay, what's happening to the oxytocin receptor here? And also the question is like, how long is this effect? Is it something that can be recovered? Is it something that just given enough time recovered? Is it something that just given enough time?

Speaker 2 31:15

But my concern is especially on the lactation side is so maybe it is recoverable, but that interim period when it's really hard or where it's not going well. Or you've got a super sleepy baby and you kind of get frustrated to the point where you're like, let's just, let's just take the other route. That's not recoverable sometimes. Most of the time. If you start formula feeding in the hospital, we know that the likelihood that full breastfeeding will return is probably pretty low without a lot of determination and self-efficacy and personal support for the person and all that. So. But I think in the immediate birth period, in the hemorrhage or the tendency to have more bleeding, I feel like there's a much stronger association with, you know, intrapartum oxytocin and the likelihood of hemorrhage.

Speaker 2 32:05

Now the other side of that argument, and the one that you know we'll get into debates about, depending on the circles of you know, clinical clinicians and scientists that you get in a room is well, maybe it's because these, these people who needed oxytocin in labor, didn't have as many oxytocin receptors to begin with, and so is it a feature of someone's like innate presentation to labor and birth that is more indicative of what's going to happen postpartum, like a hemorrhage, than the exposure itself, and that's an important consideration and it's something that informs the work that I'm doing.

Speaker 2 32:42

But I would also argue that if we're giving oxytocin synthetically to what? 70% of people in labor, then the definition of what is normal and like the normal progress. If we have to augment that many people, maybe our definition of normal needs to be updated, yes, and maybe we just need to be a little more patient, you know? Um, so yeah, and I've got a number of studies that we've done where we've tried to parse out those things and to take away all of those potential risk factors and to just look at very short term use of oxytocin in labor, and even with shorter term use of oxytocin in labor, we still see an increase in hemorrhage. So there's a lot of moving pieces in that argument, in that discussion, a lot of moving pieces in that argument and in that discussion and, um, but I think what you're, what you're hitting on is isn't, is entirely within that. You know, this is the hypothesis we're trying to test and there isn't necessarily a clear answer yet.

Speaker 1 33:42

There's a lot of hints and I think one conversation thread that I I kind of followed as you go down various rabbit holes at different times was the conversation I think it was.

Speaker 1 33:52

It was looking at epigenetics and it was kind of going through the argument, and I think Michelle O'Dent made a comment in one of his last books.

Speaker 1 34:01

Kind of come out that with the medicalisation of birth a lot more women are giving birth now that wouldn't have given birth earlier and therefore that is changing the DNA structure of the human race, and so this conversation was going along something similar that, because we've had such an increase in inductions over the last kind of few decades, has that I'm going to use the word saturation of synthetic oxytocin affected female fetuses so that maybe their receptors are not as effective.

Speaker 1 34:44

So therefore it's this generational consequence which I know is really hard to pick and to to determine. But it was a really interesting conversation down that kind of rabbit hole of looking at well, if we've been doing this for generations, is it affecting kind of like because we know that, and I love this the fact that I have a part of my grandmother, that I was in my grandmother because I was in my mother when she was a fetus, right, so that connection is there. So yeah, it was an interesting kind in my mother when she was a fetus, right, so that connection is there. So yeah, it was an interesting kind of like conversation trail.

PhD Journey and Work-Life Balance

Speaker 2 35:18

I think that intergenerational, you know, passage of of the physiology and biology and exposures and things, I think that's a really deep well of of potential knowledge that we're going to go down as we develop more ways to be able to do that, um, either in a animal model or in humans, and to really study, kind of those phenomena. And I think it's really important and, um, something that we, I think we owe it to ourselves to ask those questions because we have in so many ways fundamentally changed all of human existence with modern medicine right, I mean, I can't see anything without my contacts in, like I would have been eaten by a lion, like there's lots of things that are now being passed from generation to generation that are made possible because of our modern ways. I don't know about the oxytocin exposure. I think that potentially maternal milk or human milk is an important consideration, certainly people with cephalopelvic disproportion or having true labor dystocia, where the pelvis or the baby is, you know it's not going to come out, and now we can, you know, help that baby come out and that baby might go on to have babies and that pelvis structure or tendency to be 12 pounds at birth is going to get carried forward as well. So there are probably and I've seen a couple of anthropologic studies that have done modeling around this and that actually like the rate of CPD whether you like that term or not, but like it's that rate of CPD probably is increasing because we have more people surviving childbirth who otherwise would have perished, and so, yeah, it's, it's really tricky.

