This Podcast Will Kill You - Ep 171 Pregnancy: Act 4

Episode Date: April 1, 2025

Content Warning: This episode includes mentions of miscarriage, pregnancy loss, pregnancy complications, traumatic birth experiences, and other potentially disturbing topics related to childbirth, pregnancy, and the postpartum period. We close out our pregnancy series with a big picture view of how the childbirth experience has changed over the past century - both for the better and for the worse. From home to hospital, what have we lost and what have we gained? We also delve into the period known as the fourth trimester, examining the physiological changes that can occur after childbirth as well as one of the most common (but not commonly discussed) conditions that people develop during this time: postpartum depression. Tune into this info-packed episode, and don’t forget to send us your recommendations for future topics! Support this podcast by shopping our latest sponsor deals and promotions at this link: https://bit.ly/3WwtIAuSee omnystudio.com/listener for privacy information.

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with epic food and a drink wave. This is Alaska, the best way. Award-winning adults-only Alaska cruising from Virgin Voyages, sailing from Seattle. Explore Sailings at Virgin Voyages.com. We want to start with a disclaimer that throughout this series, we feature explanations and stories that include some heavy material, including early pregnancy, loss, stillbirth, and other traumatic experiences of pregnancy, childbirth, and the postpartum period. There's a lot I could say about the physical difficulty of carrying a baby, but I'm going to focus on the postpartum because that was what was most surprising and unsettling to me. Throughout my pregnancy, I always expected that I would start kind of falling in love with the baby.

Like I always heard people saying, I'm already so in love with you, all those 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 15 hours of labor, I gave birth and the baby was put on my chest.

And I just felt this kind of heartbreaking missed step feeling because it felt the same as it always had. There was no immediate love. There was a baby on my chest. And that was it. And then in the hospital, I kind of was feeling like I have no idea how to take care of this baby. There was kind of this helplessness. I couldn't feed it.

He wasn't latching. I could hardly 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. Like, does anyone know around me that I don't love this? baby and that I don't know how to take care of it. And my husband drove us home and I walked into the house and it was even actually when we pulled into the garage, there was this immediate sense of everything around me looks different than it did. Nothing looks familiar. It's like we drove into this kind of parallel universe that I'd never lived in before and it was very unsettling and my parents were there and everyone was so happy and I was like, something feels so off to me. and then my husband went to take the dog for a walk because we've 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 get out 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 vague feeling of desolation for a long time, and I would cry for hours at a time at night, and I just kind of, I never really felt happy. I was always just kind of leaning towards depression, I guess, and I'd never experienced depression before, so I didn't recognize it. It just felt like homesickness, like this nagging sense of homesickness that intensified or dulled,

but never went away. And the scariest part was when my in-laws visited, and my parents also visited, and they were taking turns carrying the baby all day. And when they finally, when they gave them back to me after maybe an hour, I looked down and I didn't recognize my baby. And it could have been any baby. 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, um, 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 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 away earlier, but it wasn't required, and I didn't know to ask for it. And I wish that I had been treated because that dull sadness probably stuck around for six months. And if there had been earlier intervention, I think I would have had a much more enjoyable early motherhood experience. I also told my husband that I didn't love the baby as much as I loved him and that that seemed wrong to me. And he, assured me that I'd known my husband for 10 years, so it kind of made sense that I would love him more than somebody that I'd only known for two weeks. It probably took a year for me until I, like,

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. Yeah. And we just want to thank you all again from the bottom of our hearts. We really, really appreciate it. It means the world to us. And this podcast would not be the same without all of you. So thank you. Absolutely not. Yeah. It has really,

it's such an integral part. It's amazing. It is. Yeah. Yeah. Hi, I'm Aaron Welsh. And I'm Aaron Almond Updike. And this is, this podcast will kill you. We are coming to you with the fourth and final, for now, episode in our series on pregnancy. For now. I mean, to be continued, truly. To be continued. But this is our. Bumpina-Ber-Berl season finale. That was lovely. Thank you. I did a drum, even though it was more like a trumpet. Yeah. No, I liked it. Thank you.

It was a really nice touch. Yeah. It's also our last episode recording in the Exactly Right 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. We still have an intro to get through. We do. We have some things to discuss. Yes.

If you've listened to the other episodes, you've heard these before. We've heard this before. Yeah, we want to just sort of briefly go through again what we've already covered in the first three episodes, what we're going to be covering in this episode. Talk about some of the language that we've heard. we'll be using and our goals overall with creating this series. And so we decided, like we have said, early on to dedicate four episodes to pregnancy, one for each trimester, clearly not enough to actually cover this huge experience that is pregnancy, childbirth, and the postpartum period. And so if you are like, hey, I really want to hear more about this. I want to learn about this

aspect. What about this? Send in your questions. Send in your topic ideas. We are happy to have them. This will not be the last episode on anything related to pregnancy. No. 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 transverse-year-old. a trimester of pregnancy. So in our very first episode, we talked about how you even know whether or not you're pregnant and what happens during early development. The second episode, we talked a lot about the placenta. Yeah, we did. What an incredible organ. So fun. That is. And we also talked about the physiological changes and anatomical 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 cesarean section. A lot about C-sections. It wasn't Julius Caesar, y'all. No.

Yeah. Tune into episode three to find out more. And finally, today, our fourth episode, our final episode of the pregnancy series, and our final episode of season seven, will be about the concept of the fourth trimester, talking about what changes are going on. in your body after pregnancy. And we're also going to be talking about this big picture of how the medicalization of pregnancy and childbirth changed that experience and how we moved from home to hospital and some of the consequences of that. Yes, I'm excited for this episode, Aaron.

