An OB Scientist’s Caution on the VBAC Calculator and Informed Consent with Dr. Nicholas Rubashkin MD PhD

Nick Rubashkin : We just need to broadcast society wide to really make sure that we stamp out this pernicious, racist idea that the [VBAC] calculator propagated that Black and Hispanic bodies were less capable of giving vaginal birth.

Jen Kamel: Hello, hello, and welcome to The VBAC Facts® Podcast. I'm Jen Kamel, VBAC Facts® founder. And since 2007, our focus has been to share accurate and objective information on vaginal birth after cesarean, VBAC, and repeat cesarean to parents, professionals, policy makers and the court.

Today, I am thrilled to have Nicholas Rubashkin, MD, PhD. Nick is an associate professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences at UC San Francisco where he works as an obstetric hospitalist. He holds a PhD in Global Health Sciences, also from UCSF. In his clinical practice, research, and advocacy, he seeks to address the social, cultural, and economic drivers of poor quality care and mistreatment of women and pregnant people in birth facilities.

He has published on such topics as informal cash payments, uterine fundal pressure, and obstetric violence. His dissertation research examined the ways in which a race adjusted clinical algorithm called a vaginal birth after cesarean (VBAC) calculator reproduced racism in US maternity care. Since 2022, he has been a Women's Reproductive Health Research Scholar at UCSF conducting NIH funded research on equitable access to VBAC in California. Welcome, Nick. I am so excited you're here with us today.

Nick Rubashkin : I'm really excited to be talking with you today about the VBAC calculator and wherever it takes us.

Jen Kamel: I know, you know, during our pre-interview we came up with over 40 questions. And I couldn't help myself. I emailed my readers to see if they had any questions and they had a few more to ask. So this is going to be

Nick Rubashkin : Oh, fantastic.

Jen Kamel: such a comprehensive conversation. I'd love to start with learning more about your background and how you came to focus on the VBAC calculator for your dissertation.

His Training and Background

Nick Rubashkin : Yeah, I know that when we were talking earlier, you, had asked some about my training and how VBAC was dealt with in my training. So I think I'll start there.

Jen Kamel: Sure.

Nick Rubashkin : I've generally, in medical school and in residency, trained in environments that are VBAC friendly, and that VBAC was at least available. Institutions had, I think what I would now see as, relatively high VBAC rates comparatively.

That said, VBAC wasn't really super on my radar as a medical student. Then I did residency at University of California, San Francisco. I would say I knew that it was a supported option. It was just a routine part of my training.

And when I got out into clinical practice, I worked in a community hospital, that at that time was the only hospital in San Francisco that didn't offer VBAC. They had recently been acquired by another health system and had been required by that new owner to stop providing VBAC because the model at that time was that the anesthesiologists and the obstetricians were required to be in house. Even then I would say that I believed as a provider in that practice VBAC was still accessible to our patients in terms of they could transfer to other locations in the geographically small area of San Francisco.

I've since had that belief challenged by a researcher who conducted a study at our hospital that showed especially that our Spanish speaking patients had a series of barriers and transferring out. We served probably, you know, 50 percent publicly insured population, many of which were monolingual Spanish speakers, and so that was like a bit of a light bulb turn on in terms of how important it is to have VBAC accessible at every birth facility, which I think we'll get to possibly in this discussion.

Around this same time I really became galvanized around choices in childbirth and in the global context. And so I started to bring myself into research in this area, broadly looking at choices in childbirth. And that was around home birth and birth center and different choices available in the hospital or not. And became engaged with these global discussions on these topics. And through those discussions, I think became aware for the first time of Rinat Dray's case in New York City of her being forced to have a c section when she had sought a VBAC.

And so that was kind of like the first kind of memorable lightbulb around the politics of VBAC tied to the politics of choices in childbirth in general. And so, I dedicated myself for a few years to various ways of measuring informed consent in childbirth, leading up to the dissertation, which eventually settled on studying how the VBAC calculator was invented and implemented. Really brought a lens of knowing that we were doing research and practicing in an environment in the United States where access to VBAC was severely restricted for many birthing people and that the fulfilling informed consent around VBAC was already challenging.

That's kind of the practical clinical aspects that I brought leading up to studying the VBAC calculator and the knowledge around the context of it. And knowing that myself as a provider had restrictions on my ability to provide full spectrum care, but still had to have deep experience discussing with birthing people, their options.

And I will say, one thing that we brought up in our earlier conversation is that I was primarily trained that the counseling around VBAC was one about risk. That it was about talking about the risk of uterine rupture. Balanced against the risk of quote unquote failure, or of having success, and that as a resident, I really remember that being kind of drilled into me that those were the two predominant risks to discuss and I will say that that is a piece of how the VBAC calculator was trying to answer a particular problem that obstetricians are trained to do in our counseling.

Jen Kamel: So, when you went to medical school, the attitude towards VBAC was favorable, and that's how it was positioned in your training.

Nick Rubashkin : I finished medical school in 2004, and I think that's right when VBAC rates were reaching their lowest. But I was at a place that still offered it, because they had all the in house resources. Then in residency training in the mid 2000s, I was still training at a place where VBAC, even retrospectively, was still accessible, even though the national VBAC rate was really reaching a particular low.

It was in that training that we were trained to really talk about the risk of uterine rupture and the chances of having a successful VBAC, or the chance of failure, quote unquote, using these terms, a little bit ironically and critically.

I've changed over time as a result of doing research and being in this practice space for longer. Talking about risk related to VBAC and repeat cesarean is just one piece of the conversation. And I think sometimes is treated as the only piece of the conversation. I think that one place that we could work toward moving is, having these conversations really being more about being goal oriented conversations, by which I mean:

What kind of birth do you want? How big a family do you want? What was hard for you about the last birth? What would you want to be different about this next birth?

All of those things that I've honestly picked up through, I think, other wise providers that I've had lucky, be trained by and had the fortune to be influenced by. But also through interviewing and really listening to a cohort of women who I was fortunate enough to have participated in my research has helped me see how I was trained to talk about these risks, is really different than having a goal oriented conversation.

Jen Kamel: Yeah, yeah. Do you attend births right now?

Nick Rubashkin : I do attend births right now. I work only though as a hospitalist, so I work only in the inpatient setting, and that is because I spend the majority of my time doing research on this topic.