Speaker 2 37:13

I think the other piece of this that is hard to ferret out is that we're also keeping more kiddos alive from modern NICU and surgical interventions that present, with biology and systems that you know have developed different ways of functioning that you know may cause disability, maybe not, maybe it's just alternative ways of functioning. So it's so it's so complex it is that it can be head spinning, be head spinning. So, um, and as a as a scientist, you know you're always trying to pull, bring things down to like a tiny unit of study, and so sure it's reasonable to pick one of those things and to try to dive into it, like, let's look at epigenetic regulation of the oxytocin receptor, and that's what I'm looking at, but to try to then put it back into that big context of like, well, why is it differentially methylated? That's a really big question. That's very philosophical, probably beyond my scope, above my pay grade and it has to be measurable.

Speaker 1 38:18

I think that's that's one of the hardest things to work out is how do you actually measure something, and especially when you're looking at a process that involves a person. It's easy to be scientific. Let's look at this, but well, how are we going to measure that? Oh, we have to do that by amniocentesis. Yeah, no, that's not ethical. So it's easy to be scientific. Let's look at this, but well, how are we going to measure that? Oh, we have to do that by amniocentesis. Yeah, no, that's not ethical. So it's kind of like, looking at that, that balance, um of doing that. So, reflecting on your phd, what's something now that still resonates with you that maybe surprised you?

Speaker 2 38:51

probably a a little bit of the evolution of thinking, not surprising in like, oh, I never expected my thinking to evolve, that wasn't it. But when you come in to a program with sort of a plan or an idea of what you're really hoping to get at or what you really want to focus on, and then, through the course of discovery, you, like I mentioned, you, update your priors and you start to think about, oh, this is a bigger deal, like there's a lot more here than I originally. So I was very driven to study the effects of synthetic oxytocin on outcomes. Right, that was really. That's why I wanted to go and poke prairie voles and, you know, study it in an animal model, and that's why I wanted to, you know, finish a PhD. I still think it's a really important question and I think that there's probably answers that we will come to eventually. But and maybe they're intergenerational in nature. But as I started to study more about oxytocin function, I started to realize there's a lot of variation in how oxytocin works from person to person, and so before we can address the question of how does this exogenous influence have a lasting impact or not, we have to understand how oxytocin differs from person to person and oxytocin receptors and the systems.

Speaker 2 40:17

Biology that is, informing how oxytocin is going to be uptake by the body, how it's going to be transformed, how it's going to be used, because it's clearly more potent for some people than others. Yes, not only in the clinical sense, but also in the social biology. Not everyone has the warm fuzzies with a hug, right. That's not a universal truth. So I started to evolve my thinking and the research then followed with. I got to think about individual variation and how do we not only figuring it out, but then how do we best care for people based on their biology, based on that sort of precision medicine idea that we don't just provide one way of doing things to absolutely everyone. We figure out what's best for you as a person, hopefully informed by your biology and your circumstances, which is hard to do in obstetrics. Like no one, we don't really think that way.

Speaker 1 41:16

No.

Speaker 2 41:17

Oftentimes midwives. I think some are better at thinking oh well, this is what this person needs.

Speaker 1 41:22

It was in front of me that leads back to that midwifery continuity of care, because you actually get to know the person that you're with so you can actually start to understand this is how they react for this. This is how they react for this. This is what they do or do not like. But you have the time to develop that relationship depth that you don't get in a hospital setting or if you've only got a 10 minute appointment oh, entirely yeah, because then you're reduced to numbers.

Speaker 2 41:44

It's, you know, your age is 35, your bmi is 40, your blood pressure is 138, over 85, like that or you know those are the things that are considered, not the context in which you live or the circumstances that brought you to any of those numbers. In order to better understand what to do with those numbers, I think we better not we need to better understand that person and their circumstances so that ties into that whole like social determinants piece of really getting at you know what are the circumstances in which we live.