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

Yes. And we also want to just, you know, recognize that there is no such thing as a normal pregnancy. There's no, this is what is going to happen and this is normal and that's it. The only way that it can go. The only way. There are so many different ways it can go. Hopefully we've gone over that a lot in all of 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. And some of the complications. that can happen as a result, even defining what a complication is. Exactly. Exactly. And we're going to do that today for the postpartum period. We are, we are. But first, I've remembered it this time. It's quarantini time. Erin, what are we drinking again this week? We're drinking yet again, great expectations. Great expectations. Which is a placid burita that is a non-alcoholic bev. It's really good. It's got ginger ale. It's got muddled black. berries and mint. It's got lemon juice. It is shockingly delicious. Very refreshing. Yeah, super

refreshing. I love it. I'm thinking of it right now. Me too, which I actually had one. But alas. Later today. Yes. If you want to see us make it, we made a really fun quarantini video that you can find on the YouTube. YouTube. We also were very honored to be joined by Georgia Heartstock who made us a quarantini, an alcoholic version, to go along with these episodes. She called it the ontini. The ontini. It's so great. And it's delicious. And you can find that video on YouTube as well. And you can also find, I don't know if we have said this enough, but you can find these episodes on YouTube. These pregnancy episodes, yes, with video. With video. And props. Well, yeah. And props. We're doing great today. And if you would like the recipes for these

quarantine and placebo-rida for this series. Check out also our social media. Make sure you're following us. We're now on Blue Sky. I don't know if we've said that. Sure. And also our website, this podcast will kill you.com. Which features? Do you want me to do this? Listen, let's skip it today. Okay. Check out our website. Transcripts. I just have to throw that in. Okay. Any more business. Rate review and subscribe. We love you. Thanks for listening. We'll be back soon with a new season. Yes. And we have so, like, send us your ideas along the way. We are so excited to dig more into the world of health, medicine, disease, biology, evolution, ecology. Literally, like, after we stop this, we already have a list

of things that we're like, okay, so next season, boop-but-to-oo. So like. Air quality index. Thank you, Kenton. Yes, thank you, Kenton. Okay. Let's begin. Let us. After a break. Dinner shows up every night, whether you're prepared for it or not. And with Blue Apron, you won't need to panic order takeout again. Blue Apron meals are designed by chefs and arrive with pre-portioned ingredients so there's no meal planning and no extra grocery trip. There, assemble and bake meals take about five minutes of hands-on prep. Just spread the pre-chopped ingredients on a sheet pan, put it in the oven, and that's it. And if there's truly no time to cook, dish by Blue Apron

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That's Q-U-I-N-C-E-com slash this podcast to get free shipping and 365-day returns. Quince.com slash this podcast. I found out I was pregnant on New Year's Day, 2024. I was 33, and this would be my second baby. My pregnancy was relatively uneventful and actually a little easier than my first, but both were low risk.

I went into labor naturally at 39 weeks and went to the hospital. To help things along, my midwife broke my water manually. I felt a huge gush and things really intensified from there. At this point, my memory is a little blurry, but I do remember feeling more big gushes when I had contractions.

I pushed for about an hour, and then my daughter was born. When the midwives went to place her on my chest, they discovered that the cord was very short. They could only set her on my belly, under my belly button. I asked them to go ahead and cut the cord so that I could hold her on my chest instead.

I got to hold her for maybe a minute and take some pictures before things started to go downhill. I was trying to nurse her, and then I started to feel very weak. I yelled out for someone to take the baby because I thought I would drop her. I had been distracted, but then I realized I still hadn't delivered the placenta. My midwives sprang to action and told me we needed to deliver it immediately. As soon as I pushed it out, I felt a huge gush.

My first thought was that it was amniotic fluid because it felt like when my water was broken. But then I realized all that fluid had already been delivered with baby, and I said, was that blood? I looked at the midwife who had been standing between my legs, and she was splattered with blood head to toe, like she'd been sprayed with a hose. From there, everything was chaos. All of a sudden, there were a lot of people in the room. The midwives were vigorously massaging my belly, but my uterus wasn't contracting, and I was bleeding out. I was given multiple drugs via different routes at the same time. One of these was cytotech, also known as misoprosol. 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 sell. the bleeding. Oh, my husband was doing skin to skin with the baby. I remember thinking that my great grandmother had died from a postpartum hemorrhage. I asked one of the nurses if I was going to be okay, and all she said was, we are doing everything we can. They tried using an intrauterine balloon device to apply pressure from within. Unfortunately, it got clogged with clots and didn't work for me. Staff was scooping up blood and clots off of the bed and floor and weighing it to see how much I lost. Ultimately, they said I lost about two to three liters, and I was given two liters via transfusion.

Eventually my uterus did contract and they were able to stitch me up. The other day I was looking back at those photos when I was holding my baby, and I can see that my face has a weird gray cast to it. I'm so glad that I delivered in a hospital that had all of the best medications and resources available to stop the hemorrhage. If I hadn't, the outcome could have been very different. My name is Dawn and I live in Texas. In my mid-30s, I became pregnant with my second child.

My then-husband and I were thrilled after having such joy from our first one. At my first prenatal appointment, everything seemed fine. My vatiles were good and we were able to detect a heartbeat. Since my first pregnancy was uneventful, I assumed this one would be similar. One thing that was very different about this pregnancy was the nausea. Although I had had nausea with my first pregnancy, this one was much more intense. I felt awful most of the time and struggled to do normal things. Nothing seemed to help. At my second prenatal appointment, the midwife once unable to detect a heart. 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 D&C soon.

We were, of course, devastated to have lost a baby. Shortly after the DNC, the midwife contacted me and asked me to come back into the office. In the appointment, she told me that pathology done on the placenta or fetal tissue had come back with some concerning results, which was that I had had a molar pregnancy. I had never heard of this diagnosis. She told me that I would need to come in for regular blood testing to be sure pregnancy hormone levels in my blood were steadily decreasing. After the appointment, I talked to my aunt, who was an OBGYN nurse. She gave me the highlights of a molar pregnancy, and of course, I googled on my own after talking to my aunt. My basic understanding was that a molar pregnancy is an unusual non-viable pregnancy that can sometimes develop into cancer if all the abnormal cells are not removed.

Years afterwards, my aunt told me she was very concerned for me. While the intense nausea remained for a few weeks after the DNC, my pregnancy hormone levels did steadily decline and after some time, I was fortunate to have a third pregnancy that resulted in a healthy baby boy. Since I live in Texas, I do want to mention that I'm not sure if the DNC my midwife recommended would be possible now with the unprecedented removal of women's reproductive rights. Last week, I took us through the history of cesarean sections, a procedure that has been used in some capacity since at least ancient times, but one that physicians weren't able to widely utilize until the 20th century when antibiotics, antisepsis, transfusions, and surgical technique transformed it from an almost certain death sentence to a life-saving tool. And we discussed how the high rates of C-sections have led people to question whether the surgery, life-saving, though it may be, is over-sufficient. used and what possible consequences might arise as a result. So for many, high rates of C-sections represent sort of this dark side of the medicalization of pregnancy and childbirth, where medical intervention is seen as always necessary, and women aren't trusted to give birth.