Jen Kamel: Okay. Do you recall the moment, was there a moment when you just thought, "okay, VBAC is the thing I'm going to focus on in terms of my dissertation?" What did that moment look like, or how did you come to be in that place?

How He Decided to Study the VBAC Calculator

Jen Kamel: Well, I had two dissertation advisers. One who was looking at trying to improve shared decision making VBAC. And another one who has participated in some criticisms of obstetrics from a social science perspective. And so it was hammering out dissertations and ideas with these two people that I think, you start a dissertation topic on just a bit of a hunch, and also "I've got the right experts to advise me in this area." So it was a combination.

Nick Rubashkin : I had the right team of mentors. I had a hunch that there's a lot of issues that I find really compelling around choice and power and the history and culture of obstetrics that all come to bear on VBAC in this moment. And I wanted to do something new and hopefully relevant in my dissertation. And I think that still stands, and not tout my contribution, it's a humble contribution, but nonetheless it's still the only study where a research team has actually inquired from users, clients, patients, what are their thoughts on VBAC prediction tools? So I wanted to make an original contribution as well.

I will say that the field had not yet been transformed by the real true social movement that reframed race as a risk factor in these models from not race but racism. And so I was transformed by that movement through the course of the research, as were so many people in my research ecosystem.

I had a hunch that there was difficulties that the calculator could possibly create based on my prior knowledge about the politics of VBAC. But I myself impacted by the powerful reframing around this issue. So I would say that it wasn't an immediate top of mind when I settled on the topic of studying the race adjusted algorithm.

Is VBAC a Political Issue?

Jen Kamel: You know, you've mentioned the politics of VBAC a couple times, and it makes me think of the recent decisions of the Trump administration to limit funding for grant proposals that mention words like female, pregnant persons, racism, and I have a couple different questions. One, you've talked about the politics of VBAC, but I just want to ask you pointedly, do you consider VBAC to be a political issue?

Nick Rubashkin : I mean, it's political in the sense that I think of that famous feminist truism, that the personal is political. That it strikes at the heart of core aspects of reproductive autonomy and therefore is political to people because it brings up some of the most personal issues around deciding how and when and where to give birth. But not just for individuals, for their families, for their support networks. And the VBAC calculator, it raised important issues about how entire groups of people, were treated fairly or unfairly in our health system.

So that, to me, quickly goes from what's personally political to how certain choices are deemed valid or invalid by providers or by the health system, how certain bodies are deemed functional or not functional. These really strike out some of the most significant ways that issues of power, meaning whose lives and births are valued in modern obstetrics, and whose births and lives are not valued. So I think that VBAC is really a prime example of how almost paradigmatic really, of how political birth choices are. And I'm not saying that I think that we need to be wide eyed about the politics of it so that we can try to better address I think the true issues that are happening around power.

New Limitations on Research Grants

Jen Kamel: And would these new limitations on grant proposal funding, would this impact the research that you have done in the past and perhaps intend to do in the future?

Nick Rubashkin : I am nervous. I can't comment. I can't comment because right now I just don't know. I can say that I am federally funded to examine issues related to VBAC and health equity and my interests are really to increase access to VBAC for everyone, but also specifically focusing on people who are experiencing racism and the most significant barriers to VBAC, which could include a variety of things because there's people who are encountering barriers and not everybody has the resources to navigate those barriers.

So I'm really interested in solutions that will hopefully impact everyone, but also the people who are most in need. Those are my goals and my values that underlie the research.

I currently am nervous, but I have, I can share that I have not received any specific news yet. So that's where I'm at right now.

Jen Kamel: Well, I am grateful to hear that. You know, it was funny that between the time that you submitted your bio and today when I read it, I read it through new eyes seeing NIH funded work. Because as we know funding to the NIH is being cut. So I think it's important for listeners to consider all the ways that how we vote impacts our personal lives. And this is just one example how these decisions that the federal administration is making will impact research, potentially, for years to come and research that directly impacts us all whether we're looking at childbirth in general or VBAC, repeat cesarean, a serious obstetrical conditions like placenta accreta, so like you said, the personal is political, and this is just another example.

When we say something is political, people think, well is it conservative or is it liberal? This is an issue that impacts us all and it is all of our obligations to be aware of how these decisions that we make can trickle down in ways that we've never even anticipated. So I appreciate you commenting on that.

Nick Rubashkin : If I may say also, I appreciate having this podcast because I think that as federally funded scientists, it's important for us to be communicating with the public perhaps better than we have done about what the relevance of our scientific work is to the public. I thank you for having a venue like this to be able to do that as a scientist.

Jen Kamel: Absolutely. I mean, so much of the work that we do is centered around the research and so when I saw that announcement, I think it was last week, I mean, it is striking where I did hear about that new decision and where I didn't. And I think a lot of people have no idea that that is happening. So I just want to make sure that people know, so we can voice how we feel about that.

The Many VBAC Calculators

Jen Kamel: So knowing that there are several different types of the VBAC calculator, and I think that's something that, you know, I think my readers are pretty familiar with that concept because in the times when I've talked about it, I have articles up on the website. We have a whole episode on the podcast on the VBAC calculator. People understand that there are a variety of different models. So how did you decide what version, what model of the VBAC calculator to focus on and why?

Nick Rubashkin : Yeah, your readers are informed and sophisticated, I would say, in terms of knowing that the VBAC prediction spaces is broader and more varied. I chose to focus on the prenatal version of the VBAC calculator because that was the one that was really most predominantly in use and had become the most popular one, for lack of a better word.

It's interesting, I think, to think about why that one version rose to prominence. I think it's also a question you're asking because it was a heterogeneous scientific space in that for beginning in about the nineties, multiple scientific groups were working on trying to use statistical models to predict the chances for a VBAC. And they were doing that with various combinations of risk factors which will be familiar to your readers and users of the calculator.

So often they come down to things that are individual risk factors, if you will, like body mass index, age, indication for the prior C section. And so there's a lot of scientific groups who are doing different combinations of these things to see, and then test, the statistical probabilities of combining these factors in various ways to see whether we can look at the percent chance of having a VBAC.

Amidst those different scientific groups, the particular group, the Maternal Fetal Medicine Units group, is a large research network in obstetrics. Basically in looking at this question of "can you predict VBAC," on the way to producing the prenatal version of the VBAC calculator, basically had the largest research group to study this group of patients and one of the best designed research databases. So they had the largest group and the biggest prospective group to look at this question of predicting VBAC.