Speaker 1 42:15

So how did you go about finding supervisors for the second time round? I?

Speaker 2 42:20

yeah, that's a good question. I showed up, I had been the the Oregon health and science university midwifery service and education program is was the only one in Oregon that was, you know, doing a midwifery education program, but they also had a PhD in their school of nursing and it was such a longstanding service been there for 40 years and there were, you know, phd midwives who were, you know, running and working in the faculty and I I showed up and I said this is what I want to do. And they said that sounds great. And and we went from there and we kind of, you know, created together like what was going to happen and that, because they weren't necessarily experts in biology of oxytocin, but they were able to provide that structure is how do you create the research questions, how do you develop the methods, how do you analyze the data and all of those pieces of the scientific process? Because you are already coming with a domain knowledge, yes, and the impetus to like self-study and move yourself forward. So, yeah, it just kind of worked out.

Speaker 1 43:53

I don't know if if that's a good enough answer, but it is look, opportunistic, serendipity, um are ways that have been explained when I've asked that question. So it's just like I just went and talked to people, or somebody connected me with somebody else who kind of could help me with a part of it that they couldn't. But but, yeah, right, how did you keep your sanity through it all? Because I assume you were still working at the same time. And then how did you balance everything and keep your sanity while studying?

Speaker 2 44:23

Yeah, oh, did I? That's a good question. Did you keep your sanity? I like that, I think so. I tried to.

Speaker 2 44:33

So I originally got into the PhD program and then I found out. I was like, I thought I was pregnant and so I deferred for a year and then started the program with a one year old Yep who was still like waking up every two hours. One-year-old yep, um, who was still like waking up every two hours. So, you know, sanity, uh, I don't know.

Speaker 2 44:55

There were moments, there were moments where I wanted to quit for sure, and I remember a phone call with, uh, my mentor from chicago, sue carter, who talked me down off a ledge. You know, like, you can do this. You know you, um, you started this, you can finish it. You. You know you, um, you started this, you can finish it. You know you want you're going to be proud of this. You know like to, really, and and she had, you know, she always has that very like grounding advice. So that was helpful, um, so I think sanity was brought about not by the, not by what the challenges were, because that was, you know, not by what the challenges were, because that was, you know, it was all very hard, but, um, by the support, yeah, and the encouragement, and being able to engage in dialogue with the other faculty and the other people that I worked with in the service that were all willing to put up with my ramblings about things and to have like these conversations like, well, what do you think about this idea?

Speaker 2 45:52

this, this is kind of, you know, bizarre, but like, let hear me out. And to have a community of people that are curious and, you know, want to want to see things develop and emerge from our science. So I think it's about the people you surround yourself with, just like any other thing. If, if I didn't have a supportive, um, husband, family, uh, it would have been much, much harder, yeah, um. So, yeah, sanity is kept, uh, with the people that were, you know, that were around me, because I was working as a midwife per diem for two hospitals and yeah.

Speaker 1 46:32

How long did it take you to do the whole program then I?

Speaker 2 46:35

did it in four years. I graduated in 2018.

Speaker 1 46:39

That's impressive. How did you celebrate when it was all done? How did you celebrate?

Speaker 2 46:47

Good question. So my parents came to town and we went out to dinner and just had a nice time and my dad had handed me a brochure and a check and the brochure was a brochure for a Hawaiian vacation oh nice. And a check to take that vacation. Because we had not taken a vacation and you know I don't remember how long and so we had we put that money aside. Ok, we'll do that, we promise we'll do that. And then it didn't quite happen that year. And then the next year, March of 2020, we were about to get on a plane like literally the next morning, oh nice, the stay-at-home order came. So we didn't actually get to celebrate until March of 2022. Yep, After I'd been working postdoctorally for four years. So it was a delayed gratification. It was an amazing trip, oh my gosh, yeah.

Speaker 1 47:57

Yeah, I think anywhere after COVID I think kind of enhanced the enjoyment factor of moving out of your area.