This, of course, is not the complete picture, because ultimately, as childbirth moved from the home to hospitals, rates of maternal and perinatal mortality declined as medicine developed methods to manage the complications that in previous centuries may have resulted in tragedy. But this rosy picture of modern medicine marching onwards with doctors saving the day, that really fails to capture the inevitable and often overlooked cost of progress. What did we leave behind when we moved from the home to the hospital? So today, I want to take this big picture view of how childbirth has changed over the centuries, exploring some of the factors that have underlade 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-Levett about childbirth in America from 1750. to 1950. The title sounds somewhat dry. It is one of the most fascinating books I have ever read, very enlightening. The book, A Midwife's Tale by Laurel Thatcher Ulrich, which is so good. Oh my gosh, this is the excellent history book about the life of midwife Martha Ballard. 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, Maine, in the late 1700s.

So like all the context of what was happening. Oh, how interesting. It's so good. Not to mention, like, aspects of midwifery and childbirth and so on. Okay. Another book is, I use snippets of a book called The Midwife Said Fear Not, which is about the history of midwifery in the U.S. up through today. That one is by Helen Varney and Joyce Beebe Thompson. And then finally, there's a book Blue by Rachel Moran.

not our good friend, Rachel Moran, but a different Rachel Moran, about the history of postpartum depression in the U.S. So you can probably tell based on these titles that this history section is mostly going to be primarily focused on the U.S. Love it. Yeah. There is no origin story for midwives. Their existence probably predates written history and assistance during childbirth may even be a key part of human evolution, as we kind of talked about. The word midwife means with women. And over the centuries and across the globe, midwives have taken on various roles that have held different meanings. Wise woman, all around healer, witch to the haters, and so on. But there have been a few constants that have persisted.

Midwife care often focuses specifically on women, that training often involves models of apprenticeship, that scientific knowledge is incorporated into practice, and that pregnancy and birth are considered normal life events. This is not a history of midwives. I won't be talking about like the profession today. But it is a history of childbirth and the two are of course inextricably linked. In the early years of the U.S., childbirth was at home, most commonly attended by midwives, then by midwives with occasional visits from physicians, then by physicians with a woman's friends and family in attendance, and then in hospitals with no familiar faces.

Husbands weren't even allowed in the hospital room until the 1960s, like the late 1960s, and non-spouses way later. Wow. Very interesting. Yeah. The transition from home to hospital and from midwife to physician was not uniform across the U.S.

immigrants, the less wealthy, non-white women, and those living in rural areas gave birth at home for much longer than wealthier individuals. And so to give you some idea of this timeline, in 1910, about 50% of all babies were delivered by midwives. 1910, 15%. By 1930, that number had gone down to 15%. Wow. And by 1973, about 1% of births were attended by a midwife. Wow. And compare that to 2021, which is the most recent one that I found. I'm sure there are more recent ones out there. 12% were attended by midwife. So we went all the way down and then a little bit back and back.

I will say that, I know this is U.S. centric, but that is very different than the data today for most other high-income countries even. Yes, yes. And that is wrapped up in the history of how the U.S. treated midwives, specifically laws. Okay. Yeah, yeah. The transition from home to hospital, this did not happen overnight, nor was it simply a hostile takeover by physicians. As Leavitt puts it and brought to bed, the process by which this occurred reflected the needs. women felt to upgrade and to control their birthing experiences, as well as the increasing medical management of birth. What I really, really appreciate about this quote is what I feel like so many histories of childbirth leave out, that birthing women were and are agents of change. They were not just passive bystanders of the medical and legal attacks on midwifery.

They held the power to say what they wanted their childbirth to be like. until hospitals became the default place to give birth, women often chose who would be there to help, to support, to make decisions when she could not. And the people she chose were often midwives and her female friends and family. It was like a birthing network rather than just like, here is the hospital staff. Okay. And as obstetrics became a more common part of medical training, many women opted to bring a physician into that network, believing that his professionalism, his tools, and his, expertise would ensure the safety of mother and baby. And I say his because that was almost universally the case. Yep. Yep. In 1900, only 6% of doctors in the U.S. were women. I'm actually surprised

it was even that high. I know. I know. I mean, the other thing, the other caveat to that is that, yes, there were 6%, but they had very few patients because most people didn't want to see them. But they were elected, like a lot of women who were giving birth wanted a female doctor. Okay. Interesting. back then, yeah. And of course, most medical schools banned women and non-white women from applying. What led to women choosing physicians and hospitals for childbirth is wrapped up in the professionalization of medicine and and active campaigns against midwifery. Midwives were portrayed as lacking the training and medical expertise to safely deliver babies while also being explicitly forbidden to seek that training and medical expertise. Wow.

Yeah. Okay. And women wanting to make the safest decision for themselves and their baby, broadened male physicians, believing that they would provide protection from the dangers of childbirth, which there were many. Yeah. All right. So now that we've got the big picture view, let's dig a bit deeper to see how this all went down. Yeah. We as a society have a tendency to romanticize certain aspects of the past. Like how much better food must have tasted. It didn't. I feel like I've never thought of that. Oh, yeah. Absolutely. And also, though, see our book club episode on The Poison Squad. Like, there is a reason that pasteurization is hailed as one of the most life-saving inventions. Yes. Uh-huh. 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 for, fails to acknowledge that childbirth can be dangerous. And no, it is not a disease and it's not an unnatural state of being, as early 20th century physicians believed, but it is a physically demanding experience with potential impact on both mother and babies' life and health. Although I really,

I did find it interesting that in that diary of a midwife, the Martha Ballard, she called, like, when a woman was starting labor, she called it her illness as beginning, which I'm I think is very fascinating. It was like the pregnancy was not the illness, but the delivery. Delivery. The labor was. Which maybe just shows how she saw it as like this is a potential where like there is a lot of attention that's needed here. Right.

Right. Yeah. Imagining the women of the 1700s giving birth with no fear as relaxed as could be is erasing the experience of so many who approach their labors with dread and apprehension. In the early 1800s, women in the U.S. had an average of seven children. The number of pregnancies was probably higher because that doesn't include miscarriage and stillbirth. Many women spent the majority of their adult lives pregnant, breast fading, 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. the potential loss of a child that weighed on them, it was the physical act of childbirth that carried with it the threat of death. Diary entries and letters written in the 1800s give us a glimpse into these worries as women wrote wills or gave instructions on who should care for the baby if she died.

Oh, 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 bias on it. think especially because I think a lot of what you're talking about already is like we see, and we see this in a lot of aspects of medicine, we see these pendulum swings.

