Ep 171 Pregnancy: Act 4

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We want to start with a disclaimer that throughout this series, we feature explanations and stories that include some heavy material, including early pregnancy loss, stillbirth, and other traumatic experiences of pregnancy, childbirth, and the postpartum period.

There's a lot I could say about the physical difficulty of carrying a baby, but I'm going to focus on the postpartum because that was what was most surprising and unsettling to me.

Throughout my pregnancy, I always expected that I would start kind of falling in love with the baby.

Like I always heard people saying, I'm already so in love with you, all those, you know, social media posts and what people are talking about.

And I never really felt an attachment.

But I was especially promised that when you give birth, it's the happiest day of your life.

You look down at the baby and you love them instantly more.

And it's a different love than you've ever experienced before.

And so after, you know,

three days of pre-labor and then 15 hours of labor, I gave birth and the baby was put on my chest.

And I just felt this kind of heartbreaking, missed step feeling because it felt the same as it always had.

There was no immediate love.

There was a baby on my chest.

And that was it.

And then in the hospital, I kind of was feeling like I have no idea how to take care of this baby.

There was kind of this helplessness.

I couldn't feed it.

He wasn't latching.

I could hardly hardly stand myself.

Like I needed help getting to the bathroom.

I couldn't sit up.

I didn't change into clothes.

I just felt like very sick.

And when the nurse came with a wheelchair and was going to wheel us out, I was like, how the heck am I going to go home and take care of this baby?

I have no idea and I don't even love it.

Like, does anyone know around me that I don't love this baby and that I don't know how to take care of it?

And my husband drove us home and I walked into the house and it was even actually when we pulled into the garage, there was this immediate sense of everything around me looks different than it did.

Nothing looks familiar.

It's like we drove into this kind of parallel universe that I'd never lived in before.

And it was very unsettling.

And my parents were there and everyone was so happy.

And I was like, something feels so off to me.

And then my husband went to take the dog for a walk because we'd been gone for three days.

And I...

felt a panic inside me and I left the baby with my parents and I went into my bedroom and I cried because I didn't want to be without my husband.

He was the only person who had, who knew what I'd been through the last three days.

So then I had this kind of like vague feeling of desolation for a long time.

And I would cry for hours at a time at night.

And I just kind of, I never really felt happy.

I was always just kind of leaning towards depression, I guess.

And I'd never experienced depression before, so I didn't recognize it.

It just felt like homesickness, like this nagging sense of homesickness that intensified or dulled, but never went away.

And the scariest part was when my in-laws visited and my parents also visited and they were taking turns carrying the baby all day.

And when they finally, when they gave him back to me after maybe an hour, I looked down and I didn't recognize my baby.

And it could have been any baby.

I had, I had had him for two weeks.

He was two weeks old and I didn't know who he was.

It could have been, they could have swapped him out and I would have had no idea.

And I started sobbing.

I told my husband right away and he googled

mother can't recognize baby and I watched him Google that and it was so heartbreaking.

and I came up with this kind of soothing exercise where because my son's face didn't look familiar to me I kind of broke it down into pieces and I would say like there's his mouth there's his eyes there's his nose there's his ears and I would memorize them in pieces and from then on whenever I held him I would go over and recognize each of those small pieces until they looked familiar to me to this day I don't know if it was like mild psychosis or depression by the time I went to the doctor six weeks later, it had, I mean, I was still sad and should have been treated with depression, but it wasn't so startling that the doctors picked up on it and I didn't know how to report it myself because I didn't know what to recognize.

I wish that I had seen a doctor way earlier, but it wasn't required and I didn't know to ask for it.

And I wish that I had been treated because that dull sadness probably stuck around for six months.

And if there had been earlier intervention, I think I would have had a much more enjoyable early motherhood experience.

I also told my husband that I didn't love the baby as much as I loved him, and that that seemed wrong to me.

And he assured me that I'd known my husband for 10 years, so it kind of made sense that I would love him more than somebody that I'd only known for two weeks.

It probably took a year for me until I had the solid bond that I was expecting to have right away.

And I wish that other women knew that sometimes it's just a bond that has to build as you get to know people.

And now my son is six, and I couldn't possibly love him more.

It has been so incredible to hear everyone's stories, and we really can't thank everyone enough for sharing your stories with us.

We read hundreds of first-hand accounts and it truly is such an honor and it feels so,

I can't, it feels surreal.

Yeah.

It's amazing.

So thank you to each and every one of you who wrote in and

who shared your stories.

Yeah.

We tried so hard to include as many different stories from as many different perspectives and experiences of pregnancy and childbirth and the postpartum period as we could.

And we know that as many as we included, there's so many that we didn't.

And we just want to thank you all again from the bottom of our hearts.

We really, really appreciate it.

It means the world to us.

And this podcast would not be the same without all of you.

Absolutely not.

Yeah.

It has really been, it's such an integral part.

It's, it's amazing.

It is.

Hi, I'm Erin Welsh.

And I'm Erin Almond Upday.

And this is this podcast will kill you.

We are coming to you with the fourth and final, for now, episode in our series on pregnancy.

For now.

I mean, to be continued, to relate.

To be continued.

But this is our burpin-a-brum

season finale.

That was lovely.

Thank you.

I did a drum, even though it was more like a trumpet.

Yeah, no, I liked it.

Thank you.

It was a really nice touch.

Yeah.

It's also our last episode recording in the exactly right studio.

So thank you guys for having us here.

Yes.

We're having too much fun.

We are having too much fun.

Too much fun?

No such thing.

We're just relaxing.

That's been the joke all morning.

If you listen to the first couple episodes, you get it.

Oh, my God.

Okay.

We still have an intro to get through.

We do.

We do.

We do.

We have some things to discuss.

Yes.

If you've listened to the other episodes, you've heard these before.

You've heard this before.

Yeah, we want to just sort of briefly go through again what we've already covered in the first three episodes, what we're going to be covering in this episode, talk about some of the language that we'll be using and our goals overall with creating this series.

And so we decided, like we have said, early on to dedicate four episodes to pregnancy, one for each trimester.

Clearly not enough to actually cover this huge experience that is pregnancy, childbirth, and the postpartum period.

Yeah.

And so if you are like, hey, I really want to hear more about this.

I want to learn about this aspect.

What about this?

Send in your questions.

Send in your topic ideas.

We are happy to have them.

This will not be the last episode on anything related to pregnancy.

No.

So yeah.

We've got more to go.

So much more.

We know that we haven't answered all of your questions.

We still have this episode to try,

but we definitely have not covered every possible experience that a person could have during pregnancy, childbirth, and beyond, because pregnancy is such an individual experience.

So each episode that we have done thus far has covered roughly a trimester of pregnancy.

So in our very first episode, we talked about how you even know whether or not you're pregnant and what happens during early development.

The second episode, we talked a lot about the placenta.

Yeah, we did.

What an incredible organ

that is.

And we also talked about the physiological changes and antomic changes that someone experiences throughout pregnancy.

And we touched on some of the complications that can arise.

Last episode, last week, we talked all about the process of childbirth itself,

all the different ways that you can do it.

Yeah.

A little bit about labor and modes of delivery.

And then the history of the cesarean section.

About C-section.

It wasn't Julius Caesar, y'all.

No.

Yeah.

Tune into episode three to find out more.

And finally, today, our fourth episode, our final episode of the pregnancy series, and our final episode of season seven will be about the concept of the fourth trimester, talking about what changes are going on in your body after pregnancy.

And we're also going to be talking about this big picture of how the medicalization of pregnancy and childbirth changed that experience and how we moved from home to hospital and some of the consequences of that.

Yes, I'm excited for this episode, Erin.

Me too.

We have intended for this pregnancy series, as with all of our episodes, honestly, to be inclusive of all families.

And we recognize that not everybody who experiences pregnancy identifies as a woman.

So we try wherever we can to use gender-neutral language and discuss pregnant people.

At the same time, we know that a lot of what we discuss, especially when when it comes to medical bias during pregnancy and childbirth, historically and today, is a result of gender discrimination and racism.

And so, in those contexts, we use the term woman or women.

And throughout these episodes, we also use the term mother or maternal and paternal, since these are the terms that are often used in the scientific and medical literature.

Yes.

And we also want to just, you know, recognize that there is no such thing as a normal pregnancy.

There's no, this is what is going to happen, and this is normal, and that's it.

The only way that it can be.

The only way.

There are so many different ways.

I've gone over that a lot in these episodes.

But it is really important in discussing, you know, a baseline of what is expected to happen so that we can understand what happens when things happen outside of those expectations and some of the complications that can happen as a result.

Even defining what a complication is.

Exactly.

Exactly.

And we're going to do that today for the postpartum period.

We are, we are.

But first,

I've remembered it this time.

It is quarantining time.

Erin, what are we drinking again this week?

We're drinking yet again, great expectations.

Great expectations.

Which is a placebarita that is a non-alcoholic beve.

It's really good.

It's got ginger ale.

It's got muddled blackberries and mint.

It's got lemon juice.

It is shockingly delicious.

Very refreshing.

Yeah, super refreshing.

I love it.

I'm thinking of it right now.

Me too.

Wish I actually had one, But alas.

Later today.

Yes.

If you want to see us make it, we made a really fun quarantini video that you can find on the YouTube.

YouTube.

We also were very honored to be joined by Georgia Hardstark, who made us a quarantini, an alcoholic version to go along with these episodes.

She called it the Antini.

The Antiniest.

And it's delicious.

Yes.

And you can find that video on YouTube as well.

YouTube.

And you can also find, I don't know if we have said this enough, but you can find these episodes on YouTube.

These pregnancy episodes.

These pregnancy episodes.

With video.

With video.

And props.

And props.

We are doing great today.

And if you would like the recipes for these quarantining and placebarita for this series, check out also our social media.

Make sure you're following us.

We're now on Blue Sky.

I don't know if we've said that.

Sure.

And also our website, thispodcastWillKillYou.com.

Which features?

Do you want me to do this?

Listen, let's skip it today.

Okay.

Check out our website.

Transcripts.

I just have to throw that in.

Okay.

Any more business?

Rate, review, and subscribe.

We love you.

Thanks for listening.

We'll be back soon with a new season.

Yes.

And we have so, like, send us your ideas along the way.

We are so excited to dig more into the world of health, medicine, disease, biology, evolution, ecology.

Literally, like after we stop doing ecology.

We already have a list of things that we're like, okay, so next season, boop, ba-do-so-like air quality index.

Thank you, Kenton.

Yes, thank you, Kenton.

Okay.

Let's begin.

Let us.

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I found out I was pregnant on New Year's Day, 2024.

I was 33, and this would be my second baby.

My pregnancy was relatively uneventful and actually a little easier than my first, but both were low risk.

I went into labor naturally at 39 weeks and went to the hospital.

To help things along, my midwife broke my water manually.

I felt a huge gush and things really intensified from there.

At this point, my memory is a little blurry, but I do remember feeling more big gushes when I had contractions.

I pushed for about an hour and then my daughter was born.

When the midwives went to place her on my chest, they discovered that the cord was very short.

They could only set her on my belly, under my belly button.

I asked them to go ahead and cut the cord so that I could hold her on my chest instead.

I got to hold her for maybe a minute and take some pictures before things started to go downhill.

I was trying to nurse her and then I started to feel very weak.

I yelled out for someone to take the baby because I thought I would drop her.

I had been distracted, but then I realized I still hadn't delivered the placenta.