Speaker 2 48:04

Yeah, yeah, we realised we hadn't taken like a true like vacation, like to not do anything. That was like no real agenda in 11 years. Wow, it was. It was needed certainly so.

The MUM Lab Research Projects

Speaker 1 48:18

when did you start your mum lab mechanisms underpinning maternal health? So was that started during that four years or kind of like only more recently, because you've got lots of things on it. You've been an amazing research team and I love the fact that you've involved so many undergraduates as kind of research assistants as well.

Speaker 2 48:41

It's been amazing. So the roots of that were sort of percolating in the four years that I spent at Oregon Health and Science. After graduation. I stayed there and worked as an assistant professor for four years and was funded to do some kind of groundwork in the next phases of the research program and through some funding opportunities and whatnot, I had the chance to interview and check out different places to work maybe places that had a little more sunshine than the drizzly Pacific Northwest and interviewed at the University of Arizona in Tucson and felt like it was a fantastic fit and it's sunny here every day.

Speaker 2 49:28

So I we took a, we took a leap and moved here and I had to come up with like a way to like orient this idea in this lab and like what would? What did we want to call it? And tried out a number of different things but eventually landed on the idea that it was the mum lab. So, mum's, you know biology, know biology, physiology, and it's about mechanisms, and I think of mechanisms as very broad, yes, um, from the molecular to the system and the care provided.

Speaker 2 49:59

Because those are all things that direct the physiology of, of childbirth.

Speaker 1 50:07

So you've got quite a few current projects that are going, which is, one's looking at the receptors and your PPH and you're looking at one for maternal age and looking at what is biological age. So and that one, I think I read something where, with that one, that 35 is seen as geriatric or advanced age. I hate the word geriatric, the 35. But I think I read somewhere that not there are younger people coming through with comorbidities, but there's quite a few women who are over 35 and birthing people who are over 35 that have no problems and yet we automatically assume we put them into the higher risk just because of the age, not because of looking once again at the whole package.

Speaker 2 51:02

So where are you going in that area to be able to run what's called the EPIC array, which is a molecular assessment of DNA methylation across the I think it's like 850,000 sites in the genome. So we're looking at DNA methylation patterns across that and then we'll be running a number of different epigenetic clocks, which is sort of an assessment of certain sites across the genome that are either methylated or unmethylated and those are associated with age and people can be spot on. Like your methylome looks exactly like what we would predict based on age, and some people might have an epigenetic pattern that is accelerated in terms of age, is a little bit ahead of where we would expect, and vice versa. So there may be people who, like we all know, people who are, you know, 35 and have comorbidities and appear extremely aged, you know, looking more, you know, much, much older. And on the flip side, we know 90 year olds who are running marathons and, you know, have few people's, you know. So there's clearly um, uh, let's say, a trajectory upon which we age and there's sort of this assumption that it only happens in older life but it actually starts from conception. Like the epigenetic patterns are starting to be formed at that time, and so the epigenetic clock kind of starts during fertilization and the initial setup of the methylome at that time, and then it takes off, and so that's where some of your intergenerational pieces might come in. So if the egg that's producing you has been on the planet for 15 years versus 45 years, that egg might have a slightly different way of being. So it sets up the next steps. So what we'll be doing is very shortly actually the research coordinators on our team are preparing the plates to go to the core lab so we'll be able to see the epigenetic patterns and then put those in context with the childbirth outcomes and some of the context of the pregnancy health as well.

Body Temperature and Labor Prediction

Speaker 2 53:22

So things that are more associated with age-related decline, metabolic, cardiometabolic diseases. I'm very interested in the trajectory of labor. Why do some people labor smoothly and that seems to be associated with a greater age, that with a higher age the more difficult labor can be, but not everyone. I've certainly attended births of 40-year-olds that had zero problems, and I've attended births of people who were 22 and had a labor distortion and couldn't get through it. So maybe there's something there, and if we knew better what the age, the biological age of someone was, then maybe, eventually, we could design ways to better screen and provide enhanced care for people that were biologically aged but only 28. So and then, another piece of this is that we want to look at how the context of people's lives so their burden of social adversity, the, you know, the stress and strain on the body and that experiences how does that impact the phenomenon of biological aging, or, like the weathering phenomenon that some people have talked about?

