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, still birth, 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, that 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 than it's a different love than you've ever experienced before. And so after, you know, three days of pre labor and then fifteen 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 had 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 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 the 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. 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 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'd 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 babe 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 a way earlier. 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 ten 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 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.
Yeah.
Hi, I'm Aaron Welsh.
And I'm Erin Allman.
Update and this is this podcast will kill you.
We are coming to you with the fourth and final for now episode in our series Pregnancy Now.
I mean to be continued to continue.
But this is our season finale.
That was lovely. Thank you.
I did a drum even though it was more like a trumpet.
Yeah, No, I liked it. I think it's it was. It was a really nice touch.
It's also our last episode recording in the exactly right studios. 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, okay, we still have an intro to get there. We do, we do. We have some.
Things to discuss. If you've listened to the other episodes, you've heard these.
Before, 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 the series. And so we decided, like we have said early on, to dedicate four episodes to pregnancy 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 now, 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, what an incredible organ that is, and we also talked about the physiological changes and antempal 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, Yeah, 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 cesareans actually about C section, 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 arin 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 it comes to medical bias during pregnancy and childbirth, historically and today, is a result of gender discrimination and racism, and so in those context 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.
The only way that it can be, the only way there's Differently, you.
Go 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, if I remembered it, this time, it's quarantine time, Aaron, what are we drinking again this week?
We're drinking yet again, Great expectations.
Great expectation.
Which is a plasy burrita that is a non alcoholic bev.
It's really good. It's got ginger ale, it's got muddled blackberries and mint, it's got lemon juice.
Is shockingly delicious, very refreshing.
Yeah, super refreshing. I love it. I'm thinking of it right now.
Too, which I actually had one, but alas.
Later today.
Yes, if you want to see us make it. We made a really fun quarantine video that you can find on the YouTube tube tube. We also were very honored to be joined by Georgia Hartstark who made us a quarantin ye and alcoholic version to go along with these episodes. She called it the on teeny.
The Tenius and it's delicious.
Yes, and you can find that video on YouTube as well.
YouTube 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, pregnancy episodes with video with video and props.
Well props.
We're doing great today. And if you would like the recipes for these quarantine and place rita for this series, check out also our social media make sure you're following us or now in Blue Sky. I don't know if we've said that sure, And also our website Yes podcast will kill You dot com which features do you want me to this listen?
Let's skip it today?
Okay? Check out our website transcer rips. I just have to throw that in Okay, I think more business.
Rate review and subscribe. We love you, thanks for listening.
We'll be back soon with a new season. Yeah, 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 start misology, we.
Already have a list of things that were like, Okay, so next season booo so like.
Air quality index, yes, thank you, yeah, thank you Kenton. Okay, let's begin.
Let us after a break.
I found out I was pregnant on New Year's Day twenty twenty four. I was thirty three, 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 thirty nine 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 her about an hour and then my daughter was born. When the midwives went to place around 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 do livered 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 cide attack, also known as misiposal.
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. Oh my husband was doing skinned 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 and weighing it to see how much I lost. Ultimately, they said I lost about two to three leaders and I was given two leaders via transfusion. Eventually, my uterists 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 thirties, 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 bottles 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 a nausea. Although I had had nausea with my first pregnancy, this one was much more intense. I felt awful most of the time and struggle to do normal things. Nothing seemed to help. At my second prenatal appointment, the midwife was unable 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 OBGI in nurse. She gave me the highlights of a molar pregnancy, and of course I googled on my own. After time talking to my aunt, my basic understanding was that amolar 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 capacity since at least ancient times, but one that physicians weren't able to widely utilize until the twentieth 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 sea 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 results. So, for many, high rates of sea 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 no 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 seventeen fifty to nineteen fifty. 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 marriage laws in Massachusetts or not in Massachusetts, in Maine the late seventeen hundred, so like all the.
Context of what was happenings.
Oh, how interesting.
It's so good not to mention like the aspects of midwiffery and childbirth and so on. Okay, another book is I use snippets of a book called The Midwife Said fear Not just about the history of midwiffery in the US up through today. That one is by Helen Varney and Joyce bb Thompson. And then finally there's a book Blue by Rachel Moran. Not our not our friend friend Rachel Moriann, but a different Rachel Moran about the history
of postpartum depression in the US. So you can probably tell based on these titles that this history section is mostly going to be primarily focused on the US.