My midwives sprang to action and told me we needed to deliver it immediately.

As soon as I pushed it out, I felt a huge gush.

My first thought was that it was amniotic fluid because it felt like when my water was broken.

But then I realized all that fluid had already been delivered with baby, and I said, was that blood?

I looked at the midwife who had been standing between my legs, and she was splattered with blood head to toe, like she'd been sprayed with a hose.

From there, everything was chaos.

All of a sudden, there were a lot of people in the room.

The midwives were vigorously massaging my belly, but my uterus wasn't contracting, and I was bleeding out.

I was given multiple drugs via different routes at the same time.

One of these was cytotech, also known as mesoprosol.

This drug is talked about a lot as it is the second step in a medication abortion, but it is also used to help stop postpartum hemorrhage in labor and delivery.

The hospital OB and my midwives were working frantically on me for about an hour to try to stop the bleeding while my husband was doing skin to skin with the baby.

I remember thinking that my great-grandmother had died from a postpartum hemorrhage.

I asked one of the nurses if I was going to be okay, and all she said was, we are doing everything we can.

They tried using an intrauterine balloon device to apply pressure from within.

Unfortunately, it got clogged with clots and didn't work for me.

Staff was scooping up blood and clots off of the bed and floor and weighing it to see how much I lost.

Ultimately, they said I lost about two to three liters and I was given two liters via transfusion.

Eventually my uterus did contract and they were able to stitch me up.

The other day I was looking back at those photos when I was holding my baby and I can see that my face has a weird gray cast to it.

I'm so glad that I delivered in a hospital that had all of the best medications and resources available to stop the hemorrhage.

If I hadn't, the outcome could have been very different.

My name is Dawn and I live in Texas.

In my mid-30s, I became pregnant with my second child.

My then-husband and I were thrilled after having such joy from our first one.

At my first prenatal appointment, everything seemed fine, my vitals were good, and we were able to detect a heartbeat.

Since my first pregnancy was uneventful, I assumed this one would be similar.

One thing that was very different about this pregnancy was the nausea.

Although I had had nausea with my first pregnancy, this one was much more intense.

I felt awful most of the time and struggled to do normal things.

Nothing seemed to help.

At my second prenatal appointment, the midwife was enabled to detect a heartbeat.

She did an in-office ultrasound and confirmed the fetus was no longer alive.

I don't believe any other information was gleaned from the ultrasound.

My midwife suggested that I have a DNC soon.

We were, of course, devastated to have lost a baby.

Shortly after the DNC, the midwife contacted me and asked me to come back into the office.

In the appointment, she told me that pathology done on the placenta or fetal tissue had come back with some concerning results, which was that I had had a molar pregnancy.

I had never heard of this diagnosis.

She told me that I would need to come in for regular blood testing to be sure pregnancy hormone levels in my blood were steadily decreasing.

After the appointment, I talked to my aunt, who was an OBGYN nurse.

She gave me the highlights of a molar pregnancy, and of course, I googled on my own after talking to my aunt.

My basic understanding was that a molar pregnancy is an unusual, non-viable pregnancy that can sometimes develop into cancer if all the abnormal cells are not removed.

Years afterwards, my aunt told me she was very concerned for me.

While the intense nausea remained for a few weeks after the DNC, my pregnancy hormone levels did steadily decline and after some time, I was fortunate to have a third pregnancy that resulted in a healthy baby boy.

Since I live in Texas, I do want to mention that I'm not sure if the DNC my midwife recommended would be possible now with the unprecedented removal of women's reproductive rights.

Last week, I took us through the history of cesarean sections, a procedure that has been used in some capacities since at least ancient times, but one that physicians weren't able to widely utilize until the 20th century when antibiotics, antisepsis, transfusions, and surgical technique transformed it from an almost certain death sentence to a life-saving tool.

And we discussed how the high rates of C-sections have led people to question whether the surgery, life-saving though it may be, is overused and what possible consequences might arise as a result.

So for many, high rates of C-sections represent sort of this dark side of the medicalization of pregnancy and childbirth, where medical intervention is seen as always necessary and women aren't trusted to give birth.

This, of course, is not the complete picture because ultimately, as childbirth moved from the home to hospitals, rates of maternal and perinatal mortality declined as medicine developed methods to manage the complications that in previous centuries may have resulted in tragedy.

But this rosy picture of modern medicine marching onwards with doctors saving the day, that really fails to capture the inevitable and often overlooked cost of progress.

What did we leave behind when we moved from the home to the hospital?

So today, I want to take this big picture view of how childbirth has changed over the centuries, exploring some of the factors that have underlaid those changes.

And ultimately, I want to kind of just think about this question of how can we use the past to ensure a better future.

Before I dig in, I want to shout out a few of the major sources that I used to put this together.

There was a book called Brought to Bed by Judith Walser Levitt about childbirth in America from 1750 to 1950.

The title sounds somewhat dry.

It is one of the most fascinating books I have ever read.

Very enlightening.

The book, A Midwife's Tale by Laurel Thatcher Ulrich, which is so good.

Oh my gosh, this is the excellent history book about the life of midwife Martha Ballard.

Snippets, it's such,

I love this book.

I could talk about this forever, but the way that it approaches history is fascinating because it takes, like, here's a segment, here's a month in her life.

Now, let's think about how marriage laws in Massachusetts, or not in Massachusetts, in Maine, in the late 1700s.

So, like, all the context of what was happening.

Yes.

Oh, how interesting.

It's so good.

Not to mention like the aspects of midwifery and childbirth and so on.

Okay.

Another book is, I use snippets of a book called The Midwife Said, Fear Not, which is about the history of midwifery in the U.S.

up through today.

That one is by Helen Varney and Joyce Beebe Thompson.

And then finally, there's a book, Blue, by Rachel Moran, not our

friend Rachel Moran, but a different Rachel Moran about the history of postpartum depression in the U.S.

So you can probably tell based on these titles that this history section is mostly going to be primarily focused on the U.S.

Love it.

Yeah.

There is no origin story for midwives.

Their existence probably predates written history, and assistance during childbirth may even be a key part of human evolution, as we kind of talked about.

The word midwife means with women.

And over the centuries and across the globe, midwives have taken on various roles that have held different meanings.

Wise woman, all-around healer, witch to the haters, and so on.

But there have been a few constants that have persisted.

Midwife care often focuses specifically on women, that training often involves models of apprenticeship, that scientific knowledge is incorporated into practice, and that pregnancy and birth are considered normal life events.

This is not a history of midwives.

I won't be talking about like the profession today,

but it is a history of childbirth, and the two are, of course, inextricably linked.

In the early years of the U.S., childbirth was at home, most commonly attended by midwives.

Then, by midwives with occasional visits from physicians, then by physicians with a woman's friends and family in attendance, and then in hospitals with no familiar faces.

Husbands weren't even allowed in the hospital room until the 1960s, like the late 1960s, and non-spouses way later.

Wow.

Very interesting.

Yeah.

The transition from home to hospital and from midwife to physician was not uniform across the U.S.

Immigrants, the less wealthy, non-white women, and those living in rural areas gave birth at home for much longer than wealthier individuals.

And so to give you some idea of this timeline, in 1910, about 50% of all babies were delivered by midwives.

1910, 19.10.

By 1930, that number had gone down to 15%.

Wow.

And by 1973, about 1% of births were attended by a midwife.

Wow.

And compare that to 2021, which is the most recent one that I found.

I'm sure there are more recent ones out there.

12%

were attended by a midwife.

So we went all the way down and then a little bit back up.

I will say that I know this is U.S.-centric, but that is very different than the data today for most other high-income countries even.

Yes, yes.

And that is part, that is wrapped up in the history of how the U.S.

treated midwives.

Okay.

Specifically, laws.

Okay.

Yeah.

Yeah.

The transition from home to hospital, this did not happen overnight, nor was it simply a hostel takeover by physicians.

As Levitt puts it in Brought to Bed, the process by which this occurred reflected the needs women felt to upgrade and to control their birthing experiences, as well as the increasing medical management of birth.

What I really, really appreciate about this quote is what I feel like so many histories of childbirth leave out, that birthing women were and are agents of change.

They were not just passive bystanders of the medical and legal attacks on midwifery.

They held the power to say what they wanted their childbirth to be like.

Until hospitals became the default place to give birth, women often chose who would be there to help, to support, to make decisions when she could not.

And the people she chose were often midwives and her female friends and family.

It was like a birthing network rather than just like, here is the hospital staff.

And as obstetrics became a more common part of medical training, many women opted to bring a physician into that network, believing that his professionalism, his tools, and his expertise would ensure the safety of mother and baby.

And I say his because that was almost universally the case.

Yep.

Yep.

In 1900, only 6% of doctors in the U.S.

were women.

I'm actually surprised it was even that high.

That high.

I know, I know.

I mean, the other thing, the other caveat to that is that, yes, there were 6%, but they had very few patients because most people didn't want to see them.

But they were elected, like a lot of women who were

giving birth wanted a female doctor.

Okay, interesting.

Back then, yeah.

And of course, most medical schools banned women and non-white men from applying.

What led to women choosing physicians and hospitals for childbirth is wrapped up in the professionalization of medicine and active campaigns against midwifery.

Midwives were portrayed as lacking the training and medical expertise to safely deliver babies while also being explicitly forbidden to seek that training and medical expertise.

Wow.

Yeah.

Okay.

And women, wanting to make the safest decision for themselves and their baby, brought in male physicians, believing that they would provide protection from the dangers of childbirth, which there were many.

Yeah.

All right, so now that we've got the big picture view, let's dig a bit deeper to see how this all went down.

Yeah.

We as a society have a tendency to romanticize certain aspects of the past.

Like how much better food must have tasted.

It didn't.

Did I?

I feel like I've never thought of that.

Oh, yeah, absolutely.

And also, though, see our book club episode on the poison squad.

Like, there is a reason that pasteurization is hailed as one of the most life-saving inventions.

Yes.

And I think that this romanticization happens to a certain degree also with pregnancy and childbirth.

A call for less medical intervention is understandable, especially when you consider how early medical interventions during childbirth often caused more harm than good.

But it also fails to acknowledge that childbirth can be dangerous.

And no, it is not a disease, and it's not an unnatural state of being as early 20th century physicians believed, but it is a physically demanding experience with potential impact on both mother and baby's life and health.

Although I really, I did find it interesting that in that diary of a midwife, the Martha Ballard, she called like when a when a woman was starting labor, she called it her illness is beginning, which I think is very fascinating.

It was like the pregnancy was not the illness, but the delivery.

Delivery

was right, which maybe just shows how she saw it as like, this is a potential where like there is a lot of attention that's needed here.

Right, right, right.

Imagining the women of the 1700s giving birth with no fear, as relaxed as could be, is erasing the experience of so many who approached their labors with dread and apprehension.

In the early 1800s, women in the U.S.

had an average of seven children.

The number of pregnancies was probably higher because that doesn't include miscarriage and still birth.

Many women spent the majority of their adult lives pregnant, breastfeeding, recovering from childbirth, and taking care of small children.

A baby every two or three years was kind of expected a routine part of life.

But that didn't mean that women necessarily looked towards childbirth without anxiety.

It wasn't just the loss of a child, the potential loss of a child that weighed on them.

It was the physical act of childbirth that carried with it the threat of death.

Diary entries and letters written in the 1800s give us a glimpse into these worries as women wrote wills or gave instructions on who should care for the baby if she died.

Ugh, this hurts my heart.