Their study still has a lot of weight in the scientific literature because it was the largest and best designed. So I think that was really one of the reasons that it crowded out the field and inched ahead.

But it did actually have a lesser known peer, the Flamm model. Do you know the Flamm model? So it came from a Kaiser dataset, also large, also prospective, well designed. The Flamm model required variables that were only known when somebody presented in labor. Behind developing a VBAC calculator is to get the earliest prediction possible to help patients make more informed decisions before labor starts.

Because the prenatal version of the MFMU calculator used factors that were known as early as the first prenatal visit, the idea in designing it was that was the best and most relevant kind of design because it could help people make the earliest decision.

And I think it inched forward or crowded out the Flamm model, which is actually available on the internet in some of the med calculator sites, but nobody knows about on the ground. So because it was the biggest, the best, and the earliest are the three big reasons that then the VBAC calculator got written into national guidelines in 2010.

How to Define Uterine Rupture

Jen Kamel: And so you used a word that I want to make sure our audience is clear on. You used the word prospective. Can you talk to us a little bit about why you would want a prospective versus a retrospective study? What's the difference and why is one better than the other?

Nick Rubashkin : Yeah, so my recollection of the MFMU's papers that derived from this cohort. They basically assembled this prospective cohort in the late 1990s and early 2000s. Prospective means that you, in real time, are gathering data using employed research staff to make sure that you're ascertaining the highest quality data in that moment. So you don't have to then go back to a medical record and be like, "What happened during this time? Are we actually capturing what we sought out to capture?"

So again, I wasn't part of the original structuring of this data set, nor employed or around at that time, but I think what they were trying to do as a contribution actually, the more knowledge about VBAC in particular, was that they were using a new rigorous prospective definition around uterine rupture.

Race as a Risk Factor

Nick Rubashkin : And this was like a big debate in the VBAC literature in the 90s and 2000s was it a uterine rupture or was it a just a dehiscence? And the MFMU actually, as a contribution really, with a rigorous definition that they applied in real time fashion were able to settle some debates around what is the true prevalence, or rate of occurrence, of a solid research definition of uterine rupture.

That data set was the same data set that employed race as a risk factor. The original data set that was used to make the calculator had a variety of insights. I think some were helpful in resolving certain debates about VBAC and then some that were ultimately harmful.

Jen Kamel: And so prospective versus retrospective. Prospective means you're collecting data in the moment and analyzing it. Versus retrospective, can you just tell our audience briefly what does that mean? So when they hear the words they know.

Nick Rubashkin : Retrospective data is that you're going back after the fact to try to determine what happened. Whereas prospective, you're doing it pretty much in real time. In the hierarchy of evidence, retrospective data is accorded less because of the potential for error, basically fundamental error in the data you're gathering.

Prospective is considered higher up in the data rigor ladder and therefore, to bring it back around to VBAC prediction tools, many of the early VBAC prediction tools were developed off of retrospective data. And the VBAC calculator was was developed from this prospective data cohort.

The Power of Lived Experience in Research

Jen Kamel: Okay, so can you tell us a little bit about the questions your research asked and who you talked to to find the answers?

Nick Rubashkin : Yeah, so I am, in my dissertation was getting training in really the history and anthropology of obstetrics, including particularly the feminist and anti racist critiques of obstetrics, really trying to understand how issues around scientific and clinical authority have played out around science. Power struggles around gender and race and obstetrics. And so I'd done a lot of deep reading in that and writing and summarizing prior to taking on this project of the VBAC calculator. I conducted an ethnographic evaluation of the VBAC calculator.

My job was really to follow, to understand, on one hand, how the scientists who made the VBAC calculator, how they understood themselves and what they thought was beneficial about having a VBAC calculator out in the world. And I followed the VBAC calculator, it's in some ways like investigative journalism, my job was to follow the VBAC calculator wherever it went to understand who touched it, and who changed it, and how it was modified and ultimately what its impact was particularly as hospitals, providers, and patients began to interact with the technology.

I think that I was really interested to explore how the upstream scientific decisions affected the downstream clinical practice. How those upstream scientific decisions included or excluded the voices of patients.

Ethnography is I think this beautiful method where through interviews you bring diverse voices into kind of the scientific process.

I think one of my true biggest goals was: What does it look like when we bring the people who are most impacted or supposed to most benefit from this VBAC calculator? Not only asking them, what's your reaction to this? But how is this useful to you? Or how can your perspective reveal to us some fundamental flaws or assumptions that were not clear to us.

It's Not Race, It's Racism

Jen Kamel: What were the most surprising findings you uncovered in your research?

Nick Rubashkin : I think that it's an important to realize just how normal it had become to researchers and clinicians to include race in multiple predictive algorithms. And it should be noted that the way that race was included, based on the structure of that dataset that I described from the 1990s and 2000s, was considered state of the art science. That it was NIH funded, it was following NIH protocols, and that was the dominant paradigm in place at the time. And it wasn't until through scholars and activists, who really powerfully reframed this, "it's not race, it's racism" as the risk factor.

Over the last, or toward the end of the, or late 2010s, early 2020s that I saw that paradigm shift happen through the course of my data collection and I think that was very surprising to see a paradigm upended. To see a huge shift like that to go from something that seemed very normal to something that by the time I was finishing the research, the calculator was being actively revised to remove race.

I analyze the calculator at the level science, if you will, of it was conceived, why a group of people thought it was beneficial to how it got translated into national guidelines. There were many fingerprints were on the calculator, right? In terms of how it passed through ACOG, how it ultimately got written into hospital protocols, how residents were trained.

I started your question based on where my inquiry started, which was how were these upstream scientific decisions made? And then, we might get to what the downstream consequences of some of those were.

How Race & Racism Were Built Into the Calculator

Jen Kamel: Well, and you had mentioned how the VBAC calculator was based on this data set, but can you tell us specifically how race and racism got built into the calculator? What did that actually look like?

Nick Rubashkin : I did look at the original kind of like data abstraction tools and it used a question about race and ethnicity that was based on census categories that were prevalent at the time of that data collection. So that's how the data was gathered. How the data was analyzed in the 2007 publication, that eventually became the VBAC calculator, was that Black race and Hispanic ethnicity were found to be associated with a lower chance of VBAC.