Speaker 1 54:35

so the whole crux of it, though, is really it's not the number of years on the planet, but it's the quality of the life lived so we're recognizing some of that when we look at the ace, the adverse experiences that's now come in as part of the quality of life and kind of like. When we do the postnatal screening, we're actually asking about those experiences because we know they do have impacts onto health because of that whole social determinants kind of connection.

Speaker 2 55:05

Yeah, so we'll be looking at that score actually the ACEs score in context of biological age and then childbirth. You know difficulties.

Speaker 1 55:13

Okay, this might be a really kind of way out there question Do you think there could be a relationship with the length of telomeres as well? Because that was looking at the aging process and the breakdown of the DNA. So do you think there could be a correlation?

Speaker 2 55:32

Yeah, I actually think there is. So it's different measures of aging. One is looking at the you know kind of the programming of the DNA to either be transcribed or not, and so that you know triggers, different genes to turn on or not, or to be more expressed differentially, whereas when you run out of telomeres your cells just stop replicating. So you know, I am certain that those two things I actually could probably pull up a study or two than my database here that I've looked at kind of the telomere age and the epigenetic age and to show that those two things kind of run together. The question, though, is that the which comes first yeah, is it, you know, is is the speed of of cell turnover driven by dna methylation, or is is that like an artifact of? You know changes in the methylome, so that might be harder to tease out, unless you're doing it in a cell culture. You know to be able to, like, control one of those things or another, um, but it's all related, right.

Speaker 1 56:34

It's like, basically, your body moves along a trajectory and it speeds up and slows down at various time points in one's life, and some of those things are going to show up biologically it's really kind of it's projecting a really interesting future of health care, which I know we've kind of got some scary, and I'm thinking of the moon um gadiga, I think, which was very much around health and dna. But it could be if used in the right way, because we know that technology can be used by both sides. It's a double-edged sword. But to have such a personalized care and also looking at microbe um gut microbe as well, when you put all of this stuff that's actually happening, that we can test about a person and sit there and not just look at health dna but kind of look at what the receptors are doing, what the projections is, what can we change? Some of the stuff we can't necessarily change, but we can prepare for things. That is actually quite exciting for the next kind of like 10 years or so.

Speaker 2 57:39

Yeah, I think so. I mean, certainly people are trying. They're using DNA methylation for cancer detection, for gosh. I think I saw this on a TV show that they were using DNA methylation to try to get the age of a suspect in, like a murder scene or something, so like it's clearly like the idea that the methylation in the DNA is informative. Yep, it's just a matter of what do you do with that information? Yes, how do you make it useful? How do you make it help the people who need it the most?

Speaker 2 58:16

There's certainly kind of a niche, direct-to-consumer market for selling your biological age test kits to people with the idea that you can reverse the aging process.

Speaker 2 58:29

I don't know if that's true. That sounds like a way to part with money, but you know, maybe there is some truth to certain interventions or certain um, you know whether it's nutritional or you know stress management and those types of things, and maybe that empowers people to look at their lives in a way that is different than feeling like you're I don't know out of control of everything. I don't know. I think you could go either way. Some people might feel fatal to sick If you found out you were you know, if I did my epigenetic age and it said I'm, you know, 62, I might, I might have a different feeling about the next five years, but, um, you know, what do you do with that? Information is always the question. So right right now, I am trying not to skip too far ahead, at least on the biological aging, and to try to just understand if it's at all related to some of these phenomenon that we're studying and it all comes back to social equity as well of entirely have this.

Speaker 1 59:28

It's not going to be available to everyone.

Speaker 2 59:29

Yeah, and and the ethics right, the ethics of what do you, how do you not discriminate? If you knew someone, were you not going to improve them for insurance if you knew that their, their you know biological timeline was different?

Speaker 1 59:43

and that's a whole other issue, especially with the way that health care is in your country, which confuses the hell out of me. Um, me too, and I'm just so, I'm just so glad that we've got a different system here. Well, and the other program, the other, one of the other studies that I was reading that I was quite fascinated about, because it was the body temperature and anticipating the onset of labour, and you were using one of those smart rings to measure, so something that's. Once again, it does come to social equity. You've got to have the money to buy it, but it is something that is fairly easy to provide and I know it's still kind of like modelling terms of it. But what was the outcome of that that you think might be applicable in the future?

