George Saade, MD, is a professor of obstetrics and gynecology and the director of the Maternal-Fetal Medicine Division at The University of Texas Medical Branch. He has served as the executive chair of the Texas Collaborative of Healthy Mothers and Babies since the collaborative’s beginning, and with more than 200 articles published in peer-reviewed medical journals, Dr. Saade is a recognized expert on preterm birth, preeclampsia, and the fetal origins of adult diseases. Late last year he talked with the TCHMB newsletter about how he began his career, the beginnings of the collaborative and what he's most excited about moving forward.
By Kaulie Lewis
Population Health Scholar
University of Texas System
Master's Student in Journalism
UT Austin Moody College of Communication
How did you become involved with maternal and perinatal medicine?
I like surgery, but I don't like only surgery, and I like medicine but I don't like only medicine, so this is a good field that combines both. It keeps me interested.
More importantly, though, is that so much is not well researched and not established in perinatology. When I was starting in this field, there was a lot of room for research, for developing new treatments and finding causes of diseases -- a lot more than in other fields where more people were working and doing research and things were advancing quite a lot.
Thirdly, I wanted a specialty where I could make a difference very early on. In perinatology, you’re working with two lives, young women and their babies. Whatever we can do in pregnancy will have long term benefits and implications compared to some specialty where you're treating people in the later stages in their lives.
Why do you think that there hasn't been more work done before this?
I think overall if you take the history of medicine, women's healthcare was long relegated to the side. At the time when modern medicine and surgery were developing, obstetrics was thought of as just dealing with how to deliver the baby. It wasn't thought of as a scientific medical area. Women died during childbirth, but people thought that was inevitable. They didn't really think there was anything to do about it.
Then people started to understand the physiology of pregnancy, and began to get better at preventing deaths from hemorrhage or from sepsis and infection. Then we started seeing all these other complications. Now every pregnancy is seen as precious, not just for the woman and her life but for the whole family. There’s not an expectation that you need to have 10 or 12 kids so that maybe half of them will survive.
What are some exciting things that you're seeing in the field now?
I think there is more realization now of how significant an impact pregnancy has on long-term health for both the mother and the child. Some 20 years ago David Barker, who was an English epidemiologist, popularized the idea that what happens as the fetus develops impacts long-term health. There's an association between smaller size at birth and poorer health later in life. People call it the developmental origin of adult diseases.
So now, all of a sudden, pregnancy becomes an important window. Even if the pregnancy outcome is okay, the baby survives and the mother survives, we know that there is an association with long-term health. That’s also true for the mother, because now we know that the women who have pregnancy complications also tend to have cardiovascular and metabolic diseases 10, 15 or 20 years later.
That's where I'm spending a lot of my efforts, on what I call pregnancy as a window to future health. We know that if we make sure the pregnancy is going normally, and if we follow women who have pregnancy complications or babies that have small birth weight or are preterm, we can improve their health outcomes later in life and impact health care and health costs. When it comes to pregnancy, there is a return on investment multiple times over compared to what you invest in somebody who’s 60 or 70. Those are more short-term investments.
What projects are you working on right now? Anything coming up that you're excited about?
In the lab, we’re working on development and long term health, so we have some animal models of dietary restriction and how we can prevent long-term adverse outcomes in the offspring. We also have models of pregnancy abnormalities and we're looking at what can prevent the long-term cardiovascular and metabolic diseases in the mother. It turns out that oxytocin coming from breastfeeding and lactation may have a big benefit, so that's a good sign. Hopefully when we understand this more, we can prevent these long-term adverse outcomes.
On the clinical side, in the next few months we're going to start the national trial using tranexamic acid, which is a drug that prevents fibrinolysis. It improves clotting. We're going to try that to prevent postpartum hemorrhage after cesarean deliveries.
In addition to your research and your practice, you're also the chair of the Texas Collaborative for Healthy Mothers and Babies. How did you become involved in the collaborative?
I was involved in the precursor of the TCHMB. At the time it was called Healthy Texas Babies, and it was a collaboration put together by the state that included neonatologists, perinatologists and obstetricians. Each group of specialists picked a project to work on, and the leader of the obstetricians' group chose preventing non-medically indicated inductions and deliveries before 39 weeks, which was a hot topic at the time. I was brought in to advise and work with them because I had worked with the Society for Maternal and Fetal Medicine in developing guidelines for delivery before 39 weeks. We came up with some guidelines and policies, and the state adopted these indications so that providers had to certify that if they delivered somebody before 39 weeks, the mother had to have an indication that corresponded to what we listed. It was very successful. I think we really impacted the field.