I know, I know, I'm sorry, but I feel like it's such a part that we don't think that much about, or at least I don't.

Maybe that's just putting my own.

No, I do think, especially because I think a lot of what you're talking about already is like we see, and we see this in a lot of aspects of medicine.

We see these pendulum swings.

Yes.

Right.

And we see things going from like absolutely no intervention to far too much intervention or like, and it's not just in obstetrics, right?

It's in so many aspects of medicine.

And so I think that that, we see that playing out a lot of, especially in like social media right now, where it's like, there's all the intervention or there's.

natural childbirth, which we talked about last episode of like that, that mean, that word does not have

meaning really.

And yeah, I just, I think that that is such an important part that isn't ever discussed when we're talking about like a low intervention birth or something like that.

Yeah.

That like it wasn't all roses

back in the day.

Yeah.

Yeah.

So I want to,

I pulled a lot of these quotes from Brought to Bed because I think that they're, they just illustrate this, like, this idea that it, it, it's not, there are many, there's a lot of nuance to how people felt about their impending, you know, pregnancy, childbirth, and so on.

So Lizzie Cabot wrote wrote to her sister in the mid-1800s, I have made my will and divided off all my little things and don't mean to leave undone what I ought to do if I can help it.

Sarah Ripley Stearns wrote in her diary late in her pregnancy, perhaps this is the last time I shall be permitted to join with my earthly friends.

A woman described her third birth in 1885.

Between oceans of pain there stretch continents of fear, fear of death, and dread of suffering beyond bearing.

Those who attended births, midwives, and physicians felt similar apprehension.

Like there was a physician writing in 1870 who described his feelings of alarm and gloomy forebodings after seeing a patient die unexpectedly during childbirth.

He goes on to write about how those feelings stayed with him, making it impossible, quote, while attending a case of confinement to banish the feeling of uncertainty and dread as to the result of cases which seemingly are terminating unfavorably.

Sometimes the dread wasn't isolated to the act of childbirth itself, but extended to the long period of recovery, like Agnes Reed's letter about her second pregnancy.

I confess I had dreaded it with a dread that every mother must feel in repeating the experience of childbearing.

I could only think that another birth would mean another pitiful struggle of days' duration, followed by months of weakness, as it had been before.

Yeah.

Yeah.

And when comparing historical and modern experiences of childbirth,

we use data, right?

Like we're talking about what about the data.

Right.

And our data are limited to things like maternal mortality or complicated births.

They're not that great anyway.

And we can look at, I think it's interesting to look at Martha Ballard's 814 deliveries from 1785 to 1812.

So five maternal deaths, none during delivery, all during two weeks after birth.

And that's today compared to 0.22 per every 1,000.

So 5 per 1,000, 0.22 percent.

Okay, yeah.

Okay.

Martha recorded 20 neonatal deaths.

That's 2.5 for every 100 live births compared today to 0.56.

Right.

So that I think also is very often left out of the discussion, even when we're talking about interventions that have reduced maternal mortality.

I think that it's easy to gloss over how much we have improved infant survival

and reduced stillbirth and neonatal mortality, like drastically, not even to mention like vaccines and saving lives postpartum and all of that.

Right, right, right.

But

during childbirth experience itself.

Yes, exactly.

Yeah.

Yeah.

Stillbirth, she recorded 14.

That's 1.8 for every 100.

Today, that's 0.6 in every 100.

So there's a lot of, I mean, we can use those data to a certain degree, but I think also like hearing those experiences from the women who, you know, went through this is a really fascinating part of it.

And these data also don't show us what women dealt with in other outcomes of pregnancy.

Like we talked about prolapsed uterus, fistulas, extensive tearing, perinatal mortality, and the emotional experience of that, late pregnancy loss, the range of emotions that could accompany having limited control over your reproduction.

Mary Foote described it in the 1800s as a sort of pendulum between joy and dread.

For Hannah Whittall Smith, writing in 1852, that pendulum swung more towards dread.

I am very unhappy now.

That trial of my womanhood, which to me is so very bitter, has come upon me again.

When my little Ellie is two years old, she will have a little brother or sister.

And this is the end of all my hopes, my pleasing anticipations, my returning youthful joyousness.

Well, it is a woman's lot, and I must try to become resigned and bear it in patience and silence, and not make my home unhappy because I am so.

But oh, oh, how hard it is.

Wow.

That's a really heartbreaking, Erin.

Yeah.

It's,

it's,

yeah.

Yeah.

We have gained so much and then now we're losing so much again.

But I know.

Yeah.

To not, because like, like she said, to not have any control over it.

To not have any control.

Any control over it.

Right.

And it's just like, here it is.

It is my

loss of life.

Yeah.

So yeah, even though pregnancy and childbirth were much more common historically, that didn't necessarily make them more welcome or more looked forward to.

Just as with today, women's experiences were incredibly varied and complex, and they created ways to manage their fears, whether that was surrounding themselves with familiar faces or seeking the latest medical advancements, or both.

The choices available to women depended on when she lived, where she lived, and how much money she had.

Early in U.S.

history, most births were attended by midwives who played played a largely non-interventionist, supportive role.

According to Levitt, as much as possible, they let nature take its course.

They examined the cervix or encouraged women to walk around.

They lubricated the perineal tissues to aid stretching.

They delivered the child and tied the umbilical cord.

And sometimes they manually expressed the placenta.

Historically, at least from my understanding, there wasn't a ton of post-natal care for like mom and baby.

She would be there for a bit and maybe make another visit.

But usually the woman had other friends who would come and help with like

other women in her life.

Exactly.

Yeah.

And the midwife was typically not alone in the, like in attendance.

Often there were like friends and family

there as well.

Usually female friends and family.

But as the practice of medicine became a formal profession, meaning like you had to have a certificate, you had to go to show your training here.

They had to school.

Yep.

Then they developed residency.

That's a whole episode someday probably.

Episode.

Yep.

So this act of professionalization started in the late 1700s, early 1800s, maybe even a little bit earlier in the 1700s.

Towns, that meant that towns and cities had more physicians that could be called in during birth.

And sometimes that call came from the midwife who wanted a bit of extra assistance during a particularly difficult birth.

It's been a long time since I've watched Call the Midwife.

I know.

I

loved that show.

I really loved that show.

There are probably seasons I haven't seen in

the sense out.

Yeah.

Yeah.

I should watch it.

You should.

should.

And physicians and midwives weren't always in direct opposition during this time, and many physicians saw the potential for partnership, with midwives primarily being the ones attending the births and only calling in doctors in cases of emergency.

And these occasions could also lead to tension, though, if the midwife and doctor disagreed.

Some physicians might defer to a midwife with hundreds of births under her belt, but gender and class dynamics ultimately put the authority in the hands of the doctor, no matter how little experience he had.

So I want to read you a quote from Martha Ballard's diary.

She records a few of these clashes, and here's one of them.

They, meaning the parents, they were intimidated and called Dr.

Page, who gave my patient 20 drops of laudanum, which put her into such a stupor that her pains, which were regular and promising, in a matter, stopped till near night when she puked and they returned and she delivered at seven hour evening of a son her firstborn.

Okay, Aaron, so I told you that I read read that like fictional,

okay, that whole story is in there, but in like way more detail, because it's obviously like a fictionalized version of history.

It is fascinating to hear.

And the actual like diary entry?

Yes.

And then like the just like the description, because this story, it's called Frozen River, the book.

And it's like, they go, she goes so much into like what she assumes that Martha Ballard was thinking during the time and stuff like that, which is just so like fun and fascinating.

Yeah.

Yeah.

But that story is in there.

So I knew that one.

I want to read that book.

I'm very curious because, like, there is her diary entries are so sparse in terms of like right and they're too detailed.

So, she says there's very few emotional.

There have been like a couple times where she'll say, like, poor, poor mother because she lost a baby or something.

But, but, yeah, this, and then I think there's another time she calls out Dr.

Page and he's like, What an unfortunate man, or something like that.

But it's hard to know if she's like, and who knows?

Is she irritated at him, or does she actually feel bad because he has chosen a profession that clearly is not to his skill set?

Yeah.

Oh, yeah.

So interesting.

Yeah.

Check out those books that you have.

I love those books.

As doctors became a more regular presence during childbirth, so did the doctor's toolkit, which probably helped bolster appearance of expertise, right?

If midwives took a largely non-interventionist approach, 19th century doctors did the opposite.

There was laudanum or opium, as Martha mentioned, bloodletting, even in the case of hemorrhage.

Oh my god, I still can't get.

I'm sorry, yeah.

But

we haven't talked about humors or bloodletting these all these episodes, though.

I know the humors, I didn't.

That's the only thing that I haven't mentioned is the humors.

At some point, there was something called tobacco infusions.

I don't know.

Doesn't sound right.

Surgical separation of pelvic bones, which

was often led to like permanent disability.

Yeah.

And of course, forceps.

By the mid-19th century, forceps came in all shapes and sizes and were restricted by law to medical professionals.

Like you could not own a pair of forceps unless you could prove you were a doctor.

Wow, okay.

One doctor bragged in JAMA in the mid-1880s that, I hate this quote,

quote, I take pride in stating that as far as my recollection goes, in no case of my own was a woman ever allowed to lie in suffering and danger till the cervix was completely dilated.

Oh no.

I'm sorry.

Oh, no.

Yeah.

Yeah.

They would like prophylactically use forceps.

But like before the cervix is all the way dilated?

Yes.

No.

Like before the baby had even fully entered the birthday.

They had the long, long forceps.

No, nope, nope, nope, nope, nope, nope, nope.

Nope, nope, nope, nope, nope.

So that's not how forceps are used today.

I just want to put that out there.

No, no, no, I just want to put that through there.

We have corrected, of course,

are not used in that way today.

No.

Wow.

But they used to be used.

Yeah.

Okay.

So unsurprisingly, the site of forceps was not always a welcome one.

And so the doctor would just be instructed to, like, he instructed his students to hide them.

Just wear big gowns so that you can hide your tools because it'll, you know, make the woman nervous.

If a medical school included training specifically on obstetrics, and few actually did in the late 1800s, it mostly centered on how to use these tools and rarely included hands-on supervised experience.

Awesome.

Okay, Okay, so there's one example that I want to share with you.

I don't want to hear it.

I hope it's an urban legend, but I don't know.

I would actually believe that it's not necessarily that.

Okay, it tells the story of a newly graduated doctor, official doctor, in the late 1800s who examined his first laboring patient only to be horrified at what he thought was a tumor blocking the birth canal.

He figured, okay, no, she's a goner.

I just have to wait for her to pass.

Only to realize a few minutes later, after she gave birth, that what he thought was a tumor was the baby's head.

Okay.

I thought it was going to go a different way, and I was getting very nervous.

Oh, no.

What did you think I was going to say?

I'm not going to say.

Okay, we can discuss off camera.

Okay.

Yeah.

So someone who is a medical doctor and didn't know how babies were born.

Well, I mean,

that doesn't surprise me.

No, I know.

Back in the day.

Back in the day.

Yeah, yeah, yeah.

But

wouldn't you have at least seen a diagram somewhere?

I don't know.

I wasn't in med school in the 1800s.

They did have like theaters where someone of the students could watch someone.

Can you just imagine the horror of that?

No.

Yeah.

But aside from forceps, the other major tool that was employed by 19th century physicians was anesthesia.

First ether and then chloroform were introduced in the mid-1800s, and pretty quickly they exploded in popularity.