Yes. Right? And we see things going from like absolutely no intervention to far too much intervention or like, and it's not just in obstetrics, right? It's in so many aspects of medicine. And so I think that that we see that playing out a lot of, especially in like social media right now, where it's like there's all the intervention or there's natural childbirth, which we talked about last episode of like that that mean that word does not have meaning 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 yeah that like it wasn't all roses back in the day yeah yeah yeah so i want to i pulled a lot of these quotes from brought to bed uh because i think that they're 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-1800s, I have made my will and divided off all my little things and don't mean to leave undone what I ought to do if I can help it. Sarah Ripley Stearns wrote in her diary late in her pregnancy. Perhaps this is the last time I shall be permitted to join with my early. earthly friends. A woman described her third birth in 1885. Between oceans of pain, there

stretched continents of fear, fear of death, and dread of suffering beyond bearing. Those who attended births, midwives, and physicians felt similar apprehension, like there was a physician writing in 1870 who described his feelings of alarm and gloomy forebodings after seeing a patient die unexpectedly during childbirth. He goes on to write about how those feelings stayed with him, making it impossible, quote, while attending a case of confinement to banish the feeling of uncertainty and dread as to the result of cases which seemingly are terminating unfavorably. Sometimes the dread wasn't isolated to the act of childbirth itself, but extended to the long period of recovery, like Agnes reads letter about her second pregnancy. I confess I had dreaded it

with a dread that every mother must feel in repeating the experience of childbearing. I could only think that another birth would mean another pitiful struggle of days' duration, followed by months of weakness as it had been before. Yeah. Yeah. And when comparing historical and modern experiences of childbirth, we use data, right? Like we're talking about what about the data. Right.

And our data are limited to things like maternal mortality or complicated births. They're not that great anyway. And we can look at, I think it's interesting to look at Martha Ballard's 814 deliveries from 1785 to 1812. So five maternal deaths, none during delivery, all during two weeks after birth. And that's today compared to 0.22 per every 1,000. So 5 per 1,000.2. Okay. Yeah.

Martha recorded 20 neonatal deaths, and that's 2.5 for every 100 live births compared today to 0.1,000. Right. So that I think also is very often left out of the discussion, even when we're talking about interventions that have reduced maternal mortality. I think that it's easy to gloss over how much we have improved infant survival and reduced stillbirth and neonatal mortality, like drastically, not even to mention like vaccines and saving lives postpartum and all that. Right, right, right. But like carrying it like during childbirth experience itself. Yes, exactly. Yeah. Yeah. Stillbirth, she recorded 14. that's 1.8 for every 100 today, that's 0.6 in every 100. So there's a lot of, I mean, we can use those data to a certain degree, but I think also like hearing those experiences from the women who, you know, went through this is a really fascinating part of it. And these data also don't show us what women dealt with in other outcomes of pregnancy. Like we talked about prolapsed uterus, fischel, is extensive tearing perinatal mortality and the emotional experience of that. late pregnancy loss, the range of emotions that could accompany having limited control over your

reproduction. Mary Foote described it in the 1800s as a sort of pendulum between joy and dread. For Hannah Widdall-Smith, writing in 1852, that pendulum swung more towards dread. I am very unhappy now. That trial of my womanhood, which to me is so very bitter, has come upon me again. When my little Ellie is two years old, she will have a little brother or sister. And this is the end of all my hopes, my pleasing anticipations, my returning youthful joyousness. Well, it is a woman's lot and I must try to become resigned and bear it in patience and silence and not make my home unhappy because I am so. But oh, how hard it is. Wow, that's a really heartbreaking, Erin.

Yeah. It's, it's, yeah. Yeah. We have gained so much and then now we're losing so much again. Yeah, I know. To not, because like she said, to not have any control over it. To not have any control. Any control over it.

Right. And it's just like, here it is. It is my lot as a woman. Yeah. So, yeah, even though pregnancy and childbirth were much more common historically, that didn't necessarily make them more welcome or more looked forward to. Just as with today, women's experiences were incredibly varied and complex. And they created ways to manage.

their fears, whether that was surrounding themselves with familiar faces or seeking the latest medical advancements or both. The choices available to women depended on when she lived, where she lived, and how much money she had. Early in U.S. history, most births were attended by midwives, who played a largely non-interventionist supportive role. According to Leavitt, as much as possible, they let nature take its course. They examine the cervix or encouraged women to walk around They lubricated the perineal tissues to aid stretching. They delivered the child and tied the umbilical cord. And sometimes they manually expressed the placenta.

Historically, at least from my understanding, there wasn't a ton of postnatal care for like mom and baby. She would be there for a bit and maybe make another visit. Okay. But usually the woman had other friends who would come and help with like home. Other women in her life. Exactly. Yeah. And the midwife was typically not alone in the, like,

like in attendance. Often there were like friends and family there as well. Usually female friends and family. But as the practice of medicine became a formal profession, meaning like you had to have a certificate. You had to go show your training here. Go to school. Then they developed residency.

That's a whole episode someday probably. Yep. So this act of professionalization started in the late 1700s, early 1800s, maybe even a little bit earlier in the 1700s. Towns, that meant that towns and cities had more. more physicians that could be called in during birth. And sometimes that call came from the midwife, who wanted a bit of extra assistance during a particularly difficult birth. It's been a long time since I've watched called the midwife. I know. I love that show. I've really loved that show. There are probably

seasons I haven't seen. Oh, definitely. Yeah. Yeah. We should watch it. We should. And physicians and midwives weren't always in direct opposition during this time. And many physicians saw the potential for partnership with midwives primarily being the ones attending the births and only calling in doctors in cases of emergency. And these occasions could also lead to tension, though, if the midwife and doctor disagreed. Some physicians might defer to a midwife with hundreds of births under her belt, but gender and class dynamics ultimately put the authority in the hands of the doctor, no matter how little experience he had. So I want to read you a quote from Martha Ballard's diary. she records a few of these clashes, and here's one of them. They, meaning the parents, they were

intimidated and called Dr. Page, who gave my patient 20 drops of laudanum, which put her into such a stupor, that her pains, which were regular and promising, in a matter, stopped till near night when she puked and they returned and she delivered at seven-hour evening of a son her firstborn. Okay, Erin, so I told you that I read that fictional, like, fictional, okay, that whole 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 description, because this story is called Frozen River, the book. And it's like they go, she goes so much into like what she assumes that Martha Ballard was thinking during the time and stuff like that, which is just so like fun and fascinating. Yeah. Yeah. But that story is in there. So I knew that one. I want to read that book.

I'm very curious because like there is, her diary entries are so sparse. in terms of like any detail. There's no detail. That's what she said. There's very few emotions. There have been like a couple times while she'll say like poor, poor mother because she lost a baby or something. But yeah, this. And then I think there's another time she calls out Dr. Page.