The VBAC calculator had a very particular construction of race in that you could not be Afro Latina in the calculator. They analyze the statistical categories separately and also, they compared them to everybody else, White, Native American, Asian folks were compared against Black and Latinx folks, and that had some consequences for people as how it was applied on the clinical level too. So it had a very particular construction of race in that there were mutually exclusive categories that you could only be Black, only be Hispanic, or only be White slash other which encompassed Native American and Asian folks.

Race & Ethnicity Removed from the VBAC Calculator

Jen Kamel: So how was it ultimately removed from the VBAC calculator? How was race and ethnicity ultimately removed?

Nick Rubashkin : So I talked to researchers in the MFMU and also researchers who were involved in different ways of statistically validating the VBAC prediction models. And by the time I started interviewing them, the inclusion of race in the calculator was not controversial at that time. And so this was just before these broader discussions started to happen around the inclusion of race and ethnicity in these models.

Because I interviewed people early in the process I'm surmising that it really was the societal and scientific pressure to revise these models that led to the removal of race and ethnicity from, ultimately from, the version of the VBAC calculator that's out now.

Jen Kamel: So the research found lower VBAC odds among Black and Latinx people. And so the assumption was, what was behind those lower VBAC odds? Was there any sort of analysis or critique on what could have been happening there before they acknowledged the impact that racism could have played in those labors?

Nick Rubashkin : What I conclude in doing interviews and close readings of the scientific papers and scientific ecosystem of that time is that it had just become so normal to publish studies that said race is associated with X, that it was a finding that no longer required any explanation.

And I'm not trying to absolve the researchers in this sense, because there were also other VBAC prediction tools and papers that found race was associated with a lesser chance of a VBAC.

So I think what you're getting at in this question also is that what's interesting about how scientific racism works in our era is versus past eras is that, saying that these population risk factors, namely here race as this idea of a population risk factor, is associated with a poor outcome felt, it became so normal, but it also felt less racist than saying people's bodies were different.

Which is to say that you could be a scientist working on a race adjusted tool like the VBAC calculator, you could be a clinician using this tool, and you didn't necessarily have to hold the belief that somebody's body was deficient. We're schooled in the past scientific racism that certain bodies were actually designed differently, inferior.

A New Form of Scientific Racism

Nick Rubashkin : But the calculator I think is now recognized as a new form of scientific racism that is pernicious in a different way. You can use a tool like the calculator and not necessarily believe that bodies are different. You just have to believe that this is statistically valid and that it's actually evidence.

So people would say they adopted the calculator because they knew it was a reputable evidence source that produced it because it was in ACOG guidelines because my hospital quality director said, all of these things that are tied together, it had a stamp of approval as being an evidence based tool. It's the way that scientific racism has gotten wrapped up with evidence based medicine is more how the calculator traveled from a scientific journal to the bedside.

Removing Race, Problems Remain

Jen Kamel: So what is the legacy of including race in the VBAC calculator? How does it continue to impact care? Because people might say, "Well, it's no longer in the VBAC calculator. Race and ethnicity have been removed. So now this issue is fixed." Is that true?

Nick Rubashkin : I think that removing race from the calculator most certainly will mitigate the most negative immediate impacts that the calculator had. In interviewing providers now post removal, many of them are aware that it was removed, and they report using the new one.

That said I think that we know from just the history of racism in medicine, that it can be really hard to totally shift or stamp out racist ideas that certain bodies are more capable than other bodies at giving birth.

And one thing in particular that I found was that as providers got more familiar with using the calculator, they didn't necessarily sit down to do the calculation, because it wasn't that, complicated a calculation to do. You could often roughly do a mental calculation is what I call it, about where somebody would lie.

But that mental calculation could then also bleed into racially profiling. You would maybe not inquire about somebody's race or ethnicity, you would get their race or ethnicity from the medical record, a provider would just visually assess them right in the moment and make a mental calculation, and spit out a recommendation to this patient, "you should just schedule a repeat C section."

And all of that would happen like automatically without an explanation about the thought process from the provider. And I had this really striking interview where this one Black woman who was enrolled in my study encountered a provider who made this very automatic recommendation of "oh, you should just schedule your repeat cesarean." Not knowing that, that provider had used the calculator on her and in that visit she describes how she had to pull the factors out of the provider and she eventually got clarity that race was factoring into this recommendation.

So I still worry that the calculator could have contributed to this idea that some bodies are less capable than others and that Black and Hispanic women seeking VBACs could still be racially profiled in a way that would be hard for them to challenge their providers.

Response to VBAC Calculator Critique

Jen Kamel: So how does the creator of the VBAC calculator respond to the critique that the calculator embodies racism?

Nick Rubashkin : I can't really speak to, because I didn't interview people after removal. I think that their actions to revise the calculator speak to their effort to own up to that we need to move science forward in a better way. I think what your previous question around whether removal of race is the only thing that needed to be done raises the question of what is the responsibility of the scientific group to go even further, I think is also what you're asking.

And maybe that's not their strength and they're really statistically effective people, so maybe we need to have robust scientific ecosystems that include oriented methods that perhaps like I'm doing in order to fully address the negative effects. And not just what I'm doing, but I think that advocates such as yourself and advocacy groups in general, are trying to finally close the conversation on this when we've not just removed it, but done really broad education, broad advocacy, that we just need to broadcast society wide to really make sure that we stamp out this pernicious, racist idea that the [VBAC] calculator propagated that Black and Hispanic bodies were less capable of giving vaginal birth.

Jen Kamel: Yeah. And when you have conducted your research and talk to providers who might not be aware of the VBAC calculator, what is the best way for us to ensure that all clinicians are aware of this change so that we know, at the very least, they're not using this older model that "risks out" Black and Brown people at a much greater rate.

Nick Rubashkin : Yeah, I'm hopeful that most providers are aware of the new one. Because in interviews I do see that people know that it was the Maternal Fetal Medicine Eunice Network was where the original one was, and they know where the corrected one was. But I will say that the, the internet is a an eclectic place. And there are race adjusted versions of the VBAC calculator still floating out there. The iPhone app, and I emailed iTunes, or I guess the App Store people out there, whoever they are. Never heard back about taking down the race adjusted version. That's still, I looked at it recently, it's still there in the App Store. The race adjusted versions are still out there. So I think that a patient could ask, "What version are you using?" Being able to direct people, you probably, given the size of your audience, are able to direct people to the actual website of the MFMU so that they can ensure that the most up to date version is without race being used.