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 women all around, healer, which 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 US, 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 nineteen sixties like the late nineteen sixties 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 US. 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 nineteen ten, about fifty percent of all babies were delivered by midwivesteen ten nineteen ten. By nineteen thirty that number had gone down to fifteen percent.
Wow.
And by nineteen seventy three about one percent of births were attended by a midwife. Wow. And compare that to twenty twenty one, which is the most recent one that I found. I'm sure there are more recent ones out there. Twelve percent. Okay, we're attended.
By So we went all the way down and then a little bit back and back up. I will say that I know this is US 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 US treated midwives, specifically laws. 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's 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 nineteen hundred, only six of doctors in the US were women.
I'm actually surprised it was that high.
I know, I know. I mean. The other thing, the other caveat to that is that, yes, there were six percent, 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 then 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 midwiffery. Midwives were portrayed as lacking the training in 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 broaden 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 of view, let's dig a bit deeper to see how this all went down. 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.
I feel like I've never thought of that.
Oh yeah, absolutely. And they 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 twentieth century physicians believed, but it is a physically demanding experience with potential impact on both mother and babies life and health. Although I really I did find it interesting that in that Diary of a Midwife Life, the Martha Ballard, she called like 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.
The laborers you're at, which maybe just shows how she saw it as like this is a potential where like there is a lot of attention thats needed here, right right? Yeah. Imagining the women of the seventeen hundreds 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 eighteen hundreds, women in the
US had an average of seven children. That the number of pregnancies was probably higher, yes, because that doesn't include miscarriage, stir. Many women spent the majority of their adult lives pregnant, breastfading, 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 eighteen hundreds give us a glimpse into these worries, as women wrote wills or gave instructions on who should care for the baby if she died.
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, too far, too m 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, right, 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've pulled a lot of these quotes from Brought to Bed because I think that there they just illustrate this, like this idea that 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 to her sister in the mid eighteen hundreds, 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 Sterns 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 eighteen eighty five between oceans of pain, their stretch, continence 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 eighteen seventy 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 results 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 Read'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 child bearing. 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? 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 eight hundred and fourteen deliveries from seventeen eighty five to eighteen twelve, so five maternal deaths, none during delivery, all during two weeks after birth. And that's today compared to zero point two two per every one thousand, so five per one thousand, two point two two. Okay, yeah,
Martha recorded twenty neonatal deaths. That's two point five for every one hundred live births, compared today two point five to six.
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 still birth and neonatal mortality like drastically, not even to mention like vaccines and saving life's postpartum and all that.
Right, right, but during childbirth experience itself, yes exactly, yeah, yeah, you still birth she recorded fourteen. That's one point eight for every one hundred today, that's point six every one hundred, So yeah, 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 ficials, 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 eighteen hundreds as a sort
of pendulum between joy and dread. For Hannah Whittall Smith, writing in eighteen fifty two, 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 how hard it is.
Wow, that's a really heartbreaking are Yeah, it's it's.
Yeah, yeah, we have gained so much and then now we're losing so much again.
But yeah, I know, yeah, to not because like like she said, to not have any control over do not have any control, any control over it?
Right, And it's just like here, it is, it is my it is not added 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 US history, most births were attended by midwives, who 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 perenial 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 and that it's exactly yeah, And the midwife was typically not alone in the like
in attendance. Often they were like friends and family right as well, usually formal 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 at.
School yep, then they developed residency. That's the whole episode something episode yep.
So this active professionalization started in the late seventeen hundred early eighteen hundreds, maybe even a little bit earlier in the seventeen hundreds. 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 berth.
It's been a long time since I've watched Call the Midwife.
I know, I love love that show. I really love that. There are probably seasons I haven't seen it, definitely, so yeah, yeah,
I should watch it. 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 berths 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 doctor Page, who gave my patient twenty 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 that like fictional Okay, that that story is in there, but in like way more detail because it's obviously like fictionalized version of history.