And it wasn't just like popular with doctors, everyone wanted them, especially after Queen Victoria had one of her kids with, I don't know if it was ether or chloroform,

but it was like made the news.

You know who administered it?

No.

Jon Snow.

The John Snow.

John Snow.

Of cholera fame.

Of cholera fame.

Not Game of Thrones.

Disgraced Game of Thrones fame.

Yeah.

Wow.

Yeah.

Okay.

Yeah.

And so that, that really, I think, allowed people to go, oh, I want that.

Okay.

And she was like, this was great.

Yeah.

Do what I really want.

I loved it.

Again, would highly recommend.

Okay, yeah.

And I think it's pretty easy to see the appeal if you look at some of the, I mean, even not based on today, but and like people, you, you have experienced childbirth.

But at the time, you know, in these diary entries, in these letters, women described their labor pains as travail, suffering, screams of agony, anguish, tortures, pains from hell.

And from the doctor's perspective, popular there too, right?

It made for a much more compliant patient whose arms and legs would usually be strapped down to the bed.

And yeah, this is when the bed often became the place instead of like a birthing stool, instead of leaning on somebody else, instead of doing what feels like you want to do, you were physically, in some cases, strapped down to a bed.

I'm not going to get into Twilight Sleep here

because I had a long section that I was like, this deserves its own thing when we talk about, you know, anesthesia.

Anesthesia.

But twilight birth was this thing where you would be given like scopolamine and something else.

And often the effect was not, or the goal was not necessarily to relieve pain, but it was to make you forget.

And it could induce a lot of like anxiety and delusions.

And so they would be physically strapped down.

And then this idea was that you would wake up with a baby in your arms.

A la madman.

A la madman and Betty.

Yeah.

Yep.

By 1900, ether or chloroform was used in 50% of births attended by a physician.

Wow.

Ether or chloroform.

And

we got better later on in terms of like the safety, because a lot of doctors did have concerns about the safety of general anesthesia and these in particular.

And the demand for anesthesia during childbirth actually helped to speed up the move from home birth to hospital because the equipment necessary to administer these drugs would be hard to haul around from like house to house.

The introduction of both anesthesia and other medical tools changed expectations for childbirth in the late 19th century.

It can be done quickly, safely, and with no pain.

That was what childbirth had become, right?

Like this is what medicine promised.

This is an option, yeah.

And of course, that was not always the reality, nor was it the reality for those who couldn't afford to pay for a physician.

or who felt it was taboo to have a man present during labor and delivery.

Doctors charged more for midwives.

So for instance, Martha Ballard charged $2 for her assistance during labor and delivery, and her contemporary, Dr.

Page, charged $6.

Okay.

Yeah.

This could be a lucrative job for physicians.

And as more doctors incorporated childbirth into their practice, they increasingly saw midwives as competition for patients rather than collaborators.

And instead of this high price discouraging people from hiring doctors, it played into this psychological phenomenon familiar to many of us, all of us, where higher price is equated with higher quality.

Yeah, yeah, yeah, yeah.

And that is completely understandable, right?

Who wouldn't pay whatever they could if it meant the best care possible for mom and baby?

The issue was whether it was actually the best care.

In the last few decades of the 1800s, childbirth became increasingly medicalized.

Physicians now attended nearly half of all births and tried their hands at various interventions, none of which had been adequately examined for safety or efficacy.

And while women still held the power in home childbirth, doctors were growing more resentful of that.

Conversation should be prohibited.

Nothing is more common than for the patient's friends to object to bloodletting, urging as a reason that she has lost blood enough.

Of this, they are in no respect suitable judges.

Oh, gosh.

Right.

Her friends are probably like, she is.

Like, she has been drained.

Stop.

Stop.

And he's like, oh, come on, you don't know anything.

You didn't go to Harvard Medical School.

Midwives were also blamed for high rates of pupereal fever and sepsis, despite evidence that it was, in fact, doctors who were much more responsible for the infections due to their proclivity to just go from cadaver dissection to the labor and delivery room in hospitals.

Listen to our pupereal fever episode.

So much more on that.

And in fact, maternal mortality in the U.S.

was on the decline by the end of the 19th century, but it plateaued for a while until the late 1930s, which was after most births were happening in hospitals.

Interesting.

And that's probably because of all of the adjustment.

We'll charitably call it adjustment for transition to the hospital where.

people were still trying to figure things out.

Well, and still studying and learning things because they hadn't done that, right?

Yep.

It's all, yeah, yeah.

The field of gynecology being built on the backs of people who

probably did not consent in a way that was meaningful.

Oh, yeah.

Yeah.

Read Medical Bondage for more on that.

Medical Bondage.

Yes.

Yeah.

That's such a great book.

The U.S.

seemed an especially deadly place to have a baby.

In 1910, one mother died for every 154 live births.

Wow.

Compare that to Sweden at the same time where the number was one in every 430.

Okay.

Yeah.

Wow.

In the early 1900s, U.S.

states introduced laws banning midwifery, and all midwifery became illegal in 1959 under a law that redefined midwifery as the practice of medicine.

Interesting.

Erin, I did not know that.

Yeah.

And I'm not saying that we should have like, there's like, I'm not advocating for a blanket defense of midwifery at the time because undoubtedly there were unnecessary injuries or infections and deaths at the hands of midwives, just as there were for doctors.

But those early bans did not provide any pathways for training or certification for midwives.

And so then that disproportionately impacted poor women who couldn't afford a doctor or who were then forced to go to a hot, like a hospital, which were deadly at the time.

And this is like at the time when

becoming a physician and like the process of that is becoming very well regulated.

Oh, even before then, yeah.

And then there's no pathway to become a like certified licensed midwife the way that we have today with like a registered nurse midwife kind of a thing.

And so other countries did have that pathway for midwives.

In the U.S., we did not.

Got it.

Okay.

And so then this eliminated an entire career path that women had.

So then what, what do you do?

Interesting.

Okay.

This

process.

devalued the contribution of midwives and the importance of human presence as an essential part of care.

Like familiar human presence, not just like a nurse or a doctor popping in every hour, 30 minutes, something like that.

This also furthered the notion of pregnancy and childbirth as pathologies.

The father of modern obstetrics, Joseph D.

Lee, does his name sound familiar to you at all?

I don't think I've ever talked about him.

Yeah.

Okay.

Didn't know if like in med school or something.

Okay.

He wrote in 1920,

So frequent are these bad effects that I often wonder whether nature did not deliberately intend women to be used up in the process of reproduction in a manner analogous to that of salmon, which dies after spawning.

Oh my God.

We're just fish.

That's also.

Also,

male salmon die too.

Come on.

But also that's like doesn't make evolution.

Like clearly you don't understand evolution for that to make sense because salmon spawn like bajillions of fish.

Listen.

And we're reproducing one offspring at a time.

Who's going to require intensive care thereafter?

Like, come on.

He's the father of modern obstetric care.

Not the modern synthesis and evolution.

Okay.

And for his part, because there's nuance to everyone,

most people, he was aware of the dangers that hospitals posed in terms of infections.

And he was a big advocate for home birth or like birthing centers and keeping and like creating new different types of maternity wards where it would be separate from the rest of the hospital and you had different kind of care.

Interesting.

Okay.

Okay.

Right.

Still thanks for salmon.

Fine.

But pathologizing childbirth was a way to send home the message that midwives were not qualified.

Okay.

Right.

This is a dangerous state and you need someone who has been trained in this way and has this, you know,

diploma from this university.

Right.

Okay.

Okay.

And the way that society saw women during this time, especially middle and upper class white women, as fragile and overcivilized, in need of protection.

This delicate

display.

Exactly.

Exactly.

And so all of these factors drove childbirth from the home to the hospital.

Midwifery discredited and banned the pathologization of childbirth, the growth of hospitals, women themselves choosing hospitals and physicians.

As Levitt writes, women who opted for hospital childbirth, quote, gave up some kinds of control for others others because on balance, the new benefits seemed more important.

Okay.

Yeah.

Yeah.

That's completely understandable.

Yeah.

One woman wrote to her mother in 1918, I have placed myself in the hands of a specialist in obstetrics.

I have every confidence in him, and it is a great relief.

Another described her hospital stay as a quote-unquote lovely vacation.

But some women felt the loss of familiar faces keenly.

Quote, the cruelest part of hospital childbirth is being alone among strangers.

Another called it a nightmare of impersonality.

Another, quote, months later, I would scream out loud and wake up remembering that lonely labor room and just feeling no one cared what happened to me.

No one kind, reassuring word was spoken by nurse or doctor.

I was treated as if I was an inanimate object.

Oh my God.

Yeah.

Awful.

Awful.

Truly like dehumanizing.

You are just a machine to make babies and no one cares about your mental well-being.

We know best.

This period from the 1930s to the 1960s is marked by tremendous gains in our understanding of the physiology of childbirth, which is clear from the drastic drop in maternal and neonatal mortality during this time.

But along with those gains came losses.

the loss of control and choice that women had in previous centuries, the loss of friends and family in the birthing room, and the loss of a voice.

This was just how it was.

Deal with it.

This is what you get.

And it took women years to reckon with those losses and to put words to them.

And of course, not everyone felt those losses to the same degree, right?

Some women didn't think twice about their hospital experience.

It was a lovely vacation.

Others maybe didn't love it, but didn't mind it overall.

And it was like, yeah, okay, that was

what it was and now it's done.

right exactly and then some were completely traumatized and everything in between yeah as as we've said a million times there is no universal childbirth pregnancy postpartum experience

In the 1960s and the 1970s, those who did feel the losses began to fight against them to reclaim a voice in the birthing room.

They demanded that their partners be allowed in, that they could breastfeed on their own schedule rather than the hospital-mandated one.

Oh, that is really, really interesting, Karen.

They would be like, oh, no, not here.

Give you two hours.

And they also, that was at the time, too, when it was like nurseries.

And so your baby was taken away and put in a nursery, which is like the opposite of what we do now, which also people have opinions about because then it means the mother doesn't get any rest.

Oh my God, there's so much to address.

I don't know, right?

I mean, we have, this is like jumping ahead a little bit, but

the history of this, this whole series

just shows us that like we don't have everything figured out.

And that's, I mean, that's okay.

Like things are really overall good.

Yeah.

And as people are talking about them, are researching them, are writing about them, are sharing their experiences, I think it just gives such hope that things will continue to improve.

But it is really also that is not to erase the experience of people who are like, I did not have a good time.

Right.

Yeah.

Right.

And I think, I think it is just so interesting to do what you're doing right now, Aaron, which is like look back at like, how did it used to be?

How did people feel about that at the time?

Yeah.

how did we get from there to here why did the pendulum swing this way where are we in this pendulum arc right now like even knows I know but it's so interesting to like go back and try and kind of piece it together on like because it gives you so much context that sometimes might make something that feels horrible today make more sense and then make it more like you're you can okay, I understand why this thing happened, right?

I think that's so important.

Why, where, why are we here today?

Why are we here today?

Yeah.

Did not mean to get that existential, although I'm surprised given that this is a series on pregnancy that we haven't gotten that existential.

Here we go.

Fourth cash.

Yeah.

Putting it all on the table.

All on the table.

But yeah, all of these, all of these new choices or choices that previously had not been available, things like having your partner in the room, breastfeeding whenever you want.

Do I want an epidural or not?

And so many other choices that simply probably were not available.