Reader Q: Validate Prior FTP Cesarean

Jen Kamel: Yeah. And I will include that in the show notes so people can easily find that. One of the things that I did in preparation for our interview is I emailed my readers and I said, "Hey, we are having a physician scientist who studies the VBAC calculator on the podcast. What questions do you have?"

So I've sprinkled them throughout our list of questions today, but readers, Amy and Amber both had similar questions about a prior failure to progress or FTP cesarean.

Amy asked, "How do we validate true failure to progress when using the calculator? Many folks change providers. And so even with an operative report, FTP is written, but hard to validate."

What would you say to reader Amy?

Nick Rubashkin : I think this is such a great question and is really a question that gets to the heart of what happens when we make certain upstream scientific decisions about what should be included in calculators and how that gets packaged and transformed and reaches a patient.

And I think that Amy's referring to the possibility that because many of these calculators include a prior c section for, quote unquote, failure to progress that that can be hard to challenge.

That c section is treated as a fact in your past. And because it's treated as a fact and flows through this calculator and prediction tool, it has this huge weight of scientific authority.

When I interviewed women, and everybody in my study identified as women, so that's why I'm using that term. In various ways, we're asking for VBAC calculators that had more nuance around their categories. This happened with every category, people would say, "Okay, I get that, that I'm of a higher age, but what does that really mean around my current physical fitness?" Or, "I get that the calculator is putting me as a higher BMI, but is that a Eurocentric standard? Tell me more about how BMI fits."

They felt like the calculators painted them in really broad strokes. And again, this is why I just love, I love how this question raises this core issue of painting things in broad strokes versus getting more individualized assessment. And it comes up in all of the factors that go into calculators and of course came up around race and ethnicity because people were like, "I identify as part White and half Hispanic and like what is what does that have to do with, where do I fit into this calculator?"

This led people to critique the calculator's racism, because they were saying, like, "How does being half Black and half White in this relate to my ability to give birth?" And that made people jump to, if this is that relevant for this calculator, it's not about biology, it's about racism. I want to tie together this question to general critiques that the women I interviewed had about calculators in general.

So to get to the failure to progress, I absolutely agree this is like a core issue of using VBAC calculators, especially in environments where C section is currently overused. And we know that there's a huge variability, hospital to hospital, about what counts as a failure to progress C section. I think that it really can be helpful as a patient to have a really clear understanding of how your labor was conducted leading up to what led to your C section for, we'll say, arrest of labor diagnosis.

I know that the calculators say failure to progress, but an arrest of labor diagnosis. So that your future provider, should you change hospital site, can get a sense of, they weren't following a short timeline, they followed some standard criteria. I think that having some knowledge about how your labor was managed and be able to say, it seemed like my providers didn't give me enough time and were not following guidelines or they did.

Swedish Study: 10cm FTP Diagnosis & Future VBAC Odds

Nick Rubashkin : Two more thoughts. I love this question about how could we design a next generation of VBAC calculators that gave more nuance around arrest of labor diagnoses. There is some data in a Swedish cohort that was not yet rolled into a VBAC calculator that looking at whether arresting labor before 10 centimeters, or arresting labor after 10 centimeters, predicted VBAC. And actually arresting after 10 centimeters, so in the pushing phase, was a higher prediction of having a future VBAC versus arresting earlier.

And I think that actually challenges some of the wisdom on the ground, at least in the United States that arrest of descent, means a more narrow pelvis and you won't be able to push your baby out next time. But there is some statistical data that says that maybe, that if you reach full dilation, that it could be a higher chance of a VBAC.

So I think there's ways that next generation calculators could maybe get more nuance around the arrest of labor. Final point on that, cause I love, do you mind if I give another point?

Jen Kamel: Please, no, no, no, please, yes.

Script for Using the Calculator

Nick Rubashkin : What's at the core of these calculators is that there, on the one hand, there are factors that could be associated with a lesser chance of success and maybe there are some true biological factors that could vary and make it more difficult to have a vaginal birth.

But it still rests on this idea that bodies are essentially fixed, like that what happens in one labor is going to happen in the next. I think what I hear from this question, and also from providers who are a little bit more sophisticated users of the VBAC calculator, they might say, "Sure, this is what this is giving us, but I hear from you that your goal might be to still try to have a vaginal birth. Let's see what we might be able to change in this next pregnancy to have a different outcome."

It's this idea of, are bodies essentially fixed or are they flexible? And could the baby be in a different position? Could the baby be smaller? Maybe you won't get chorioamnionitis and have a tired uterus. I think that the heart of this question too is a question about whether hope that the next labor could be different.

Reader Q: Psychosocial Elements of FTP

Jen Kamel: I love the study that you mentioned from Sweden because I have a question from a reader later on that I'm going to ask you that directly relates to that. But in the meantime, I had another question here from Amber who said, "How do you diagnose or how do you address failure to progress in a previous labor? Do you consider the psychosocial elements that contributed to it? In other words, it might not have been failure of the labor to progress so much as a the patient responding to something negative that stalled the labor."

What do you think about Amber's question? Because you know, when we talk about failure to progress, it's so fixated on "this is how dilated you were for so many hours, and therefore you're failure to progress" without taking into consideration what could have contributed to that failure to progress, such as the psychosocial situation at the time.

Nick Rubashkin : Absolutely. And I think that Amber's question gets to this heart of the, I keep bringing it back to the calculator that the calculator,

Jen Kamel: Well, that's what we're talking about.

Nick Rubashkin : about, but it's such a, I swear that calculator is just an incredible vehicle or window into many of these core debates about the pros and cons of science in obstetrics. And so

Jen Kamel: Yes.

Nick Rubashkin : one hand what Amber's asking about is that at the center of the calculator is this very biomedical model of cesarean that pathology develops out of anatomic or physiologic factors that then make a labor deviate from normal and result in a c section. The problem is, we know that labor and childbirth is a much more culturally, psychologically, politically, as we've been saying, institutionally time in someone's life, from one labor to the next, dynamic phenomenon.

So I absolutely think that the psychosocial aspects of what was going on for that particular birthing person in that labor are really relevant and super relevant for thinking about, what could be done differently the next time if that's important to that person. There are people who having an unplanned c section the first labor was just really devastating, and having a second unplanned c section would be really hard for them, and having a repeat c section could be a healing thing for that person.

Science Beyond VBAC Calculator Comes From Oncology!