It is fascinating to hear.
The actual like diary entry.
Yes, and then like the like the description because this story it's called frozen for 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 isn't 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 so sparse in terms of like rightail, that's what she said, very few emotions. There have been like a couple times well she'll say like poor poor mother because she lost a baby or kind of thing. But but yeah, this and then I think there's another time she calls out doctor Page and she'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 is chosen a profession that clearly is not to his skill set.
Yeah, yeah, so interesting.
Yeah, check out this those books to check out 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, nineteenth century doctors did the opposite. There was laudanum or opium, as Martha mentioned, blood letting even in the case of hemorrhage.
Oh, I still can't get I'm sorry. Yeah, but yes, we haven't talked about he are blood letting these all these episodes, So.
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 great, surgical separation of pelvic bones, which was often led to like permanent disability yea, And of course forceps.
By the mid nineteenth 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 eighteen eighties that I hate this quote. Okay 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 survices all the way dilated.
Yes, no, like before the baby had even fully entered the berth, that they had the long long forceps.
No, nope, nope, nope, nope, nope, nope, nope.
Yeah, nope, nope, nope, nope, nope.
Okay, that's not how forceps are used today. I just want to put that out there.
No, no, no, put that over there. We have corrected, of course.
Yeah, are not used in that way today. No, Wow, 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 make the woman nervous. If a medical school included training specifically on obstetrics, and few actually did and the late eighteen hundreds, it mostly centered on how to use these tools and rarely included hands
on supervised experience. Awesome, Okay, there, 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 led, but I don't know. I would actually believe that it's not necessarily that. Okay. Tells the story of a newly graduated doctor, official doctor in the late eighteen hundreds, 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. I'm not going to say, okay, we can 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, I'm that doesn't surprise me.
No, I know. Back in the day, yeah, yeah, but sorry, wouldn't you have at least seen a diagram somewhere?
I don't know, I wasn't in med school in the age.
They did have like theaters where someone 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 nineteenth century physicians was anesthesia. First ether and then chloroform were introduced in the mid eighteen hundreds, 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, John Snow as John John Snow of Color Effe color not disgraced Game of Thrones. Yeah yeah, wow yeah, And so that that really I think allowed people to go, oh, I want that, And she was like, this was great.
Yeah, it again, I would highly recommend.
Yes, okay, yeah, and it's I think it's pretty easy to see the appeal if you if you look at some of them, I mean, even not based on today, but like and like people you know you have experienced child grouth, but the 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, anthesia, 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 believe pain, but it was to make you forget and it could induce a lot of 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.
Alah Madmen Allah.
Madmen and Betty Yeah yep. By nineteen hundred, ether or chloroform was used in fifty percent of births attended by
a physician. Wow, ether or chloroform. And we got better lead around in terms of like the safety because a lot of doctors did have concerns about the safety of like 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 nineteenth 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, 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 two dollars for her assistance during labor and delivery and her contemporary doctor Page charged
six dollars. 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 the psychological phenomenon familiar to many of us. All of us were higher price is equated with higher quality. 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 eighteen hundreds, 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 blood letting 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, stoppedop. And he's like, oh, come on, you don't know anything.
Yeah, you didn't go to Harvard.
Medical schools were also blamed for high rates of pupil fever and sepsis, despite adence that it was in fact doctors who were more much more responsible for the infections due to their proclivity to just go from cadaver dissection to the labor and delivery room in hospitals. Listened to
our pupil fever episode. There's so much more on that, And in fact, maternal mortality in the US was on the decline by the end of the nineteenth century, but it plateaued for a while until the late nineteen thirties, which was after most births were happening in hospitals. Interesting, okay, and that's probably because of all of the adjustment we'll call 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, Medical Bondage. For more on that, Medical Bondage. Yes, yeah, that's such a great book. The US seemed an especially deadly place to have a baby. In nineteen ten, one mother died for every one hundred and fifty four live births.
Wow.
Compare that to Sweden at the same time, where the number was one in every four hundred and thirty.
Okay, yeah wow.
In the early nineteen hundreds, US states introduced laws banning midwiffery, and all midwiffrey became illegal in nineteen fifty nine under a law that redefined midwiffery as the practice of medicine.