Right.

and we are now i think coming to terms with some of these like the choices and the range of choices and i i will say too that that is a double-edged sword right since the 1970s women along with researchers doctors nurses midwives doulas partners parents have examined the childbirth experience from every angle asking what do i want what's best for me what's safest for baby how do we balance everyone's needs

and today, there are so many choices, there are so many options, and there are so much information out there that it can feel overwhelming.

How do you make the right choice, especially when the internet has very strong opinions about everything?

What happens when you are not able to choose or if the choice is made for you?

Navigating pregnancy, childbirth, and the fourth trimester is a huge challenge, which is the understatement of this series.

I'm getting like so many flashbacks right now.

It's a lot.

From your chat, yeah.

Yeah.

Yeah.

Yeah.

Yeah.

Keep going.

How am I, is this the right story?

Is this the right choice?

Was that the right choice?

If I don't make a choice, what does that mean?

And then if this happens.

Yes.

And what if there's a choice that like, did I have a choice?

I'm not sure.

Yeah.

That, yeah.

And there are a million voices telling you, yes, no, maybe in conflict, maybe not in conflict.

Do this, do that.

That we have more choices and more knowledge today than we did 60 or 100 years ago is a powerful testament to the work of countless women and modern medicine striving to make this a safer and better experience.

And of course, there's still room for improvement.

There will always be room for improvement.

But understanding our past, understanding what we lost during the medicalization of pregnancy, as well as just how much we've gained, is crucial for creating a better future.

Recognizing those gains is especially important because I think sometimes we take them for granted

or we lose sight of them next to the negative impacts of medicalization.

That is what stands out the most to us.

For instance, take postpartum depression and other postpartum perinatal mood disorders.

From pupil insanity in the late 19th century, which is what it was called, well, which is what it was a diagnosis.

It's not necessarily,

there's more nuance to pupil insanity.

Yes, yeah.

To what was called baby blues post-World War II, to postpartum depression finally making it into the DSM-4 in 1994.

1994.

I told my mom that and she was like, really?

Just wait.

Oh, and it's not even, I know.

And then in there, there's like a whole journey about how it got in there and was it actually put place in there in an appropriate way.

And what we don't have in there today.

What we don't have in there today.

And then

also, like, there's the book Blue is really fascinating too, because it talks about how postpartum depression became like gained more awareness.

And it was through the work of a lot of people, advocates who worked really strongly to make people more aware of this potential outcome.

But the way that popular media often seized on postpartum depression was through the most sensationalist news stories possible.

And so then that was like, I think in some ways had this effect of, oh, well, I didn't, I don't think I had postpartum depression because it wasn't bad.

You know, exactly.

It wasn't that bad.

Some of the extreme scenarios.

Right, right.

And I think that we have now, like, there's been such incredible representation in the media.

And it's still, again, room for improvement.

But yeah, I mean, I think it's safe to say that since the late 1800s, postpartum depression, postpartum mental health has really been on a journey.

And ultimately, creating a clinical definition for PPD, imperfect though it may be, it opened up research areas for treatment.

It raised awareness and established ways to treat people or reach people who might need help.

And it removed some of the blame that had been so central to postpartum mental health for decades.

Oh, she's depressed because she hasn't accepted her role as a mother.

Thanks, Freud.

She's got PPD because she had a C-section.

Right.

Working moms bring on PPD themselves because they're just not equipped.

Yeah.

Yeah.

Yeah.

Blame certainly remains.

It is not gone by any means.

But turning this into a more, having a more biological framework for understanding this has helped to remove some of that to some degree.

And there is, of course, downside to this medicalization, right?

It has discouraged to some degree consideration of systemic and societal drivers that might underlie PPD that I know you're going to talk about.

I sure am.

Because if you're treating it just as a hormonal or chemical imbalance, then it's like, so, but it's not happening in a vacuum.

Oh my God, Aaron, I literally can't believe how well this is like segueing into what I'm going to talk about.

It's like we do this.

It's almost like it's our job.

But yes, 100%.

Yes.

And it.

creates boundaries around what is normal.

Right.

And those boundaries might be different for different people, but it's really hard to incorporate that into a medical definition, right?

And I will say also those boundaries are a necessary part of any medical definition.

But having that lack of nuance in understanding the individual can also be really have consequences associated with it.

Yeah.

Personalization of care is a crucial aspect, not just for PPD, but also for childbirth and pregnancy more broadly.

And I want to end with yet another quote by Judith Walser-Levitt.

I really love this book, as you can tell.

Quote, throughout American history, women have wanted and have worked to achieve their own ideals of childbirth, ideals that have developed and been nurtured within their own communities in conjunction with the rest of their life experiences.

Childbirth remains, as it has always been, a cultural event as much as a biological one.

Problems emerged during the middle of the 20th century because the hospital acted to homogenize the birth experience and make it similar for all women.

But childbirth cannot successfully be reduced to one kind of experience and at the same time satisfy the wide range of expectations women bring to it.

The diversity that women seek will continue to reflect the differences of the women themselves.

End quote.

And chills.

And with that, Erin,

I'll turn it over to you.

You're leaving me right there, huh?

Tell me about the fourth trimester.

Okay.

You might need a little breather after that.

Okay, we can do that.

We'll take a break and then get get into it.

Shall we?

Let's do it.

Hi, I'm Morgan Sung, host of Close All Tabs from KQED, where every week we reveal how the online world collides with everyday life.

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At 32 years old, I got pregnant for the first time.

I had what you'd call a textbook pregnancy.

Healthy baby, low risk and a noticeable glow.

But there was a lot of things that I wasn't warned about and things that just weren't talked about unless I brought them up.

Hubby and I started trying for a baby in September and luckily enough by November I was pregnant.

My first symptom wasn't morning sickness or anything like that.

In fact it was excruciating period pain.

I genuinely thought I was about to have the worst period ever as some kind of cruel drug.

Turns out it was implantation.

The next time I felt that level of pain was actually an active labour.

Within two weeks of conception my body already started changing.

My boobs went from an A to a C cup almost overnight and they continued to grow throughout my pregnancy and got pretty big during breastfeeding.

My stomach also grew quickly.

I was mostly water because baby boy was measuring perfect the entire time.

I was very lucky when it came to nausea.

I only experienced it for about a week and cardamom tea helped a lot.

I only vomited twice, once from a bad meal which my husband also got sick from, and once when I accidentally ate bacon because pork was a major food aversion for me, which is kind of surprising given my Italian-Australian background.

Thankfully, since my husband is Muslim, pork wasn't something I had to deal with in the house.

The cravings did start really really early.

At first, it was salt and vinegar chips and anything sour, especially lemon ice cream.

In the second trimester, I craved corn and coffee.

Of course, I only drank decaf, but I never drank coffee before pregnancy.

Funnily enough, I'm still drinking it now after giving birth.

By the third trimester, my cravings had evolved to steak with an egg on top.

On the flip side, I couldn't stand chicken or pork.

Even the smell of chicken made me nauseous, to the point that if my husband ate it, he had to brush his teeth before coming near me.

Pregnancy also came with a long list of symptoms I just wasn't prepared for.

Blood noses, grey hairs, loose ligaments, ligament pain triggered by sneezing, dry skin, exhaustion that left me sleeping for 10 hours at night and then still napping for four hours during the day, acid reflux and reoccurring thrush, which I had never experienced before pregnancy.

The physical strain was pretty intense.

At times, it felt like I'd done a hardcore leg day at the gym or I'd been riding a horse bareback for hours.

I had to give up weightlifting and running because I was just too exhausted, but I did manage to do a little bit of yoga a couple of times a week, and maybe that's why I could still tie my own shoes at nine months pregnant, who knows.

In my third trimester, I needed an iron infusion.

My iron levels were actually fine, but my hemoglobins were slightly lowered, so it was recommended that I do it.

Around this time, baby boy started moving into position, and I could feel every shift.

There was a moment when I genuinely thought that he might just fall out because of how low he moved.

Despite all the unexpected symptoms, I got the birth experience that I wanted.

I had a pain relief, water birth, and in the final moments, I reached down and pulled my baby out myself.

It was an intense and transformative experience, and one that I'm really grateful for.

Looking back, I know I was lucky to have such a smooth pregnancy, but that doesn't mean it was easy.

There were a lot of challenges, surprises, and lots of moments of discomfort.

Through it all, my body did exactly what it needed to do, and I'm so grateful for my body for doing that and for giving me my beautiful, healthy baby boy.

Hi, Aaron's.

My name is Miranda, and I want to thank you for allowing me to share my pregnancy and birth journey.

I have to say that overall my pregnancy journey was relatively uneventful and I'm very thankful for that for the health of myself and of my baby boy who is now 18 months old.

I will say the most annoying and most prominent pregnancy symptom I had was actually carpal tunnel syndrome, which going into pregnancy, I had no idea that that was a common symptom.

I spent probably the second half of my pregnancy with my hands being numb or tingling or painful almost 24-7.

So that was definitely frustrating.

Other than that, towards the end of my pregnancy, I started to have some gestational hypertension.

So we did a few non-stress tests and biophysical profiles to make sure that I was safe and that my little guy was safe.

On the 4th of July, maybe I had a little too much fun on the lake and enjoyed some salty snacks, but my blood pressure did go pretty high, so they ended up deciding to induce me when I was due in mid-July.

So it was not too early.

I really didn't need much of a kickstart for labor, thankfully.

I started labor pretty darn quickly without even having any Pitocin.

Unfortunately, I did not progress in labor as we'd hoped.

I was in labor for 18 hours and I was dilated to nine and a half centimeters and I was stalled out.

So after about six hours stalled out, my son's heart rate started dropping and my doctor advised us that we could wait a little bit longer and potentially have to have an emergency c-section

or we could just do a c-section now.

And after 18 hours of labor, I was on board with that.

We had a beautiful and wonderful C-section experience and I'm so thankful for all of the staff and my husband and my mom for being there to support me.

I was was very surprised by the swelling after the C-section.

I couldn't wear shoes for two to three days.

But other than that, my little guy was happy and healthy, and I had an overall great experience.

Thank you.

So last week, at the end of episode three, I ended where most conversations regarding pregnancy end, and that is once the baby's delivered.

Right.

Everything's over.

Yeah.

But that's not where pregnancy ends.

At all.

So Erin, you just walked us through a lot of the kind of social and institutional and like high-level factors that have caused this shift in where delivery happens and how these things have kind of contributed to a lot of the big picture postpartum outcomes.

Those big picture things are like maternal mortality rates,

even like postpartum depression rates, which we'll get into.

And so, that is where I'm kind of picking up your threads right there.

Perfect.

But then I'm going to unravel them a little bit more to also remind us of what is going on biologically in this so-called fourth trimester.

Yeah.

Why it might be rocky for some of us.

And my favorite, what do we know about evidence-based ways to improve outcomes?

Oh, evidence-based.

What a beautiful phrase.

I just love it.

You want a spoiler alert on what it is?

We don't know.

Public health.

Oh, okay.

Don't worry.

We know.

We don't know.

No, we do.

Public health, but then public.

Do we invest in public health?

Maybe we will.

Someone will listen to this episode and be like, aha.

I didn't want to read the Lancet Global Health article, but I listened to this podcast will kill you, and now I have all the answers.

Okay.

I do also want to quickly acknowledge what I am not going to talk about in this episode, even though it's so cool.

And that is the physiology of the newborn.

Yeah.

Just like like I kind of breezed through early embryonic development and I didn't talk at all about the rest of fetal development.