Nick Rubashkin : I will say that the calculator, and the science behind the calculator, and the original references in the first calculator paper, were actually referring to the oncology literature. It's this kind of biomedical project to be able to predict where a pathology will progress and how it will behave in the future. And doing that in the cancer world is very different than doing it in the birth world. I think a fundamental issue about the risk of a cancer progression is a very different risking process than happens with risk for having a C-section, which there are numerous other, as we know patient, provider, institutional, and the role of science in the form of the VBAC calculator, that affect your risk for a c-section in ways that cancer modeling does not capture.

Calculator Contributes to Informed Consent?

Jen Kamel: So we've talked a lot about the VBAC calculator and all of the science that went in it. And the reason why we're having this conversation today is because I did that initial podcast episode on the VBAC calculator and you reached out to me and you said, "I still think this has some value in terms of informed consent" and I was like "tell me more," and so we started chatting and I really want you to share with the audience what value do you see the VBAC calculator contributing to informed consent because I see it as a very simplistic formula that is used in a very simplistic way and that doesn't really take into account the whole complexity of the situation and the individual circumstances for that person. So I'd love to hear from you what the value you see it bringing.

Nick Rubashkin : I think that I want to emphasize, I'm going to answer that in the negative first, because I don't think that we've totally covered what a danger it was to inform consent.

Jen Kamel: Okay.

Nick Rubashkin : and that really also gets us emphasize the point around that because the calculator assessed Black and Hispanic patients as having lower probabilities for a VBAC on average, which were scores that were 5 to 15 points lower than White patients with similar risk factors, that depending on how the hospital or provider implemented, the calculator was used to take away a shared decision making model for VBAC interested Black and Hispanic patients who were told that their scores were too low.

And there were some implementations of the VBAC calculator that used the calculator as like a hard and fast rule. That if you had a score below usually 60, 50 or 60 percent, which of course because of the way the calculator factored race, it didn't really take much for a lot of Black and Hispanic patients to fall below certain thresholds.

That there were even places where they were forbidden to attempt a VBAC. Thankfully that was a less common implementation of the calculator.

I think the best data we have on that is that it was in a survey of certified nurse midwives, that 20 percent of the time the calculator was used to discourage or prohibit VBAC. But that's still 1 in 5 at least to the best of our knowledge.

So I want to hammer home that was the most problematic and damaging way that the calculator was implemented, was when absolute thresholds were used. I will say even still in interviewing providers post removal, there are places that still use calculator cutoff scores as a hard and fast rule to decide who and who shouldn't have a VBAC. So I think, for me, that is still a challenge that we are experiencing around VBAC calculators.

Where to Start: VBAC Calculator & Informed Consent

Nick Rubashkin : How can they be used? I think that they can be used as a conversation starter leading into a goal oriented conversation. And that, I did find, was how some providers were migrating to using them.

I want to back up a second and say, another way that I saw my research was trying to interview a range of providers to see how the calculator, whether we could, the calculator was published without any instructions on how to use it. It was just assumed that providers would know how to use it.

And providers really kind of like used it in the way it was intended, if you will, which is to say, using those cutoff scores, because that was actually written out on how to use it. There were instructions on how to use it that way, but then, providers were left to time I don't see it really influence people, that the people who are coming in to see me are either really committed to VBAC, or really committed to a repeat C section, and I'm not here to talk them out of their what their goals are.

There w ere other people who use the calculator and this is where, what I think how it could support informed consent is for people who were really kind of patients who are really seeking out some information about, "What are my chances that this might not work out. That was a really hard experience for me. I worried that it could happen again."

And a provider would clue in and be like, "We have some tools. This is the tool. This is what goes into it. This is the number. How do you feel about this number?

But really, I think what we're getting at is, what would it be like for you to have another unplanned C section? And if emotionally or whatever is behind that for you, it would be a really difficult thing then, maybe having a repeat caesarean is what you're getting at.

Or what would feel like a number that would be high enough for you to try? What would feel like too low? How could we change, this number? What are some things we could do differently, I think I mentioned this before, that might increase your chances of having a VBAC compared to last time?

Can we conduct the labor differently? Maybe in an ideal world, this wouldn't be an induction. Can we try to facilitate spontaneous labor?"

I think what you're hearing behind what I'm saying is that ultimately, it becomes a goal oriented conversation that is discussing this tension between our bodies.

Are laboring bodies flexible, and could we get to a different outcome? Are they fixed, and are we thinking about that line of thinking? And also what's the emotional context for you here?

Controlling Risk in Advance

Jen Kamel: Yeah. So one of the things that we talked about in our pre interview was the concept of controlling risk in advance with statistics. Can you tell me more, share with the audience what that means?

Nick Rubashkin : Yeah, we were talking about coming from the notion of putting an anthropologic lens on the calculator, and trying to answer this question of really why has it been globally obstetricians who've developed these tools as scientists, and why has it been midwives, by and large, who were the earliest scientific critics of these tools.

And it really comes to this very obstetric notion. We are the profession that sees ourselves controlling risk which is to say, the chance for death or disability in childbirth, through surgery or medications, which both are, I'm naming as invasive techniques here, things that we try to change the course of a pathologic process to hopefully get to a better outcome.

So VBAC calculators rest on kind of an obstetric idea in that they are foundationally, obstetric tools because they are designed to deal with the risk of something happening in childbirth and to avert that risk with surgery in advance.

And so that's very much a way to ask a scientific question from the perspective of an obstetrician and to try to answer it clinically as an obstetrician by scheduling surgery.

Jen Kamel: So when we were talking earlier, you said that one of the things that came out of this research is the concept of who gets to decide what questions are important to ask, what risks matter, and how to interpret those risks. Can you tell us more?

Nick Rubashkin : I think that really key was the earlier question that you asked. So many people who had prior C sections, who I put this calculator in front of, were asking for more nuance in the statistical categories. And like I said, every category raises that question. Age, BMI, race, ethnicity, failure to progress.

People don't experience statistical categories as individualized to their situation. So there's this tension between the broad strokes of population things that we do it with science and the person in front of you. And that's one. Two, the outputs of the models in terms of who gets to decide what score is too low or too high.

I will say there was a huge double standard around how low scores and high scores were treated from a perspective in terms of there were people who told low scoring Black and Hispanic patients that they could not try for VBAC based on a low score.

What was interesting was that there were high scoring people who wanted repeat C sections, and I'm not advocating for forcing those people into VBACs, but it was interesting that their choices were sanctioned while other people's choices were restricted, which, does that make sense?