Speaker 2 1:00:33

Yeah, that's a great question. This has been like a pet side project since 2018. That is finally like coming to fruition in a lot of ways and we're getting some additional funding to be able to do a broader study of this. But so how to explain if, right now, right, we have a due date for people, we give them a 40 week due date, which is fairly meaningless, and we say, well, labor could start anytime, but here's your duty. And so everyone hangs their hat on this 40 weeks. And then if the baby comes early quote unquote then it's like, oh, what a surprise, the baby came early.

Speaker 2 1:01:16

But I think it would be really interesting to reframe this and to say when the baby is ready, the baby will come, and that might not be till 41 weeks, or maybe it's 38. And for some people, there's real consequences if we aren't able to anticipate when that labor could happen, or when that baby seems to be signaling that it's ready, or that the body you know, maternal body is ready. And, you know, in the context of spontaneous preterm birth, or for people that are really wishing they, you know, would like their labor to start on its own, but if they're on a trajectory for a 44 week onset of labor. You know that's information that they might want to have versus it'll probably start between 40 and 41. And so let's just be patient, right?

Speaker 2 1:02:04

And in the US there's people who have to travel quite a bit of a distance to get to a hospital. Now we have whole regions that are what we call maternal care deserts, so you're driving an hour or two hours to get to the hospital. If you want to be back, you've got to travel even further sometimes. So people are, you know, showing up at emergency rooms ill-equipped for births. They're delivering at home despite not wanting to be there.

Speaker 2 1:02:31

You know, it's one thing if you're choosing it, but so all of those consequences I think are real for people. In addition to, maybe we would better handle the trend of induction if we knew how to anticipate when labor might start. Right now I feel like our shift to pushing everyone to have a labor induction well before the due date is because we have this uncertainty of when labor will start. But if we had an idea, then maybe we would feel a little bit more calm about the fact that someone who's completely healthy could probably wait another week and their labor stay would be shorter. Their recovery might be, might be faster if they especially if they don't end up with a C-section. You know it, it remains to be seen, but it's a testable hypothesis at least.

Speaker 2 1:03:19

And so we've developed this algorithm based off of skin temperature from the smart rings, and um it was um it. It worked fairly well in the small sample that we tested it in. So now we're going to test it in a bigger sample with people who are at risk for preterm labor and then among a population who's hoping for a physiologic birth in like a birth center setting. So we have a good chance of not having a ton of inductions, and so we're going to start enrolling for that study in the next month, I think and yeah, so hopefully we'll.

Speaker 2 1:03:52

We'll see where it goes from there, but I envision a way like these devices yes, they're sold for several hundred dollars, but the technology and the bones of it are not that expensive. They could, we could develop this at scale to make it much more accessible or affordable, or put it into some other format, like a rental, that would allow people some insight into their physiology. And you know, there's a lot of data that's being collected by these rings and these devices that I think could be informative for understanding changes in physiology and pregnancy understanding changes in physiology and pregnancy.

Speaker 1 1:04:31

That's, that's thanks. And especially using, like you've got, the deep learning models, when used in the right way, are quite a good tool. When used without governance, um well, lazy and dangerous, as is happening in a lot of places yeah, just like almost any tool, right, you can be used for good or or for evil.

Speaker 2 1:04:53

Um, I I think that if we had a good way of predicting when labor would start, across human history like, we would have figured it out by now. Yes, um, and using a simple, seemingly simple idea of body temperature. Um, it works in mammals, but mammals are more simplistic in terms of their reproductive you know, I don't know trajectory and expectations, and so you know the body temperature changes works in a lot of mammals to be able to predict parturition, but in humans, because we have all of these intertwined physiologic mechanisms and kind of redundant pathways to make sure that humans get born, it's not as straightforward. It's not like you can pee on a stick and be like I'm going to give birth tomorrow. It doesn't work that way and that's why we have so much variation and so much uncertainty and like second guessing of what we should do.