Interesting, eron, 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 midwiffery. At the time, because undoubtedly they were unnecessary injuries or infections and deaths at the hands of midwives, just as
there were for doctors. But those early bands 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 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, yes, 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 thing.
And so other countries did have that pathway for midwise in the US we did not get 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 thirty 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 at all? I don't think I've ever talked about him, Yeah, okay, I didn't know if
like in med school or something. Okay, he wrote in nineteen twenty. 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 so, because salmon spawned 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 case and not the modern synthesis and evolutionary Okay, I'm for his part because there's nuance to every 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. But pathologizing childbirth was a way to send home the message that midwives were not qualified. Right, this is a dangerous state, and you need someone who is has been trained in this way and has this
you know, diploma from this university, right, yea. And the way that society saw women during this time, especially middle and upper class white women, as fragile and over civilized in need of protection this birth exactly, exactly, And so all of these factors drove childbirth from the home to the hospital. Midwiffrey 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 because, on balance, the new benefits seemed more important. Okay, yeah, yeah, that's completely understandable.
Yeah.
One woman wrote to her mother in nineteen eighteen, 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, so no one cares about your mental well being. We know best. This period from the nineteen thirties to the nineteen sixties is marked by tremendous gains and 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.
Sure, was what it was, and now it's done right exactly.
And then some were completely traumatized and everything in between. Yeah, as we've said a million times, there is no universal childbirth, pregnancy, postpartum experience. In the nineteen sixties and the nineteen seventies, 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. Yeah, and they would be like, oh no, not here two hours.
And they also that was at the time 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 a mother doesn't get any rest.
Oh my god, there's so much 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, yeah, just shows us that, like we don't have everything figured out. And that's I mean, that's okay. It is things are really overall good, yeah, and which 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, How did we get from there to here? Why did the pendulum swing this way? Where are we
in this pendulum arc right now? It's so interesting to 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 you can, Okay, I understand why this thing happened, right, I think that's so important.
Why 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 for that. 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 your partner in the room, right, 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 voices and the range of choices. And I will say too that that is a double edged sword.
Right.
Since the nineteen seventies, women, along with researchers, doctors, nurses, midwives, dulas, 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 you.
Yeah, yeah, yeah, yeah, yeah, keep going home?
Is this the right strugg the right choice?
Is that the right choice?
If I don't make a choice, what does that mean? And when 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 sixty or one hundred 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, yes, or we lose sight of them. Next to the negative impacts of medicalization, that is what stands out the most to us.
Yeah.
For instance, take postpartum depression and other postpartum perinatal mood disorders from pupil insanity in the late nineteenth century, which is what it was called, well, which is what it was a diagnosis, so it's not necessarily there's more. There's more nuance to pupil insanity, yes, yea, to what was called baby blues post World War two, to postpartum depression finally making it into the DSM four in nineteen ninety four. Nineteen ninety four, I told my mom that she was like,
really 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 it was it actually put place in there in an appropriate way.
And what we don't have in there today.
They 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 aiined 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 postprime depression because it was you know, exactly, wasn't that bad? So 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 eighteen hundred's postpartum depression post part of 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 postparti 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. Working moms bring on PPD themselves because they're just not equipped. 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, sure, am By, because if you're treating it just as a hormonal or chemical imbalance, and 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 in.
To what I'm going to talk about, Like we do this, it's like it's our job.
But yes, 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 loved this book. As you can tell quote, throughout American history, women have wanted and have worked to achieve their own deals 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 twentieth 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, err and oh turn it over me right there. Tell me about the fourth trimester.
Okay, you might need a little breather after that.
Okay, we can do that.
I'll take a break and then get into it.
Sho, let's do it.
At thirty two years old, I got pregnant for the first time. I had what you'd call a textbook pregnancy, healthy baby, low risk, and a noticeabook low.
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 harmy and I started trying for a baby in September, and luckily enough, by November, I was pregnant. My first symptom wasn't warning 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 joke.