I am not going to talk about the physiology of the newborn, but it is really cool and fascinating.

We'll do it someday.

It's the second, fourth trimester.

Exactly.

Yeah.

But we're, this is pregnancy.

And so this is the fourth trimester of pregnancy.

Yeah.

Pregnant person.

For years.

Okay.

Physiologically, there is still a lot of changes to take place after the baby and placenta have been delivered.

Now, the placenta, our favorite, is the primary organ that was making all of the hormones that kept the pregnancy going.

So, once that placenta has been delivered, you have a rapid withdrawal of placental hormones, and that results in significant decreases because the placental hormones are like there's a whole bunch of different things, and a lot of them, it's not necessarily just like estrogen and progesterone alone, but it's like hormones that are telling us to make more estrogen and progesterone and stuff.

It's like both a radio tower.

It's not just like a trans, okay, here's what I was thinking.

Love is blind.

It's not just the window between the two, right?

It's like if the window were also saying, now go get flowers.

It's also the producers.

Yes.

It's the producers.

This analogy does not need to exist, but I like it.

Love a bad analogy.

Yes.

Okay.

It's that.

Okay.

It is the producer, the director, whatever.

But so once this placenta is gone, you have a significant and pretty rapid, like in a number of days, weeks, decline in estrogen and progesterone, especially.

And this cascade is what results in a lot of the physiologic changes that we see.

So I'm going to kind of walk through, again, a little bit system by system about what some of these changes are.

Most of these changes kind of get you back to, and I hate to say back to, because it's really a new normal.

But in terms of your physiology, a lot of it is closer to pre-pregnancy levels

of the stuff that we're going to talk about.

By about six weeks, some of it takes about 12 weeks.

So can I ask a question about like what?

How different are those changes?

Like, is there just a way so I can, in my head, quantify what that looks like?

And I guess it's hard to know like how much estrogen is actually

those numbers.

Yeah.

I don't know.

I think one of the graphs that I had in last episode showed like hormone concentrations and stuff like that.

But there's also such ranges, and especially like anyone who is menstruating, your levels fluctuate so much with your menstrual cycle.

Okay.

I will say that after, like in postpartum,

you have a withdrawal of these hormones.

So they go down to very low levels.

And if you are breastfeeding, they remain suppressed because of prolactin that's being so like the withdrawal of progesterone skipping around in my notes the withdrawal of progesterone causes an increase in prolactin which is the hormone that stimulates milk production so if you are then breastfeeding you continue to have high levels of prolactin and that suppresses the release of LH which is luteinizing hormone and FSH which is follicle stimulating hormone and those are what would induce a normal ovulatory and menstrual cycle right and And that is why you see suppression of menses during breastfeeding and why that is, for a lot of people, a good form of contraception.

But doesn't always

mean that way.

But I mean, it is like it's more effective than condoms.

Okay, that's interesting.

It does not get, I had a whole paragraph on this somewhere, but I can't even find it.

So I'm going to just talk to you from my brain.

It is, I forget the exact number, but it is actually quite effective, but it's only for the first six months postpartum that we have good data on it.

And it's only when people are exclusively breastfeeding, which does not include pumping, because it is also breastfeeding on demand, which means that you are breastfeeding based on your newborn's cues and not necessarily on an hourly schedule, which is what you end up having to do if you're exclusively pumping.

Right, right.

Not everybody is going to remain amenorrheaic, which means they're not having menses.

But it is, it has actually, as per the World Health Organization guidelines, it is a effective and recommended form of birth control for a lot of people.

Oh my God.

Okay.

I didn't know that.

And there's more nuance because I know a number of people people who have gotten pregnant while breastfeeding.

Absolutely.

And so there's more nuance too, because if you are sort of supplementing with formula or if you're having to be away and then you're pumping and things like that, then absolutely your menses can come back earlier than that six months.

Yeah.

They can come back in a matter of weeks.

Again, it's going to be different person to person.

That's why it's not 100% effective.

Right.

You know what I mean?

But yeah, it is.

It is really interesting.

Yeah.

I love that.

Tangent for us there.

I love a tangent.

Me too.

So yes, we see this big hormonal change.

And then a lot of those physiologic changes that happened to sustain the pregnancy are going to kind of unravel themselves.

So your blood volume, which again had increased by about 50%

during pregnancy, is going to return to pre-pregnancy baseline within a matter of weeks.

And what that means is that you immediately after birth have way more fluid on your body than your body thinks that it needs now that there's no placenta there secreting hormones to say keep up this blood volume.

So your kidneys have to take over the work of excreting all that extra fluid.

And so your kidneys have to further increase their diuresis.

And so you have this physiologic diuresis.

So a lot of times you'll have, you'll be very kind of puffy immediately postpartum.

And that's because of all this excess fluid that your kidneys are now just trying to like shunt out.

And then you're peeing all the time because of that.

And how long does that last?

A few days usually for the like the physiologic diuresis.

I think it, I don't remember the the exact days that it peaks, but it's like a few days and then you kind of go back to your pre-pregnancy baseline-ish.

Yeah.

Your GI tract, which remember slowed down a lot during pregnancy because of progesterone.

It actually slows down even further during labor and it will start to return to a pre-pregnancy type of functioning.

Like mobility will come back within a few days.

But in those first few days immediately postpartum, you can have that continue, like it's a little bit more slow and that can result in constipation.

This is exacerbated by C-sections because those are, again, abdominal surgeries where it can cause the bowels to kind of like go to sleep a little bit.

And so that can mean that you can end up a little bit constipated.

Plus, opioids are often used.

And so those slow down the bowels even more.

Super slow.

So that can make people either very nervous about their first bowel movement postpartum because whether you had a vaginal delivery or a C-section, you might be worried about a hard stool that might be harder to pass.

So yes, that's the thing that can happen is constipation postpartum.

Usually gets better within a few days, unless you're on opioids continuously.

Okay.

Yeah.

Your uterus, which of course had to grow so large that it displaced all of the rest of your organs,

like we talked about last episode, has to shrink back down.

And it does this very quickly, except that it doesn't go all the way back to like pre-pregnancy baseline until a number of weeks later, closer to like six weeks later, because it just has to like continue to shrink.

Part of that process also means a couple of things are happening to like encourage that process.

One is that the release of oxytocin, which is triggered by breastfeeding.

So, for people who are breastfeeding, they're going to have an increase in the release of oxytocin.

That oxytocin is the hormone that stimulates uterine contraction.

So, that's going to cause further uterine shrinkage back down to like the size of a fist, which is what it is pre-pregnancy.

And is that

pumping or breastfeeding?

Pumping or breastfeeding, either one.

And then, even if you are not breastfeeding, it's still going to shrink on its own.

It just might maybe take a little bit longer or things like that.

Okay.

But yeah, so that it's going to take a few weeks before it really goes back down.

It's not like an automatic.

It clamps way down, but it doesn't like go back.

It takes time.

Yeah.

Takes time.

And as part of all of this, as this uterus is continuing to shrink and contract, it also means that you are going to be shedding all of the remnants of your endometrium, regardless of your mode of delivery.

You are going to be shedding this lining of your uterus and your uterus is remodeling its whole inner lining.

So you have a lot of vaginal bleeding.

This is called lochia.

That's like just what we call the postpartum bleeding.

How much is it called lochia?

L-O-C-H-I-A.

Huh.

Lochia.

And how, how long does that last?

How much blood?

Like, yeah.

So how much blood can vary,

of course.

Of course.

It usually can last anywhere from like a couple of weeks to a month or more, totally person dependent.

Okay.

Yeah.

And the amount of blood, like relative to a regular, like if you have more regular periods.

What is a regular period, Aaron?

For an individual,

that doesn't even track.

No, yeah.

It totally varies.

What I will say is what we, okay.

We talked a lot about postpartum hemorrhage last episode.

Yeah.

Delayed postpartum hemorrhage is also a thing where you can have a hemorrhage that occurs later on after delivery in the days or weeks post days.

And so what I will say is like the general advice in terms of how much is too much bleeding,

I don't actually like to give medical advice on this podcast.

This is not medical advice.

We are not your doctors.

Please consult your doctor.

But usually if somebody is bleeding so much that they're like completely saturating pads for like hours in a row or they're passing very large blood clots, that is usually considered too much bleeding.

Okay.

So it's kind of, it should be like a moderate amount, but not like heavy, heavy bleeding.

Right.

But again, can very vary.

Some people have very little bleeding.

Okay.

Yeah.

And then we, of course, have milk production, which we kind of already talked about.

So I can skip it unless you have any other questions about that.

When does it really like?

Of course I have questions about that.

Kidding me?

So the first milk, quote unquote, that you produce,

all of this is stimulated by, again, this withdrawal of hormones and then the increase of prolactin.

But even even as that process, before that process has really kind of kicked in in those first couple of days, your body is producing this substance called colostrum.

And that's that kind of yellowy, like it's a different texture, it looks different substance.

We actually start making that most people during about the second trimester.

Some people might notice it, some people might not.

And then it takes usually two or three days on average for your breast milk to come in

in people who aren't going to be breastfeeding.

There are a lot of situations that can cause challenges to that, whether it's delayed milk production.

One of the risk factors for delayed milk production might be a C-section.

The mechanism there, not fully known.

Right, we don't know.

But it is the case that C-section is associated with an increased risk of delayed milk production.

Also, early delivery, whether that's early term, which would be before 37 weeks,

or like late preterm, it's like 34 to 36 weeks or so in there, Or even just that like early term, 37, 38 weeks, sometimes people have a little bit of a delay or have like a little bit of a delayed start in their breast milk production.

And then there is so many individual factors as well that play in.

Have you ever breastfed before?

Like so many different things.

There's also infant factors that can really contribute to like this successful breastfeeding relationship.

Babies who are born early, either that early term or preterm, might have difficulty latching.

They might not have really good muscle tone yet because they weren't fully developed in utero.

And so they don't have a great suck.

Like there's literally so many things.

And I feel very strongly about the rhetoric around breastfeeding today.

Yeah, we do.

I do feel that it deserves its whole own episode.

We will do one.

We absolutely will because there is a lot to unpack there.

And the short answer is, in my opinion, and per medical establishment, regardless of whether they admit it or not, Fed is best.

Okay.

Long story short, two to three days for breast breast milk production postpartum usually.

Now,

during all of these physiologic changes that we've gone through, whether you notice them or not, like you might not notice your blood volume changing, but you might notice that you're peeing a lot, sort of a thing.

You also have just given birth either vaginally or through a C-section.

So you might have stitches either in your abdomen or in your perineum, or maybe not.

In either case, you're probably going to be sore.

There's going to be pain that is there because of the whole process that literally just happened.

Yep.

And then on top of that, you have an infant or multiple who needs literal constant care.

Constant around the clock

cannot be left alone for like a minute,

who sucks at sleeping.

They suck at it.

Why are they so bad at sleeping?

Why are they so bad at sleeping?

They suck at pooping.

They're not even good at pooping at

pooping.

They suck at eating.

Yeah.

They cannot figure it out.

And you are now entirely responsible for them.

Yeah.

This is a very difficult time period.

Yeah.

Even if you are good at it or you've done it before or something like that, it's very hard.

And we talked in these last few episodes a lot about the risky parts of pregnancy.

The postpartum period really often, especially in the US, gets dismissed.

Oh, right.

Yeah.

But all of these physiologic changes that we've gone through,

they don't reverse themselves automatically.