And he's like, what an unfortunate man or something like that. But it's hard to know if she's like, and who knows, is she irritated at him or does she actually feel bad because he is chosen a profession that clearly is not to his skill set. Yeah. Oh, it's so interesting. Yeah. Check out those books if you want. 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, 19th century doctors did the opposite. There was laudanum or opium, as Martha mentioned, bloodletting, even in the case of hemorrhage. Oh, my God, I still can't get. I'm sorry, yeah. But yes. We haven't talked about humors. bloodletting all these episodes. 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. Damage. Yeah. And of course, forceps. By the mid-19th century, foreseps 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. Mm-hmm. One doctor bragged in JAMA in the mid-1880s 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 for. forceps. But like before the cervix is all the way dilated? Yes. No. Like before the baby had even

fully entered the birth? No, no, no, no, no, no, no, no, no, no, no, no, no, nope, nope, nope, nope, nope, nope, nope, nope. Okay, nope, nope, nope, nope. Okay, that's not how forceups are used to corrective the course. We have corrected the course. Or not used in that way today. No. Wow. But they used to be used. Yeah. Okay, okay, okay, okay, okay. So unsurprisingly, the sight of forceps was not always a welcome one. And so the doctor would just be instructed to, like he instructed his students to hide them, just wear big gowns so that you can hide your tools because it'll, you know, make the woman nervous. If a medical school included training specifically on obstetrics and few actually did in the late 1800s, it mostly centered on how to use these tools and rarely included hands-on supervised experience. Awesome. Okay, so there's one example that I

want to share with you. I don't want to hear it. I hope it's an urban legend, but I don't know. I would actually believe that it's not necessarily that. Okay, tells the story of a newly graduated doctor, official doctor, in the late 1800s who examined his first laboring patient only to be horrified at what he thought was a tumor blocking the birth canal. He figured, okay, 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 we're going what he thought was a tumor was the baby's head. Okay. I thought I was going to go a different way, and I was getting very nervous. Oh, no, what did you think I was going to say? I'm not going to say. Okay, we can discuss off-camera. Yeah. Okay. Yeah, so someone who is a medical doctor and didn't know how babies were born.

Well, I mean, that doesn't surprise me. No, I know. Back in the day. Back in the day. Yeah, yeah, yeah. But wouldn't you have at least seen a diagram somewhere? I don't know. I wasn't in med school in the 1800s. They did have like theaters where someone, the students could watch some. Can you just imagine the horror of that? No. Yeah. But aside from forceps, the other major tool that was employed by 19th century physicians was anesthesia.

First, ether and then chloroform were introduced in the mid-1800s, and pretty quickly they exploded in popularity. And it wasn't just like popular with doctors. everyone wanted them, especially after Queen Victoria had one of her kids with, I don't know if it was ether or chloroform. Okay. But it was like made the news. You know who administered it? No. John Snow.

As in John Snow? Of color of fame. Of color of fame. Not Game of Thrones. Not disgraced Game of Thrones fame. Yeah. Wow. Yeah.

And so that really, I think, allowed people to go, oh, I want that. Okay. And she was like, this was great. Yeah. I loved it. Again. Would highly recommend. Yeah.

Yeah. And it's, I think it's pretty easy to see the appeal if you, if you look at some of the, I mean, even not based on today, but like, and like people, you know, you have experienced childbirth. 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. Okay. Because I had a long section that I was like, this deserves its own thing when we talk about, you know, anesthesia. But Twilight birth was this thing where you would be. given like scopolamine and something else. And often the effect was not or the goal was not

necessarily to relieve pain, but it was to make you forget. And it could induce a lot of like anxiety and delusions. And so they would be physically strapped down. And then this idea was that you would wake up with a baby in your arms. Al-a-madman. Al-a-madman and Betty. Yeah. Yep. By 1900, ether or chloroform was used in 50% of bloods. births attended by a physician. Wow. Ether or chloroform. We got better later on 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 19th century. It can be done quickly, safely, and with no pain. That was what childbirth had become, right? Like this is what medicine promised. This is an option, yeah. And of course, that was not always the reality, nor was it the reality for those who couldn't afford to pay for a physician or who felt it was taboo to have a man present during labor and delivery. doctors charged more for midwives.

So, for instance, Martha Ballard charged $2 for her assistance during labor and delivery, and her contemporary Dr. Page, charged $6. Okay. Yeah. This could be a lucrative job for physicians, and as more doctors incorporated childbirth into their practice, they increasingly saw midwives as competition for patients rather than collaborators. Okay. 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, where higher price is equated with higher quality. Yeah, yeah, yeah. And that is completely understandable, right? Who wouldn't pay whatever they could if it meant the best care possible for mom and baby? The issue was whether it was actually the best care. In the last few decades of the 1800s, childbirth became increasingly medicalized. Physicians now attended nearly half of all births and tried their hands at various.

interventions, none of which had been adequately examined for safety or efficacy. And while women still held the power in home childbirth, doctors were growing more resentful of that. Conversation should be prohibited. Nothing is more common than for the patient's friends to object to bloodletting, urging as a reason that she has lost blood enough. Of this, they are in no respect, suitable judges. Oh, gosh. Right. Her friends are probably like, she is, like, she has been drained. Stop. Stop. And he's like, oh, come on, you don't know anything. You didn't go to Harvard Medical School. Midwives were also blamed for high rates of puperal fever and sepsis, despite evidence that it was, in fact, doctors who were much more responsible for the infections due to their proclivity to just go from cadaver dissection to the labor and delivery room in hospitals.

Listen to our puperal fever episode. So much more on that. And in fact, maternal mortality in the U.S. was on the decline by the end of the 19th century, but it plateaued for a while until the late 1930s, which was after most births were happening in hospitals. Interesting. And that's probably because of all of the adjustment, well, all 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.

You read Medical bondage for more on that. Medical bondage, yes. Yeah, that's such a great book. The U.S. seemed an especially deadly place to have a baby. In 1910, one mother died for every 154 live births. Wow. Compare that to Sweden at the same time where the number was one in every 430. Okay.