Jen Kamel: Absolutely. Yeah, so you're saying the people who scored really low were told VBAC isn't an option for you, but the people who had really high VBAC prediction scores who wanted a C section were told, sure, absolutely have a C section. Is that what you're saying?

Nick Rubashkin : So it really shows the choices that were comfortable with people making around risk are the ones that align with using cesarean birth as a solution for risk. And, because if we, if, in some ways, if we carried the logic of the calculator to its extreme, which I'm not advocating for, people with high scores who were scheduling repeat cesareans could have equally been pressured into vaginal births. I'm not saying that

Jen Kamel: Yeah.

Nick Rubashkin : Whereas the low scoring people were being pressured into c sections, right? If you wanted to be consistent in the way you were applying the calculator's coercion, that would have been consistent. But the inconsistency tells us how on both sides, we're more comfortable with using c section as a solution for risk.

That's what gets to that issue that you're asking about, is like, who gets to decide what risks matter and what solutions are applied to those risks in terms of people who were given low scores and they were told that their only option was a c section. People wanted more options.

They were like, what if I exercise differently and change my diet and grow a smaller baby and what if I get a doula to support me and I feel better supported? There were all these ways that people were asking for a broader toolkit than defaulting to surgery as the only solution to the risk that the calculator identified.

Jen Kamel: Well, and as we're having this discussion, one of the things that keeps on coming up for me is how narrow the VBAC calculator is in terms of the information it seeks.

One of the questions that I make a point of asking every single person I talk to about VBAC is, were they ever asked how many children did they want to have? And the answer is almost 98 percent of the time, no, they were not.

And I think that is such an important question to ask. And I think it's such an important thing that the VBAC calculator doesn't ask because that whole risk assessment really changes if someone has one prior cesarean and they might want three or four more children.

That is a very important factor to consider that the VBAC calculator does not consider and that I think physicians in general do not consider and do not ask their patients. Do you have any thoughts or comments on that?

Nick Rubashkin : Well that goes back to what I said at the beginning of the interview is that, I was trained in a, I would say VBAC supportive environment. And I think that our rates demonstrate that, but the calculator is representative of kind of the risk paradigm that obstetricians do science in, and obstetricians like myself were trained in, and that when I was trained, really thought that this was only counseling around labor was only about talking about risks. And you're right, the calculator narrows that to talking about a set of risk factors that do not at all capture the really diverse goals that people bring to their birth after a cesarean including, family size, including wanting to be the first person to hold their baby, to not have it be a surgical team, but they really want their baby on their chest or to people who want to repeat c section and they want it done in a trauma informed way that is more family centered than their first c section was.

So many goal oriented ways that we could be tuning into what these very human needs are for people around their births after cesarean, which yeah, you're totally right, are just not captured by our risk modeling.

The Fundamental Ethical Issue

Jen Kamel: So tell us more about how the VBAC calculator makes sense to physicians culturally and how that differs from midwifery.

Nick Rubashkin : Yeah, I interviewed midwives, including ones who practiced in the hospital and in the community, and especially the ones that practice in the community, they were my like cultural outsiders a bit. Like they had not heard of the calculator or never used it by and large. And it was almost, if you will, go with the anthropology metaphor of it was like a foreign language, stumbling on a foreign object of like, how do you use this? Like it was totally unclear to them. They were like dumbfounded.

I'm thinking of this one community midwife who said this really powerful thing of, why would you use a tool like this was something, the effect of a quote. She said, "It means that you have this underlying notion that the labor isn't going to work and it sounds it's efficient and great and like we could just do this in advance, but what about supporting the woman through the labor that she wants?" And so

Jen Kamel: Yeah.

Nick Rubashkin : in that one statement, it really came to the whole question you just asked about who has the scientific authority to say how the future is going to play out.

So I still interview midwives who, even with the new tool, have a fundamental ethical issue with it in terms of this tension between having a tool that appears to have the authority to say "this is how your next labor is going to go" versus, having the authority rest in the birthing person and supporting them through what their goals are.

So I think that covers why I think a midwifery ethic and philosophy challenges VBAC prediction and that it comes through and why some midwifery scientific groups were among the first to challenge the use of the calculator.

You can find that in the literature, particularly around this question around the scientific authority to say someone shouldn't attempt a VBAC based on low calculator scores.

Jen Kamel: Well, and the other thing that you had said to me that really stuck with me is the idea that not everyone wants to use surgery as a default.

The 60% Threshold

Nick Rubashkin : Let me back up a sec to drive one more point home about the calculator and why people were really attached to this like 60 percent threshold.

What the MFMU found was that when people who were assessed to have scores below 60 percent attempted labor and then transitioned into another unplanned c section, and they compared those people who had scores below 60 percent but scheduled a c section in advance.

The people who scheduled the c section in advance had a total complication rate of 1.5%, at or below a score of 60%, versus the ones labored and then had an unplanned c section, had a complication rate of 3%.

So it was based on that risk of three versus one and a half that people developed this idea that scheduling a c section in advance when scores were below 60 percent, made sense.

And providers on the ground thought they just understood that it's safer to schedule a c section. What we're talking about here is that people were denied the ability, patients were denied the ability to evaluate what that three to one and a half percent chance meant to them.

Just knowing that, how meaningful it is for some people to try to have a VBAC, I can guarantee you that a three to one and a half percent difference isn't going to make a big difference to a lot of people.

I, as a clinician, that may be statistically significant, but a three to one and a half chance, isn't to me, I think, super clinically significant and that to say that statistical significance does not always equal personal significance in this situation. So I think that's a really important thing to keep in mind.

Jen Kamel: Absolutely. At one point you mentioned to me how the research is silent on how to increase VBAC odds, rather there is this focus on predicting surgery. Can you tell us more about that?

Nick Rubashkin : There have been some studies that look at how to do people's chances for VBAC change over time? I think, if you use the prenatal version of the VBAC calculator versus the intrapartum one, if I'm remembering right, that question was done.

So that there is some chances that it increases over the course of pregnancy. And I think that is known. What I want to say is that in studying the implementation of the calculator, that there was an intrapartum version.

The intrapartum version used factors that were known when somebody got admitted to labor. It also had race and ethnicity. That calculator was lesser used, and I think that it's because people were really focused on using the prenatal calculator, because it seemed to offer this like very early, rigorous prediction of the future.