And they are still kind of changing and finding a brand new baseline in this postpartum period, which means that we are still at increased risk of things like postpartum preeclampsia.

Yeah.

Okay.

Of delayed postpartum hemorrhage, like I talked about.

There's also the risk of infections like endometritis, which can happen post-delivery.

So there is a lot of different topics that I could go into, but what I'm going to now shift to focusing on is one of the biggest contributors to postpartum morbidity, and that is postpartum depression and postpartum anxiety and other postpartum mood disorders.

So postpartum depression, which is the one that gets probably the most pressed these days and is the most well-defined because it does exist kind of in the DSM-5,

it is generally recognized as more than two weeks, and sometimes it's like has to be developed in the first four weeks of a depressed mood

in the postpartum period.

And we use a number of different screening tools that are very well validated, like this questionnaire, which is called the Edinburgh Depression Scale or Edinburgh Postpartum Depression Scale, to decide if somebody meets criteria or needs additional evaluation for postpartum depression.

So it's a series of questions, and they're things like, how, like in the last two weeks,

how often have you felt like I'm not looking forward to enjoyment with things?

Or how often some of the ones that I really hate are like, do you feel like you are worried for no good reason?

This is when I told you, I feel like I lie on these because I'm like, sorry, I am very worried for a very good reason.

For a good reason, yeah.

I have been anxious for no good reason at all, or I've been crying for no reason.

Right.

To ask someone to say, are your anxieties justified?

Are your worries justified?

Like, that's not, yeah.

Yeah.

But that's just my personal feelings.

These are very well-validated

tools for screening.

And so this is the kind of first thing that's recommended that everybody during pregnancy and postpartum is supposed to be offered questionnaires like this to try and identify people who are perhaps experiencing postpartum mood disorders or who are at risk of developing postpartum mood disorders.

Globally.

Postpartum depression has an estimated prevalence of 17%.

That is so much higher than any of the other complications that we have talked about.

Yeah.

Like so much higher.

That global number, though, is not like you can't just leave it there.

Okay.

Because the variation geographically is huge.

Okay.

Now, low and middle income countries, prevalence is significantly higher, significantly higher than in high income countries.

The average, if you just lump all low and middle income countries, which is not a fair thing to do, but if you do that, then the prevalence is estimated at around 20%.

High-income countries, the average is like 15 15.5%.

But as you can see, there's a graph that's in a paper that I cite that shows this huge range in distribution.

Some countries are as high as 30 in the 30 percentile.

So yeah, so the range is really, really huge.

And a lot of high income countries, the prevalence of postpartum depression is in the single digits, like 8%, 9%.

The U.S.

and the U.K.

are a little bit of outliers in the high-income country bracket, where the prevalence is estimated at 18 and 20%, respectively.

Okay.

Okay.

Now, pause for a second because we're going to Aaron math this a little bit.

Yeah, yeah.

Because that is in the US, we have an estimated around 3.5 million live births every year.

If 18% of those and postpartum depression is not limited to live births.

So this also encompasses depression, post-miscarriage, and stillbirth, which those rates are even higher.

But even if we just look at those numbers, three and a half million live births, 18%

of those people having postpartum depression is over 630,000 people in just the U.S.

every year.

That's not a small number of individuals or families that are being affected.

Yeah.

So

that's postpartum depression, which is just one of the postpartum mood disorders.

Postpartum anxiety.

I have a question.

Sorry.

I know you're you're like, I really don't know.

I just want to.

I know, I know, I know.

Okay.

This map that shows the rate of postpartum depression or the prevalence.

Prevalence or

prevalence.

Yeah.

Okay.

Is postpartum depression, is this all being defined in the future?

It's all being defined as DSM-5 definitions.

DSM-5 definitions.

Yeah.

Postpartum anxiety, another one of the postpartum mood disorders, estimated to affect 8 to 12% of people postpartum.

Here's the big problem here.

Okay.

We don't have diagnostic criteria.

There is no such disorder in the DSM.

There is no disorder that is called postpartum anxiety.

We also do not have a screening test.

In theory, the EDS should be capturing people who are at risk for postpartum anxiety-type mood disorders

and depressive disorders, but it doesn't.

Like, there's no screening test for anxiety that is universally administered in the postpartum period.

And there is also not a specific like disorder that is recognized as a postpartum anxiety disorder.

So then people have to, like, in to get a diagnosis, quote unquote, whether that's important or not is a different discussion, but it would then be a different type of anxiety disorder, like a generalized anxiety disorder, obsessive-compulsive disorder, right?

Like all these other types of anxiety disorders, because anxiety is a symptom and not a diagnosis.

Okay.

A few questions here.

So a person could have postpartum depression and postpartum anxiety.

Absolutely.

Okay.

Secondly, then, do postpartum depression, postpartum anxiety, like, because I know that in reading about the history, the postpartum, like there was a huge fight or struggle to get postpartum to be a specific thing.

And part of that was related to insurance and stuff so that it's like, oh, if this was preexisting, we're not going to cover it.

Correct.

But,

and so then that postpartum period was shown as a risk factor.

And that is how we got postpartum depression as a diagnosis.

But then what,

what?

So

I think it's usually, it has to last longer than two weeks.

Okay.

Because the first two weeks postpartum, people can have a depressed mood that is still called the baby blues.

Yeah.

The postpartum blues.

Which is, people have described it as infantilizing, but

I don't agree with that.

Yeah.

In the 60s, do you want to know what like, I think it was Dr.

Spock or something.

You know, like the Benjamin Spock who was like, this is is how to care for you.

No, I only know this Spock with like the live long and prosper.

This is relative.

Okay.

Yeah.

Not really.

Oh, I was like, I was like, he's an alien.

That's why I was so confused.

No, it was recommended that to pick to like, oh, if you have baby blues, pick yourself up by getting yourself a new hat or treat yourself to a new dress.

Go get your hair done.

Get your hair done.

That was literally in the middle.

Okay.

Yeah.

Love that.

Anyway.

Yeah.

So lasting more than two weeks.

More than two weeks.

And then in terms of the onset of development, it's like usually the first year postpartum is all still considered within the postpartum period.

Okay, that's what that was my terribly worded question I was trying to get.

The like overall timeframe.

Yeah, yeah.

Yeah, yeah, yeah.

And then, of course, there is also the most severe spectrum of maternal, like postpartum mental health disorders, and that is postpartum psychosis, which is not called postpartum psychosis.

It's brief psychotic disorder with postpartum onset is the dsm5 title but this is the onset of hallucinations or delusions and like disorganized behavior and and things like that that usually go along with depression or depressive symptoms during this postpartum period This is thought to be relatively rare, though our studies are not as robust on it, but estimated between 0.86 to 2.6 per 1,000 births.

So it's commonly cited as like one to two per thousand based on a global analysis from 2017.

But it is also the most acutely dangerous of the maternal mental health disorders because this can be, it can be very severe and

really disturbing for the mom and the family.

And so often results in hospitalization.

Yeah.

I think I told you this, Erin, but I listened to a book called a memoir called Inferno, a memoir of motherhood and madness by Catherine Cho.

And it was about this person's experience with postpartum psychosis.

And it was a really

insightful and meaningful and also like really, I just, it feels like a really important book.

I really appreciated it.

But the other thing that I think was really interesting about that was how she talked about she was in the U.S.

when

this happened and when she was hospitalized, but she was actually like traveling

from the UK where she lived in the UK.

And the treatment is very different different in terms like the management of like okay well keep mom with baby okay

keep mom separate from baby in the US and just like interesting I just

yeah yeah all the the different all the different choices and I will say that our understanding of like the neurologic or the biologic basis that underpins postpartum depression anxiety psychosis like it is poor to say the least that's like an understatement it is very often blamed especially in like popular media press about postpartum depression on quote unquote hormones.

Yeah.

Maybe there is some data that that might be true for this quote unquote baby blues period,

where I also, it's important to say that like 40 to 70% of people can experience this like mood lability during those first two weeks.

And that is when our hormonal shifts are the most extreme.

So sure, maybe that is responsible for that first period, but we actually do not have data to suggest that there are hormonal differences in people who are experiencing other postpartum mood disorders past that two-week period and people who do not.

So we do not understand it the same way that we don't understand the biologic causes of depression or anxiety or other mood disorders outside of the postpartum period.

However, however, what is clear from the epidemiological correlates, from the facts that, for example, as we saw globally, the rates are significantly higher in low and middle income countries that lack health infrastructure,

that lack access to health care in the prenatal and postnatal period,

or that rates of postpartum depression are significantly higher in lower-income households in high-income countries that lack access to health care, that they are higher in people who are subjected to additional stressors, such as abusive or unsafe relationships or unintended pregnancies.

What is clear from these epidemiological studies is that a lot of the factors that contribute to an increased risk of postpartum depression and other mood disorders are potentially modifiable

and not on an individual level.

So important.

Not on an individual level.

Yeah.

And in fact, the single greatest risk factor for postpartum depression and postpartum anxiety are untreated anxiety and depression outside or during pregnancy.

So, if we can actually recognize and provide treatment of mental health disorders outside of the context of pregnancy, we can help reduce the burden of postpartum disorders as well.

So, I'm going to now shift this to talk about what we know,

some data, about how to improve postpartum outcomes overall.

Evidence-based.

Evidence-based medicine.

I found a quote from an article from 2016 in the American Journal of Obstetrics and Gynecology that said, and I quote,

the intense focus on women's health prenatally is unbalanced by infrequent and late postpartum care, end quote.

Yep.

And that in the United States of America is an understatement

because postpartum care is not just infrequent for most people in the U.S., it is one singular visit, which 40% of people, especially those on public insurance, do not usually attend.

And it occurs at six weeks postpartum, which is when I already said that most of those changes that are happening are done.

They're done.

Contrast this with getting weekly visits for at least the first four weeks prior to delivery, and then every two-week visits for the several months prior to that.

Like, yeah.

Well, okay, also then, Aaron, and I feel like I'm jumping ahead.

Give it

during pregnancy, who are you seeing?

And then after pregnancy, who are you seeing?

Oh, Aaron, let me tell you as a family medicine physician what my feelings about that are.

Yes, in the U.S., our system is very fragmented.

Yes.

We are generally seeing OBGYN providers primarily during prenatal period, during your all your prenatal visits.

And then afterwards, you're seeing a pediatrician and you are seeing them pretty frequently.

And they are there for baby and not for you.

And then you see your OBGYN one time at six weeks.

Yeah.

Okay.

So

this

concept of a fourth trimester is a recent concept, at least in U.S.

medicine.

And it really is kind of an admission of our failure thus far to adequately care for people who have recently given birth.

In the U.S., an estimated 23% of employed women return to work within 10 days postpartum.

Sorry.

10 days?

10 days postpartum.

And if that is not one of the most shocking statistics, then I don't know if you've been paying attention to these episodes.

Now, that is not the case everywhere.

So I'm going to walk you through a paper that really was very interesting.

It was a comparative analysis that compared and contrasted postpartum care, prenatal and postpartum care in the US and five other high-income countries.

Because again, this is what we have to compare to, like kind of apples to apples, right?

And this compared the U.S.

to France, Japan, Australia, England, and the Netherlands.

And we know from things like the data on maternal mortality that outcomes are very different in the United States compared to all of those other high-income countries.

Our maternal mortality rates are three times as high as France and the UK and nearly 10 times as high as Australia.

Our maternal mortality rates in the U.S.

have been on a rise faster than any other countries, though there has been a rise in the UK, but it's been at a less substantial rate compared to the US.