Yeah. Wow. In the early 1900s, U.S. states introduced laws banning midwifery, and all midwifery became illegal in 1959 under a law that redefined midwifery as the practice of medicine. Interesting. Yeah. Yeah. And I'm not saying that we should have like a, there's like I'm not advocating for a blanket defense of midwifery at the time. because undoubtedly there were unnecessary injuries or infections and deaths at the hands of midwives,

just as there were for doctors. But those early bans did not provide any pathways for training or certification for midwives. And so then that disproportionately impacted poor women who couldn't afford a doctor or who were then forced to go to a hospital, like a hospital, which were deadly at the time. And this is like at the time when becoming a physician and like, the process of that is becoming very well regulated. Oh, even before then, yeah. And then there's no pathway to become a like certified licensed midwife the way that we have today with like a registered nurse midwife kind of a thing. And so other countries did have that pathway for midwives. But we didn't

in the U.S. But in the U.S. We did not. Got it. Okay. And so then this eliminated an entire career path that women had. So then what what do you do? Interesting. Okay. This process devalued the contribution of midwives and the importance of human presence as an essential part of care. Like familiar human presence, not just like a nurse or a doctor popping in every hour, 30 minutes, something like that. This also further the notion of pregnancy and childbirth as pathologies. The father of modern obstetrics, Joseph D. Lee, does his name sound familiar to you at all? I don't think I've ever talked about him.

Yeah. Okay. Didn't know if like in med school or something. Okay. He wrote in 1920, so frequent are these bad effects that I often wonder whether nature did not deliberately intend women to be used up in the process of reproduction in a manner analogous to that of salmon, which dies after spawning. We're just fish. Also, male salmon die too. Come on. But also, that's like, doesn't make evolution. Like, clearly you don't understand evolution. for that to make sense. Because salmon spawn like

bagillions 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. Our case selection. Not the modern synthesis and evolution. Clearly. Okay. I'm for his part, because there's nuance to everyone.

Of course. 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. All right. Still thanks for salmon.

Fine. But pathologizing childbirth was a way to send home the message that midwives were not qualified. Okay. Right. This is a dangerous state and you need someone who has been trained in this way and has this, you know, diploma from this university. Right. Okay. Okay. Okay.

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, right? Which is such delicate flowers. Exactly. Exactly. And so all of these factors drove childbirth from the home to the hospital. Midwifery, discredited and banned the pathologization of childbirth, the growth of hospitals, women themselves choosing hospitals and physicians. Okay. As Leavitt 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 1918, I have placed myself in the hands of a specialist in obstetrics. I have every confidence in him and it is a great relief. Another described her hospital stay as a quote unquote, lovely vacation. But some women felt the loss of familiar faces keenly. Quote, the cruelest part of hospital childbirth is being alone among strangers. Another called it a nightmare of impersonality.

Another quote, months later, I would scream out loud and wake up remembering that lonely labor room and just feeling no one cared what happened to me. No one kind reassuring word was spoken by nurse. or doctor. I was treated as if I was an inanimate object. Oh, my God. Yeah. Awful. Awful. Truly, like, dehumanizing. You are just a machine to make babies, so no one cares about your mental well-being. We know best. This period, from the 1930s to the 1960s, is marked by tremendous gains in our understanding of the physiology of childbirth, which is clear from the drastic drop in maternal and neonatal mortality during this time. Okay.

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

They demanded that their partners be allowed in, that they could breastfeed on their own schedule rather than the hospital mandated one. Oh, that is really, really interesting. Yeah. They would be like, oh, no, not here. Q2 hours. And also that was at the time, too, when it was like nurseries. And so your baby was taken away and put in a nursery, which is like the opposite of what we do now, which also people have opinions about because then it means the mother doesn't get any rest. Oh, my God, there's so much to go back.

I know, right? I mean, we have, this is like jumping ahead a little bit, but the history of this, this whole series just shows us that like we don't have everything figured out. And that's, I mean, that's okay. It is. Things are really overall good. Yeah. And because 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. Also that. is not to erase the experience of people who are like, I did not have a good time. Right. Right. And I think, I think it is just so interesting to do what you're doing right now, Erin, which is like, look back at like, how did it used to be? How did people feel about that at the time? Yeah. How did we get from there to hear? Why did the pendulum swing this way? Where are we in this pendulum arc right now? Leave a nose. Yeah. I know, but it's so interesting to like go back and try and kind of piece it together on like, because it gives you so much context that sometimes might make something that feels horrible today, make more sense, and then make it more like you can, okay, I understand why this thing happened, right? I think that's so important.

Why are we here today? Why are we here today? Yeah. Did not mean to get that existential, although I'm surprised, given that this is a series on pregnancy that we haven't gotten that existential. Here we go. Fourth of. Yeah. Putting it all on the table.

All on the table. But yeah, all of these new choices or choices that previously had not been available, things like having your partner in the room, breastfeeding whenever you want. Do I want an epidural or not? And so many other choices that simply probably were not available. Right. And we are now, I think, coming to terms with some of these, like the choices and the range of choices. And I will say, too, that that is a double-edged sword, right? Since the 1970s, women, along with researchers, doctors, nurses, midwives, doulas, partners, parents have examined the childbirth experience from every angle asking what do I want, what's best for me, what's safest for baby, how do we balance everyone's needs?

And today, there are so many choices. There are so many options and there are so much information out there that it can feel overwhelming. How do you make the right choice, especially when the internet. has very strong opinions about everything. What happens when you are not able to choose or if the choice is made for you? Navigating pregnancy, childbirth, and the fourth trimester is a huge challenge, which is the understatement of this series. I'm getting like so many flashbacks right now.

It's a lot. From your child. Yeah. Yeah. Yeah. Yeah. Keep going in. How am I?

Is this the right stroller? the right choice? Was that the right choice? If I don't make a choice, what does that mean? What does that mean? Yes. And what if there's a choice that like, did I have a choice? I'm not sure. Yeah. And there are a million voices telling you, yes, no, maybe in conflict, maybe not in conflict. Do this, do that. That we have more choices and more knowledge today than we did 60 or 100 years ago is a powerful testament to the work of countless women and modern medicine striving to make this a safer and better experience. And of course, there's still room for improvement. There will always be room for improvement. But understanding our past, understanding what we lost

during the medicalization of pregnancy, as well as just how much we've gained, is crucial for creating a better future. Recognizing those gains is especially important, because I think sometimes we take them for granted. 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 puperal insanity in the late 19th century, which is what it was called. Well, which is what it was a diagnosis. It's not necessarily, there's more nuance to puperal insanity. Yes. Yeah. to what was called baby blues post-World War II to postpartum depression finally making it into the DSM4 in 1994. 1994. I told my mom that and she was like, really?

Just wait. Oh, and it's not even, I know. And then in there, there's like a whole journey about how it got in there and was it actually put place in there in an appropriate way. And what we don't have in there today. What we don't have in there today. And then also like there's the book blue is very good. really fascinating too because it talks about how postpartum depression became like gained more awareness and it was through the work of a lot of people advocates who worked really strongly to make

people more aware of this 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 don't think I had postpartum depression because I wasn't that bad. You know, exactly. It wasn't that bad. Only the extreme scenarios. Right, right.