Turns out, it was implantation. The next time I felt that level of pain was actually an active labor within two weeks of conception, my body already started changing. My boobs went from an age with seacup almost a night 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 the 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 cardamin 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 version for me, which is kind of surprising giving 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 early at first, to as salt, venigo, chips, and anything sour, especially lemon ice cream. In a second trimester, I craved corn and coffee. Of course, I only ate 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 maybe nauseous, to the point that if my husband ate it, he had to brush his teeth before coming miming. Pregnancy also came with a long list of symptoms. I just wasn't prepared for. Blood noses, gray hairs, loose ligaments, ligament pain triggered by sneezing, dry skin, exhaustion that left me sleeping for ten 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 bearback 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 time 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 load, 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 berth, and in the final moments, I reached down
and pulled my baby at 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 I 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 eighteen 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 twenty four to seven, 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 in biophysical profiles to make sure that I was safe and that
my little guy was safe. On the fourth 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 potocin. Unfortunately, I did
not progress in labor as we'd hoped. I was in labor for eighteen 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 sea section, or we could just do a sea section now, And after eighteen hours of labor, I
was on board with that. We had a beautiful and wonderful sea 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 very surprised by the swelling after the sea 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 Aarin, you just walked us through a lot of the kind of social and institutional, 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 I'm kind of picking up your threads right there, perfect, but then I'm gonna unravel them a little bit more to also remind us of what is going on biologically in this so called fourth trimester, why it might be rocky for some of us. And my favorite, what do we know about evidence based ways to improve outcomes?
Evidence based? What a beautiful phrase. Oh, 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 know health.
But then, yeah, 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. Just 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. Second fourth trimester exactly.
Yeah, yeah, but this is pregnancy, and so this is the fourth trimester of pregnancy. Yeah, pregnant person, Yes, 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 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 we're also saying now go get flat. Also the producers, Yes, the producers. 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.
Okay, 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 twelve 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.
Yeah, 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. I will say that after like in postpardum, 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 to 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 lutinizing hormone, and FSH which is follicle stimulating hormone, and those are what would induce a normal ovulatory and menstrual cycle, and that is why you see suppression of mensis during breastfeeding, and why that is for a lot of people a good form of contraception.
But doesn't always it doesn't.
But okay, in no 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 gonna just talk to you from my brain. Yeah, 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. Not everybody is going to remain a menner reec which means they're not
having mensis. But it is it as actually, as per the World Health Organization guidelines, it is an effective and recommended form of birth control for a lot of people.
Oh my god, Okay, I didn't know that there's more nuance because I know a number of people who have gotten pregnant. Absolutely 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 mensies can come back earlier than that six months. 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 one hundred percent effective what it means, but yeah, it is.
This is really interesting. Yeah, how about 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 fifty percent 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 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 like the physiologic diuresis, I think it. I don't remember 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 your GI tract, which remembers 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. So that can make people either very nervous about their first bowel movement postpartum because if 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 happens. 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 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 things are happening to 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.
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. But yeah, so that it's going to take a few weeks before it really goes back down. It's not like a automatic It clamps way down, but it doesn't like go back takes time.
Yeahs sense.
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 lokia. That's like just what we call the postpartum heating l o chia.
Huh lokia. And how how long does that last? How much blood?
Like, yeah, so how much blood can vary? 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 like relative to a regular like if you have more regular periods.
What is a regular period.
For an individual that doesn't even that?
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.
Posts or weeks okay.
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. We can hould your doctor. But usually if somebody is bleeding so much they're 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 farely 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 as that process, before that process is 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 okay. 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 sea section. The mechanism there not fully known right, we don't know, but it is the case that sea section is associated with an increased
risk of delayed milk production. Also early delivery, whether that's early term which would be before thirty seven weeks, or like late pre term it's like thirty four to thirty six weeks or so in there, or even just that like early term thirty seven thirty eight 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 the 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, I do feel that it deserves its whole own episode.
We will do one, absolutely, because there is a lot to unpack there. Yeah, 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 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 paraneum 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. 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 there. They suck at eating. They cannot figure it out, and you are now entirely responsible for them. This is a very difficult time period. 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 postpart and 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 change and finding a brand new baseline in this postpartum period, which means that we are still at increased risk of things like postpartum pre acclampsia 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 five. 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 there are 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.