Speaker 2 1:05:50

So I think this is an application where we need some advanced intelligence to get outside of the human, like linear thinking and say, because that's what the deep learning models do, is it takes we're measuring temperature every minute across many, many months in pregnancy, so that's a lot of data. The deep learning models can look at all of that complexity, across all of the different dimensions of temperature change from day to night, from minute to minute, from day to day, from three days to three days, you know, like all of these different patterns that emerge, and to find ones that are significant for kind of impending forecasts of labor, starting that shift in, whether it's progesterone, estrogen, you know, estrogen dominance or a cortisol change, that are all going to be reflected in body temperature, but in nuanced ways. So I think, in situations like this, where, like humans haven't figured it out, then maybe AI can.

Speaker 1 1:06:48

Definitely a good partnership. Is there anything else that you're excited about?

Future of Personalized Birth Care

Speaker 2 1:06:51

that you've got projects coming up that you're excited about getting into finishing starting well so I mean, like the oxytocin research is is in our entering our third year of um, an neh funded study. We have um, um, three, two, three, four, three years left. Um, and knock on wood quick that that will get funded. Um, it has to be. Yes, we're, we're, everyone's been on pins and needles and so, um, you know it's supposed to be a non-competitive renewal for funding in later this this spring. So I'm hopeful.

Speaker 2 1:07:32

But we've been collecting salivary DNA to assess the oxytocin receptor genetics and epigenetics and in a subset of people we're also looking at a little piece of myometrial tissue that's collected during a plan cesarean, from the top edge of the incision, and we study that in the lab using myography and we'll be doing gene expression and trying to get at some of that desensitization and figuring out if it's driven in part by some of the methylation or the genetic factors. So we've made a ton of progress. We've collected over 600 DNA specimens already. So we're getting close to the end of that and I'm really excited to be able to move that to the next phase where we're going to start genotyping. We're going to start putting all the pieces of the puzzle together, none of which would be possible, by the way, without that big team of people that you see on that website, because they all do the day to day, you know, figuring it all out, and I'm trying to just herd the cats, which is an important job, a very important job.

Speaker 2 1:08:40

So that that's coming forth. Hopefully, in the next few years we'll have some like big data to show. And then, yeah, we're launching that new study to validate our algorithm. So between all of that, it's quite a bit. Keeps us pretty busy.

Speaker 1 1:08:59

Excellent. It is exciting stuff. I mean the personalized care and I know that in cancer treatment and oncology personalized treatment with looking at dna has been a such a big kind of boost as opposed to let's just fill you up with poisons and hope something works. That personalized care has been so beneficial for a lot of people. So seeing that applied and transferred into other areas and especially within, to pregnancy and laboring and birth, is um, I find that exciting I'm excited by it.

Speaker 2 1:09:34

I I hope it works right, like I mean we're. I, I have hope, I have belief that it's um, it's grounded in in real data and I think I think we're um, we're hopeful, we're going to learn a lot. Um, you know, science is a process and sometimes it's two steps forward, one step back, but I'm um, I know that we're going to, we're going to learn something important. Um, it's just like when any phase of research, I think, you start off in one direction and you're always going to take a slight turn or you're going to pivot a little bit because of something that presents itself.

Speaker 2 1:10:11

So, but if we're right and it works and we're able to better predict hemorrhage or better able to predict people who are insensitive to oxytocin, then you know the next phase would be a clinical trial of okay, if you, as a midwife, had this information about this person's not being very likely to respond to oxytocin, what would we do differently? And so that's a really exciting phase of thinking about. Well, you know, being careful about how you apply screening tools and information and monitoring and all of that, and knowing that we've made mistakes in the past. Keeping all of that in mind, how do you take new technology, new innovation and tools and actually apply it to the best situations possible. So I would love to see a world where we have standards of care for safety but we have individualized and personalized approaches, that's informed by biomarkers, physiology, personal preference, you know beliefs, goals, plans, all of those things, and we can take that all into account. Yeah, I'd like to see that be tried and tested.

Speaker 1 1:11:23

Well, watch this space, because we will in a few years. I hope so. Thank you very much for your time.

Speaker 2 1:11:32

Thank you for having me. It's been lovely.