And I think that we have now, like there's been such incredible representation in the media. And it's still, again, room for improvement. But yeah, I mean, I think it's safe to say that since the late 1800s postpartum depression, postpartum mental health has really been on a journey. And ultimately, creating a clinical definition for PPD, imperfect. though it may be, it opened up research areas for treatment. It raised awareness and established ways to treat people or reach people who might need help. And it removed some of the blame that had been so central to postpartum mental health for decades. Oh, she's depressed because she hasn't accepted her role as a mother. Thanks, Freud. She's got PPD because she had a C-section. Right.

Working moms bring on PPD themselves because they're just not equipped. Yeah. Yeah. Yeah. Blame certainly remains. It is not gone by any means. But turning this into a more, having a more biological framework for understanding this has helped to remove some of that to some degree. And there is, of course, downside to this medicalization, right? It has discouraged to some degree consideration of systemic and societal drivers that might underlie PPD that I know you're going to talk about. I sure am. Because if you're treating it just as a hormonal or chemical imbalance, then it's like, so, but it's not happening in a vacuum. Oh, my God, Aaron, I literally can't believe how well this is, like, segueing into what I'm going to talk about. It's like we do this sometimes. It's almost like it's our job. But yes, 100%. Yes.

And it creates boundaries around what is normal, right? And those boundaries might be different for different people, but it's really hard to incorporate that into. a medical definition, right? And I will say also those boundaries are a necessary part of any medical definition. But having that lack of nuance in understanding the individual can also be really have consequences associated with it. Yeah. Personalization of care is a crucial aspect, not just for PPD, but also for childbirth and pregnancy more broadly. And I want to end with yet another quote by Judith Walser-Levett. I really loved this book, as you can tell. quote. Throughout American history, women have wanted and have worked to achieve their own ideals of childbirth,

ideals that have developed and been nurtured within their own communities in conjunction with the rest of their life experiences. Childbirth remains, as it has always been, a cultural event as much as a biological one. Problems emerged during the middle of the 20th century because the hospital acted to homogenize the birth experience and make it similar for all women. But childbirth cannot successfully be reduced to one kind of experience and at the same time satisfy the wide range of expectations women bring to it. The diversity that women seek will continue to reflect the differences of the women themselves, end quote. And chills. And with that, Erin, turn it over to you. Just leaving me right there, huh?

Tell me about the fourth trimester. Okay. You might need a little breather after that. We can do that. We'll take a break and then get into it, shall we? Let's do it. Anyone who works long hours knows the routine. Wash, sanitize, repeat.

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with immersive shore excursions and zero kid energy. Virgin Voyages.com. At 32 years old, I got pregnant for the first time. I have what you'd call a textbook pregnancy, healthy baby, low risk, and a noticeable glow. But there was a lot of things that I wasn't warned about and things that just weren't talked about unless I brought them up. Harvey and I started trying for a baby in September, and luckily enough, by November, I was pregnant.

My first symptom wasn't morning sickness or anything like that. In fact, it was excruciating period pain. I genuinely thought I was about to have the worst period ever as some kind of cruel joke. Turns out it was implantation. The next time I felt that level of pain was actually an active labour. Within two weeks of conception, my body already started changing. My boobs went from an age with C-cup almost overnight, and they continued to grow throughout my pregnancy and got pretty big during breastfeeding. My stomach also grew quickly. I was mostly water because baby boy was measuring perfect the entire time. I was very lucky when it came to nausea. I only experienced it for about a week and cardam and tea helped a lot. I only vomited twice, once from a bad meal, which my

husband also got sick from, and once when I accidentally ate bacon because pork was a major food aversion for me, which is kind of surprising 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 it was salt and vinegar chips and anything sour, especially lemon ice cream. In the second trimester, I craved corn and coffee. Of course, I only drank decaf, but I never drank coffee before pregnancy. Funnily enough, I'm still drinking it now after giving birth.

By the third trimester, my cravings had evolved to steak with an egg on top. On the flip side, I couldn't stand chicken or pork. Even the smell of chicken may be nauseous, to the point that if my husband ate it, he had to brush his teeth before coming near me. pregnancy also came with a long list of symptoms I just wasn't prepared for. Blood noses, grey hairs, loose ligaments, ligament pain triggered by sneezing, dry skin, exhaustion that left me sleeping for 10 hours at night and then still napping for 4 hours during the day. Acid reflux and reoccurring thrush, which I had never experienced before pregnancy.

The physical strain was pretty intense. At times it felt like I'd done a hardcore leg day at the gym or I'd been riding a horse bareback for hours. I had to give up weightlifting and running because I was just too exhausted, but I did manage to do a little bit of yoga a couple of times a week, and maybe that's why I could still 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 hemoglobin's were slightly load, so it was recommended that I'd do it. Around this time, baby boy started moving into position, and I could feel every shift. There was a moment when I genuinely thought that he might just fall out because of how low he moved. Despite all the unexpected symptoms, I got the birth experience that I wanted. I had a pain relief, water birth, and in the final moments, I reached down and pulled my baby 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 it needed to do, and I'm so grateful for my body for doing that and for giving me my beautiful, healthy baby boy. Hi, Aaron's. My name is Miranda, and I want to thank you for allowing me to share my pregnancy and birth journey. I have to say that overall, my pregnancy journey was relatively uneventful, and I'm very thankful for that for the health of myself and of my baby boy, who is now 18 months old. I will say the most annoying and most prominent pregnancy symptom I had

was actually carpal tunnel syndrome, which going into pregnancy, I had no idea that that was a common symptom. I spent probably the second half of my pregnancy with my hands being numb or tingling or painful, almost 24-7. So that was definitely frustrating. Other than that, towards the end of my pregnancy, I started to have some gestational hypertension. So we did a few non-stress tests and biophysical profiles to make sure that I was safe and that my little guy was safe. On the 4th of July, maybe I had a little too much fun on the lake and enjoyed some salty snacks, but my blood pressure did go pretty high, so they ended up deciding to induce me when I was due in mid-July. So it was not too early. I really didn't need much of a kickstart for labor. Thankfully, I started labor pretty

darn quickly without even having any potocin. Unfortunately, I did not progress in labor as we'd hoped. I was in labor for 18 hours and I was dilated to nine and a half centimeters and I was stalled out. So after about six hours stalled out, my son's heart rate started dropping and my doctor advised us that we could wait a little bit longer and potentially have to have an emergency C-section or we could just do a C-section now. And after 18 hours of labor, I was on board with that. We had a beautiful and wonderful C-section experience, and I'm so thankful for all of the staff and my husband and my mom for being there to support me. I was very surprised by the swelling after the C-section. I couldn't wear shoes for two to three days. But other than that,

my little guy was happy and healthy, and I had an overall great experience. Thanks. Thank you. So last week at the end of episode three, I ended where most conversations regarding pregnancy end. And that is once the baby's delivered. Right. Everything's over. Yeah. But that's not where pregnancy ends. At all. So, Erin, you just walked us through a lot of the kind of social and institutional, like high-level factors that have caused this shift.

in where delivery happens and how these things have kind of contributed to a lot of the big picture postpartum outcomes. Those big picture things are like maternal mortality rates, even like postpartum depression rates, which we'll get into. And so that is where I'm kind of picking up your threads right there. Perfect. But then I'm going to unravel them a little bit more to also remind us of what is going on biologically in this so-called fourth trimester. Yeah. Why it might be rocky for some of us. And my favorite, what do we know about evidence-based ways to improve outcomes?