And maternal mortality is incredibly unequal, with Black American women dying at nearly three times the rate.

In 2022, maternal mortality for Black women was 50 per 100,000 live births, compared to 19 per 100,000 for white women and 16 per 100,000 for Latino women.

And I will say the numbers were different in 2021, but we don't know if that was because of COVID or what.

But this trend has been there for decades.

Yeah.

Okay.

And so this comparative analysis was looking at prenatal and postnatal care, not just looking at like delivery method or like one time point, but like, let's look at these overall systems of care to see if there are any big themes that come out.

And boy, how do you do they?

So as a baseline to understand where a lot of other countries maybe are getting ideas from, the World Health Organization recommends immediate postpartum care.

So, like immediately in that postpartum period, like after delivery of placenta for the first 24 hours, and then care in the first 24 hours, and then additional visits at three days, seven to 14 days, and at six weeks postpartum.

And that should include both maternal and newborn care.

And again, in the U.S., our care is divided between specialists in obstetrics and gynecology and pediatricians.

So, in this comparative analysis, in every other country that they analyzed, aside from the U.S., postnatal care included home visits, universal home visits that begin immediately post-discharge from the hospital and are specifically intended to address both maternal and infant health.

These programs are typically run, Erin, by midwives or nurses who are trained in prenatal care and infant care.

Yep.

The U.S.

has absolutely no such universal system.

None.

We have some programs programs in some parts of the country, or maybe some specific cities, but they only ever target specific populations that are considered high risk, which also means that they usually carry with them a lot of shame and stigma.

Yep.

Okay.

Yep.

Now, it's also true that the US, in this comparative analysis, was the only country where the majority of our prenatal care was conducted by OBGYNs as opposed to midwives.

Okay.

We also in the U.S., it's not just postnatal care, it's not just postpartum care.

We have huge inequalities in our access to care early in pregnancy because of our ridiculous insurance system.

Those are my editorialization.

That wasn't in the paper.

So that, like, even though in the U.S., pregnant people are guaranteed access to Medicaid services.

However, individuals like from data, individuals that are on public insurance, such as Medicaid, start prenatal care significantly later.

They in many states, lose their insurance at 60 days postpartum.

I'm sorry.

Yeah.

What?

And that, what that means is that in the U.S., more people are coming into their pregnancy without any access to health care to address their underlying or chronic health conditions that existed prior to pregnancy.

Then they have the bare minimum of prenatal care.

And in fact, over 6% of pregnant women in the U.S.

have no prenatal care care at all, or they don't start prenatal care until the third trimester, even though, again, they're supposed to be eligible for Medicaid services.

And then they attend one postpartum visit if they're lucky, and then they lose their insurance again.

It is not like this in other high-income countries.

Period.

Period.

Now, there is data, and I think you mentioned this at one point.

I don't remember in which episode, that like the prevalence of a lot of conditions that we know are associated with an increased risk of adverse pregnancy outcomes, right?

Things like hypertension, diabetes, older maternal age at your first pregnancy.

We know that these things are associated with riskier pregnancies.

And some of these things are in fact on the rise in the US and elsewhere.

And certainly that likely contributes to some of the trends that we are seeing.

But I think that what ends up happening in the rhetoric about this

is that politicians, especially, and organizations and even individuals lay this blame on individuals themselves.

It's because of your pre-existing condition.

It's your medical complications.

It's your age.

Oh, you chose to have a career first.

It's your choice.

And that makes it seem like it was unavoidable, or it was your, it was your lifestyle.

Lifestyle, yeah.

That is a lie,

period.

Across the globe, not just in the U.S.,

millions of maternal deaths each decade are due to preventable factors.

And this is not just coming from me.

This is coming from the Lance at Global Health 2024.

They said, and I quote,

these maternal deaths are, quote, tangible manifestations of the prevailing determinants of maternal health and persistent inequities in global health and socioeconomic development.

Yep.

Yep.

So we know, I'm getting like sweaty from how angry I get about this because it's like, I feel really passionate about this.

Justifiably angry.

We know the things to do to prevent this.

We can prevent maternal mortality.

We can prevent adverse neonatal outcomes as well by doing what, Aaron?

Let me tell you.

Number one, access to universal health care.

Number two, specifically, access to comprehensive.

This is again from data.

This is not just me, Aaron Alman Updike, saying this, okay?

I say this, but this is literally the data that we have on what prevents access to the citizens.

We have sources.

We have citations.

We need universal access to comprehensive and modern contraception so that people can plan if and when they want to get pregnant.

Yep.

We need universal, legal, safe access to abortion services, which are life-saving medical care.

Medical care.

We need universal access to high-quality prenatal, intrapartum, and postpartum care, which includes midwives and obstetrics and gynecology and family physicians and pediatricians, all of it.

All of it working together.

Working together as a medical system.

And this particular paper does not get into this like deep of detail, but I have other sources that show that guaranteed paid parental leave, which we also do not have in the U.S., is in fact associated with reductions in the risk of postpartum depression, depression later in life, lower risk of intimate partner violence, which is at its peak during pregnancy and postpartum.

Yep, it is.

Paid parental leave also increases the likelihood and duration of breastfeeding.

So, folks who are all making sure that everyone breastfeeds, that's a thing that can help it.

And it is directly associated with decreased infant mortality.

Sorry.

We have a playbook.

The answer is here.

We know the answers.

We just have to implement them.

Yep.

I'm done

no but it's it is

ah it's really hard sometimes because it's like on the one hand i want to find that very

inspirational or like hopeful or like here look we know how to do this we have it is hopeful we have had these answers i know for so long i know i know it I know it.

It's true.

It's true.

It's true.

It's true.

But we have the answers.

We know the answers, right?

These answers just have to be enacted.

And they are being done in certain places.

They are.

In this, I mean, the state-by-state mortality data in the U.S.

is like shocking.

If you go to the CDC website and you look at like what the rates are in like one state versus another, it's like the disparities are very severe.

Systemic racism plays a huge role in all of this in the United States, in addition to like the quality of care that people get depending on what color their skin is.

So there is a lot of things that are not easy to fix.

I mean, they could be easy to fix because we know how to do them.

We can fix parts of most everything.

Right.

Yeah.

But, so, we've, we've done all your work for you.

It requires investment.

It does.

And that is the hardest thing to convince people.

That's our constant theme, and it's my favorite thing on this podcast: Will Kill You.

Investment and trade-offs.

And investing now is public health.

And public health is investing and saving money.

And it's not.

Yeah.

Yeah.

I know.

So, Aaron.

I can't believe.

Are we done?

We're done for now.

We're done with this season.

We're done with this series.

I have so many feelings about everything.

Me too.

I also, I just want to say, because I know that there was a lot of parts of this series where we got very heavy.

We got very heavy.

And where we focused a lot on the kind of complications or things that can go wrong.

I

love

to know.

these things and know at the same time in my brain how often everything goes

just fine.

Absolutely.

And it is beautiful and amazing and phenomenal to like see that happen and to know that it happens so frequently.

It truly is.

Like I, I get, I really love prenatal care.

I really love this whole process.

I just love everything about this.

And I really loved doing this, even though I know we focused a lot on the bad things.

Well, I feel like there's,

it's all about contextualizing

everything.

Yeah.

Right.

Like you and I had a lot of discussions about this.

Like, how do we balance this approach where we're not doing the what to expect while you're expecting?

Like, you just lay back and lay back and have it.

Let everyone else do the work.

It's totally fine.

And it's like, knowledge is power.

It is.

And, but we also.

And it can increase my anxiety.

And it can increase anxiety.

And so I feel like this is, you know, we really did try hard to balance like talking about what are the pieces that we feel are valuable to talk about.

And also while not talking about everything that is valuable to talk about.

So it's,

yeah, but it is, it's true.

Like, I hope we didn't make everyone be like, oh, God.

Oh, God.

Never for me.

Never for me.

Or

our, you know, healthcare system and country is broken.

Totally broken.

I mean, I

have no interest in having any of their kids.

Definitely not.

Absolutely not.

I'm done.

But there were moments in this where I was like, oh, like, you know,

reading, like relearning these things.

And

it's a little bit of magic, I feel.

Absolutely.

Yeah.

I mean, I think I have never, I've never wanted to have kids, but throughout the series, I called my mom so often to be like, oh, what about this?

Did you take a pregnancy test?

Did you, like, tell me about your ultrasound?

Tell me about your delivery.

What was it like?

You know, she waited for one of my brothers.

ER was on, and she was like a, like a rabid ER fan.

And she was like, I went into labor and I waited.

I watched ER and then I went to the hospital because I didn't want to miss it.

Yeah.

And that was before DVR.

But like that experience, like so many things that we had never talked about before about pregnancy and thinking about her experiences.

And it just, that was, it's been such an amazing process to like do all this reading and think about.

Yeah.

Think about so many different aspects of it.

Oh, if you want to learn so much more.

So much more.

We've got sources.

Oh my God.

I feel like this was a one.

This is, yeah, I have a lot of books for this.

I know.

I'm going to briefly, because I've already mentioned a few of them, I'll mention them again.

So Brought to Bed by Judith Wolster Levitt.

Tina Cassidy, a book called Birth, The Surprising History of How We Are Born.

Barbara Ehrenrich and Deirdre English wrote a book called Witches, Midwives, and Nurses.

It's like a classic feminist.

feminist text.

Rachel Moran, again, Blue, A History of Post-Prime Depression in America.

Joyce Thompson and Helen Varney Burst, A History of Midwifery in the United States.

Laurel Thatcher Ulrich, A Midwife's Tale, The Life of Martha Ballard based on her diary, and again, that memoir, Inferno, by Catherine Sho.

I had a lot of papers for this one.

I already shouted out a couple, like that Lancet Global Health 2024 paper that was a global analysis of the determinants of maternal health and transitions in maternal mortality.

Such a good read.

There was also the paper I mentioned, it was from the American Journal of Obstetrics and Gynecology, titled The Fourth Trimester, A Critical Transition Period with Unmet Maternal Health Needs.

I think I might have said 2016.

It was actually 2017.

And then the paper where the map of postpartum depression trends came from was from translational psychiatry from 2021.

That was titled Mapping Global Prevalence of Depression Among Postpartum Women.

But we have so many more on our website, this podcastwokillyou.com, where we list all of the sources from this episode and every one of our episodes from all seven seasons.

So many sources.

So many.

You know, we've said thank you every single episode and we we mean it every single episode.

And thank you to every single person who provided a first-hand account, who sent in their first-hand account, who thought about sending in a first-hand account.

Like we appreciate you.

This series would have not been the same by any means without you.

No, it means the absolute world to us.

Thank you.

Thank you.

Thank you.

Thank you.

Thank you.

Thank you to everyone here at the Exactly Right Studios.

We're really sad to have to leave because we had so much fun doing this.

I know.

Thank you to today, Liana and Jessica and Brent and Craig and Tom yesterday, everyone, all of you here.

Thank you, thank you, thank you.

Thank you to Blood Mobio for providing the music for this episode and all of our episodes.

And thank you to you, listeners.

Seven seasons in, four whole episodes on pregnancy.

Thank you for sticking with us.

Yes.

In this short break between seasons, tell us what you want to hear more of.

Mm-hmm.

Always, we love to hear it.

Yeah, we do.

And a big thank you, of course, to our generous, beautiful, fantastic fantastic patrons.

We appreciate your support so very much.

We really do.

Thank you.

Until next season,

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