I am been anxious for no good reason at all. Right, 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, 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 recommend 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
seventeen percent. That is so much higher than any of the other complications that we have talked about, like, so much higher. That global number, though is not 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 in middle income countries, which is not a fair thing to do, but if you do that, then the prevalence is estimated at around twenty percent. High income countries, the average is like fifteen and a half percent. 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 thirty in the thirty 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 eight nine percent. The US and the UK are a little bit of outliers in the high income country bracket, where the prevalence is estimated at eighteen and twenty percent respectively. Okay, okay, now pause for a second because we're gonna err and
math this a little bit. Because that is, in the US, we have an estimated around three and a half million live berths every year if eighteen percent of those, and postpartum depression is not limited to live births. This also encompasses depression post miscarriage and still birth, which those rates
are even higher. But even if we just look at those numbers, three and a half million live berths, eighteen percent of those people having postpartum depression is over six hundred and thirty thousand people in just the US every year. That's not a small number of individuals or families that are being affected. So that's postpartum depression, which is just one of the postpartum mood disorders post part of anxiety.
I have a question. Okay, sorry, I know you're like, 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. Okay, what is postpartum depression? Is this all being defined?
It's all being defined as DSM five definitions.
Yes, depressions.
Post Partum anxiety another one of the post partum mood disorders, estimated to effect eight to twelve percent of people postpartum. Here's the big problem here, Okay, we don't have diagnostic criteria. There is no such disorder. 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, yeah, 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 post part of anxiety disorder. So then people have to like 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 type of anxiety disorders, because anxiety is a symptom and not a diagnosis.
Okay, good questions here, So a person could have postpartum depression and postpartum anxiety absolutely, Okay. Secondly, then do postprium depression post partum ascis 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 pre existing, we're not going to cover it.
Correct.
But 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 was 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'd agree with that. Yeah.
In the sixties, do you want to know what, like I think it was doctor Spock or something, you know, like the Benjamin S. Bacao was like, this is how to care for people.
I only know this Spock with like the livelong and prosper.
This is relative Okay, yeah, not really. Oh 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 DoD.
That was literally okay, yeah, I love that anyway.
Yeah, so lasting 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 was trying.
To get the like overall time frame.
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 DSM five title.
But this is the set.
Of hallucinations or delusions and like disorganized behavior 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 zero point eight six to two point six per one thousand berths. So it's commonly cited as like one to two per thousand based on a global
analysis from twenty seventeen. 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 am I think I told you this, Aaron, But I listened to a book called a memoir called Inferno, a Memoir of Motherhood and Madness by Catherine Choe, and it was about this person's experience with postpartum psychosis. And it was a really insightful and meaning full 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 US when this, when this 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 in terms of like the management okay, okay, well keep mom with baby, okay, UK, keep mom separate from baby in the US, and just like interesting, I just yeah, yeah, all 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. It'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 forty to seventy percent of people can experience this 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 healthcare in the prenatal and post natal period, or that rates of postpartum depression are significantly higher in lower income households in high income countries that lack access
to healthcare, 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, and in fact, the single greatest risk factor for postpartum depression and postpartum anxiety are untreated anxiety and depression outside or during pregnant and see
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 from data about how to improve postpartum outcomes overall at ready based. I found a quote from an article from twenty sixteen in the American Journal of Obstetrics and Kynecology.
That's it end 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 US. It is one singular visit which forty percent 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 the 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? Aaron?
Let me tell you, as a family medicine physician what my feelings about that are. Yes, in the US, our system is very fragmented. 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 US 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 US, an estimated twenty three percent of employed women returned to work within ten days.
Postpartum, sorry ten days.