And there's this, again this idea that bodies are essentially fixed, that how you've assessed somebody early in their pregnancy will be a constant that follows them, even if they don't get diagnosed with gestational diabetes this time, if they have a healthier diet, or they have more labor support. None of those things matter, just the prenatal prediction.

I think that people became really focused on the prenatal prediction because there's this sort of focus in VBAC counseling around "you've got to decide" and we've got to put you in a risk kind of selection box.

Rather than an alternative approach of, and this may not be an alternative approach that not many people I think, followed this amongst the women I interviewed, but there were some who were like, I'm not ready to make this decision. I want to see how the pregnancy how this happens and this happens. I want to see how I'm feeling in my body at full term. Then I'll make a decision. Not many people went that way, but it made me think whether that kind rare way that people make decisions, whether that could be elevated more.

We have this tool, it can tell us now, in this ways, with these significant limitations, how this labor might go. But you don't need to, rush the decision right now. I've seen that some people want to wait until, this point.

Or they want to like, see that their baby's head is down this time, because yeah, your first C section was for breech, and I totally understand it's hard for you to think about these options until you get that guarantee that this baby is going to be different and it's going to be head down.

I think we have to really think about how much the reason that people had their first C section really influences how they are monitoring certain events in the next pregnancy as it unfolds, even up until, until labor is happening.

I want to put that out there. We're trained at, and perhaps socialized, women socialize that we have to make this decision. It's a high pressure decision. But what would it look like if we backed off and maybe took some of the pressure out of that? And, saw how things unfolded.

Jen Kamel: Well, and that makes me think of the pressure that many parents feel in, quote, having to schedule a C section or have one on the books at 40 or 41 weeks, and how that surgery date, it's almost haunting them from the future. Can you comment on the the necessity of having that scheduled c section date on the books as opposed to just waiting for labor to present spontaneously?

Nick Rubashkin : I put the thought out there as a researcher who's going to be looking into this issue, this exact issue, in terms of working with patients to explore this very topic, while also realizing that there could be tremendous barriers in the realities of how labor units are staffed and scheduled.

Will say, I want to share that when I was in clinical practice, I was taking care of this one patient through her pregnancy who wanted, she had a C section, wanted a repeat C section. But she wanted to have her repeat cesarean when her body told her she was going to go into labor. She didn't want to schedule it. She wanted to wait until contractions or her bag of water open as the signal to have her C section.

And that was such an important patient interaction for me to be like, that's a really meaningful event for people, for their body to announce that their baby is ready and not have the surgery scheduled.

And I, just made me realize to your question that so much of not just our science, but our clinical routines are really around, in order to safely conduct C sections, it is helpful to have well rested teams with blood banks open and all the daytime staffing hospitals and just how that is a reality that can be quite different than the mystery of childbirth, that people want to be able to experience their baby announcing the time rather than us scheduling the time.

So I think that it would require some shifts in our clinical routines and perhaps scientists quantifying how many people would want this as an alternative as compared to the pressure of having a scheduled surgery.

Because certainly there are people who are like, it really helps them to know the date, but I do have the question like you that, are there, based on this patient and the question you're asking, how how many of them might want for their bodies to announce the time.

Goal Oriented Conversations

Jen Kamel: As we wrap up, can you tell me more about the concept of surgery as a default and how that concept drives the use of the VBAC calculator?

Nick Rubashkin : I think one point to hammer home. I want to make sure I do my duty of really emphasizing what was the even potentially deadly consequences of the scientific racism of the calculator and how that related to using surgery as the default, right?

The racism of the calculator constructed Black and Hispanic bodies as deficient, as less, not able to have vaginal birth, and the obstetric assumption that surgery as the default for low scores, was the combination of how the racism of the calculator intersected with using surgery as a default.

That is connected to an entire history in the United States where excessive surgical intervention has been used on Black and Hispanic populations to develop fistula surgeries, to forcibly sterilize people. You bring up the surgery default question. I just want to really make sure we connect that in these final moments to the racism of the calculator and how damaging that was. And how that's connected to an entire history in American obstetrics.

Going forward, the idea of VBAC prediction tools is that, okay, we've assessed you to have this lower probability for a vaginal birth in the future. There's one possibility of scheduling the C section in advance.

I think in the future, hopefully, we can have a broader set of tools that we can offer people including, okay, this is one perspective, there could be a kernel of truth here, that looking at using these factors there could be a greater chance of this outcome in the future.

Let's think about also how we might be able to change that outcome. What contributed to that outcome in the beginning? Could we change the course of this pregnancy possibly to have a different outcome, if that's important to you? What are your goals in this pregnancy? How big is your ideal family size. How important is it for you to have a vaginal birth? How important is it for you to have skin to skin contact and you be the first person to hold your baby? All the things that come up for people as relevant in having a VBAC versus having a repeat cesarean.

So if we can use calculators as a way to launch into goal oriented discussions where people are supported, real options to increase their chances of a VBAC, if that's their goal, I think that's the ideal state that we're moving toward.

Jen Kamel: Well, Nick, I think that is a wonderful way to conclude today's interview. I hope perhaps we can have you back another time to go through the rest of our questions because there's still so much more to discuss.

Nick Rubashkin : I really appreciate the opportunity to talk about this at length, because as you can see, I just love talking about VBAC calculators. And I'm just passionate about the topic and could nerd out with you as a fellow VBAC nerd for a long time.

Jen Kamel: Well, great. I'm glad because there's still so much that we had written down and wanted to discuss that we just didn't get to. And you know what, that's okay, because we'll just come back another time and revisit. But thank you so much for sharing your experience, your perspective, for fleshing out this concept of the VBAC calculator.

And next time when you come back, I would love to share more about how clinicians can manage the those lower predicted odds, how we can communicate that to parents as well as clinicians and help them navigate and really get the best out of the VBAC calculator while avoiding some of the pitfalls that people encounter. Does that sound like fun?

Nick Rubashkin : Yeah, let's do it.

Jen Kamel: Great. So until next time, I'm Jen Kamel, VBAC Facts® founder. And don't forget what we're about. Since 2007, our focus has been to provide accurate and objective information on vaginal birth after cesarean and repeat cesarean to parents, professionals, policymakers, ha ha, it is political, and the court, so all decisions can be informed, ethical, and just. I'll see you again in two weeks. Take care. Bye. Thank you so much, Nick!

Nick Rubashkin : That was fun.

Jen Kamel: This was great. That was super fun.