So that's how I became part of Healthy Texas Babies. When the state decided to formalize this group and make it into a collaborative, I applied to be on the executive committee because I saw how impactful such a group can be. We still have some challenges, but it’s a young collaboration that’s moving in the right direction.
What are some of those challenges? What are some things that you are hoping to improve in the collaborative?
Connecting all the different stakeholders is the first step and the biggest challenge here because of how spread out Texas is. People say, “Well, state X or state Y did this project, did that,” but I can say from talking to other state collaboratives that they don't have the same challenges we have in Texas.
Take North Carolina. No patient in the state is further than 70 miles from a major medical center. We don’t have that in Texas. Here patients may have to travel 200 miles to reach a major medical center. That’s why so many deliveries in Texas occur in small, rural hospitals, and those hospitals often don’t have the infrastructure to collaborate on our projects. They’re doing a great job, but they have limited resources and may not be able to be a part of the projects that we want to do, whether it’s collecting data or instituting programs or implementing toolkits or bundles. If we push them too much, they may stop doing obstetrics altogether. Most of them are probably losing money on obstetrics already, so you can't just keep pushing them because otherwise they’ll have to close and then those patients will have nowhere else to go.
So in a sense it's a fine balance between what we want to do and what's feasible in Texas. That’s the biggest challenge that we have to overcome before we can do much more than what we are doing right now.
The other challenge is that Texas isn’t one of the states that often mandates things from the state government down to practitioners, so we're limited on what we can do. We can go to people and tell them that we're here to help, we're here to give them options for what they can do and how they can improve, but we can’t mandate what they have to do. If you combine that with the distances and the fact that rural hospitals are more common in Texas, you can see how it's going to be very hard to implement something that we think should be done.
All that being said, it’s remarkable how many hospitals TCHMB is working with.
I think the word is spreading. We're developing a very large collaborative and these things take time for everybody to get on the same page. I also think that our work with UT Health Northeast and Dr. Lakey’s team has improved our ability to reach out to hospitals. From the TCHMB newsletter, the Texas Health Journal, the work on organizing data and data analysis, all of that has tremendously increased our capacity to move things forward. Even though the collaborative was around before UT Health Northeast came on board, I think that partnership has made us a better collaborative.
"People say, 'Well, state X or state Y did this project, did that,' but I can say from talking to other state collaboratives that they don't have the same obstacles we have in Texas. "
What are you most excited about moving forward?
Collaborating with the perinatal advisory committee on the levels of neonatal care is going to be very important. I think the neonatal part of the collaborative is working really well because all the state’s NICUs have been connected for several years. They all function collaboratively. And now there is an official status for levels of neonatal care, so the NICUs have to be certified and they have to work together. The state is divided into regions and they have to work within those regions, and so that's something the collaborative can leverage and use to improve our communication and to improve our impact.
Next there’s going to be similar levels for maternal care and that’s huge, because this will be the first time that that’s happened. The NICU levels have been around for 20 or 30 years, but the maternal levels are new. So we need to seize this opportunity to work through that structure, to help educate and spread the message and the projects that we want to do. This is really the next step that’s going to propel us to the next level. I think we have some exciting years ahead of us.
Especially in this moment when maternal care in Texas has been getting a lot of attention because of our maternal mortality rates. Is that connected to why these maternal care levels are being implemented?
It's another chapter in the same story. About five years ago, I and some of my colleagues wrote a call to action. Why were we having these maternal mortalities? It was a national thing, not just for Texas.
We said then that neonatologists had developed these levels of NICU care in the ‘70s and they'd improved them in the ‘80s and ‘90s and now it’s a standard thing to have levels of neonatal care. Why weren’t we doing the same for maternal care? Then the Society for Maternal and Fetal Medicine and the American College of Obstetricians and Gynecologists put a group together and came up with the recommendations for levels of maternal care.
I do believe that the levels of maternal care will improve pregnancy outcomes and decrease maternal mortality and, importantly, maternal morbidity. It may take some time to see the benefits, but I have been told by many colleagues that just having the discussion about this has improved the support they get.