Ten 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 US 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 ten times as high as Australia. Our maternal mortality rates in the US 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 twenty twenty two, maternal mortality for Black women was fifty per one hundred thousand live births, compared to nineteen per one hundred thousand for white women and sixteen per one hundred thousand for Latino women. And I will say the numbers were different in twenty twenty one, 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 twenty four hours, and then care in the first twenty four hours, and then additional visits at three days, seven to fourteen days, and at six weeks postpartum, and that should include both maternal and newborn care. And again, in the US, our care is divided between specialists in
obstetrics and kynecology and pediatricians. So in this comparative analysis, in every other country that they analyzed aside from the US, postnatal care included home visits universal home visit 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 US has absolutely no such universal system none. We have some 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 obgins as opposed to midwives. Okay, we also in the US, it's not just postnatal care, it's not just postpartum care. We have huge inequalities in our acts as 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 US 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 sixty days postpartum. Mm hmm, I'm sorry, yeah, what and that What that means is that in the US, more people are coming into their pregnancy without any access to healthcare 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 six percent of pregnant women in the US have no prenatal 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 aged
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 medic complication, is your age, Oh.
You chose to have a career first, it's your choice.
Yep, Yeah, 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 US. Millions of maternal deaths each decade are due to preventable factors. And this is not just coming from me. This is coming from the Lancet Global Health twenty twenty four. They said, and I quote these, 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 we can 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 erin.
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 Onrman Updike saying this. Okay, I say this, but this is literally the data that we have on what prevents.
Adversources we have.
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 wives and obstetrics and gynecology and family physicians and pediatricians, all.
Of it, all of it working together.
We're together as annical 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 US, is in fact associated with reductions in the risk of postpartum depression, depression later in life, lower risk of intimate partner violence, which is added is peak during pregnancy and postpartumy. 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. I'm done.
No, but it's it is. Oh, 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 answer. 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 tru 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 in this I mean, the state by state mortality data in the US 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 required no 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 in saving money and it's not.
Yeah, yeah, I know, so, Aaron, I.
Can't believe are we done? We're done for now.
While 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 and 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 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 focus a lot on the bad things.
Well, I feel like there's it's it's all about contextualizing it is 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 back and have anyone else do the work. It's totally fine, and it's like knowledge is power.
It is, and but we also 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, yeah, and also while not talking about everything that is valuable to talk about. Yeah. So it's yeah, but it is. It's it's true, Like I I hope we didn't make everyone be like oh God, oh God for me, never for me or our our you know, healthcare system and country is broken broken.
I mean I have no interest in having any other kids.
Definitely not absolutely not.
I'm done.
But there were moments in this where it's.
Like, oh, you know, reading, like relearning these things, and yeah, it's it is.
It's a little bit of magic.
I feel absolutely yeah.
I mean I think I have never I have never wanted to have kids. But throughout this series, I called my mom so often to be like, oh, what about this? Did she 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, it's 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. Ah, if you want to learn so much more, so much more, we've got source it.
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 gonna briefly because I've already mentioned a few of them, mentioned him again, so Brought to Bed by Judith Wollster 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
blew a history of postprimum Depression in America. Joyce Thompson and Helen Varney Burst a history of midwiffrey in the United States. Laurel Thatcher Ulrich a midwives Tale, The Life of Martha Ballard based on her diary, and again that More Inferno by Catherine Show.
I had a lot of papers for this one. I already shouted out a couple like that Lancet Global Health twenty twenty four paper that was a global analysis of the determinants of maternal health and transitions and 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 twenty sixteen,
it was actually twenty seventeen. And then the paper where the map of postpartum depression trends came from was from Translational Psychiatry from twenty one that was titled Mapping Global Prevalence of Depression among Postpartum Women. But we have so many more on our website, this podcast will kill you dot com, where we list all of the sources from this episode in 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 mean it every single episode, And thank you to every single person who provided a first hand account, who sent in their firstend account, who thought about sending in a first hand account like we. We appreciate you. This is we. This series would have not been the same by any means without.
You, No, it's 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. Are really sad to have to leave.
Because we had so much fun doing this, I know.
Thank you to today Leanna and Jessica and Brent and Craig and Tom yesterday, everyone all of you here, thank you, thank you, thank.
You, ah thank you to Bloodmobile for providing the music for this episode and all of our episodes.
And thank you to you listeners seven seasons in for all 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.
Always we love to hear it. And a big thank you, of course to our generous, beautiful, fantastic patrons.
We appreciate your support so very much.
We really do. Thank you.
Until next season.
Wash your hands, Sealthy Animals, M.