Oh, evidence-based. What a beautiful phrase. Isn't it? I just love it. You want a spoiler alert on what it is? We don't know. Public health. Oh, okay.

I was like, don't worry, we know. We don't know. No, we do know. Public 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. Yeah. Just like I kind of breezed through early and. brianic development, and I didn't talk at all about the rest of fetal development. I am not going to talk about the physiology of the newborn, but it is really cool and fascinating. We'll do it someday. It's the second fourth trimester. Exactly. Yeah. But we're, this is pregnancy, and so this is the fourth trimester of pregnancy and the pregnant person here. 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. is the primary organ that was making all of the hormones that kept the pregnancy going.

So once that placenta has been delivered, you have a rapid withdrawal of placental hormones, and that results in significant decreases because the placental hormones are like, there's a whole bunch of different things. And a lot of them, it's not necessarily just like estrogen and progesterone alone, but it's like hormones that are telling us to make more estrogen and progesterone and stuff. It's like both a radio tower. It's not just like a trans. Okay, here's what I was thinking about.

Give it to me. 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 flowers and make a cake. It's the producers. Exactly. This analogy does not need to exist, but I like it.

We 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. 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. Yeah. By about six weeks, some of it takes about 12 weeks. So can I ask a question about like what, how different are those changes? Like, is there just a way so I can in my head quantify what that looks like? And I guess it's hard to know like how much estrogen is actually, you know, those numbers? Yeah. Yeah. I don't know. I think one of the graphs that I had in last episode showed like hormone concentrations and stuff like that.

But there's also such ranges and especially like anyone who is menstruating, your levels fluctuate so much with your menstrual cycle. Okay. I will say that after, like in postpartum, you have a withdrawal of these hormones. So they go down to very low levels. And if you are breastfeeding, they remain suppressed because of prolactin that's being. So like the withdrawal of progesterone, skipping around in my notes, the withdrawal of progesterone causes an increase in prolactin, which is the hormone that stimulates milk production. So if you are then breastfeeding, you continue to have high levels of prolactin. And that suppresses the release of LH, which is lutinizing hormone and FSH, which is follicle stimulating hormone.

And those are what would induce a normal ovulatory and menstrual cycle. Right, right. That is why you see suppression of mencies during breastfeeding and why that is, for a lot of people, a good form of contraception. But doesn't always happen that way. But, I mean, it is more, like, it's more effective than condoms. Okay, that's interesting. Yes. It does not get.

I had a whole paragraph on this somewhere, but I can't even find it. So I'm going to just talk to you from my brain. It is, I forget the exact number, but it is actually quite effective. But it's only for the first six months postpartum that we have good data on it. And it's only when people are exclusively breastfeeding, which does not include pumping, because it is also breastfeeding on demand, which means that you are breastfeeding based on your newborn's cues and not necessarily on an hourly schedule, which is what you end up having to do if you're exclusively pumping. Not everybody is going to remain amenoreic, which means they're not having men C's. But it is, it has 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. Yes. There's more nuance because I know a number of people who have gotten pregnant while breastfeeding. 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 mencies can come back earlier than that six months. Yeah. They can come back in a matter of weeks. Again, it's going to be different person to person. That's why it's not 100% effective. Right, right. Right. But yeah, it is. It is really interesting. Yeah. How about that?

A little tangent for us there. I love a tangent. Me too. So, yes, we see this big hormonal change. And then a lot of those physiologic changes that happened to sustain the pregnancy are going to kind of unravel themselves. So your blood volume, which again had increased by about 50 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 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 diaresis. And so you have this physiologic diarasis. So a lot of times you'll have, you'll be very kind of puffy immediately postpartum. And that's because of all this excess fluid that your kidneys are now just trying to like shunt out and then you're peeing all the time because of that. And how long does that last? A few days usually for the like the physiologic diaresis. 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. Yeah. Your GI tract, which remember slowed down a lot during pregnancy because of progesterone. It actually slows down even further during labor. And it will start to return to a pre-pregnancy type of functioning. Like mobility will come back within a few days. But in those first few days immediately postpartum, you can have that continue like it's a little bit more slow. And that can result in constipation.

This is exacerbated by C-sections because those are, again, abdominal surgeries where it can cause the bowels to kind of like go to sleep a little bit. And so that can mean that you can end up a little bit constipated. Plus, opioids are often used. And so those slow down the bowels even more. Super slow, yeah. 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 happen is constipation postpartum. It 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. And all the way back to like pre-pregnancy baseline until a number of weeks later, closer to like six

weeks later, because it just has to like continue to shrink. Part of that process also means a couple things are happening to like encourage that process. One is that the release of oxytocin, which is triggered by breastfeeding. So for people who are breastfeeding, they're going to have an increase in the release of oxytocin. That oxytocin is the hormone that stimulates uterine contraction. So that's going to cause further uterine shrinkage back down to like the size of a fist, which is what it is pre-pregnancy. And is that pumping or breastfeeding? Or breastfeeding, either one.

And then even if you are not breastfeeding, it's still going to shrink on its own. It just might maybe take a little bit longer or things like that. Okay. But yeah, so that it's going to take a few weeks before it really goes back down. It's not like an automatic. It clamps way down, but it doesn't like go back. Takes time. Yeah.

Makes time. And as part of all of this, as this uterus is continuing to shrink and contract, it also means that you are going to be shedding all of the remnants of your endometrium, regardless of your mode of delivery. You are going to be shedding this lining of your uterus, and your uterus is remodeling its whole inner lining. So you have a lot of vaginal bleeding. This is called lokia. That's like just what we call the postpartum bleeding. How do you spell lochia? L-O-C-I-A.

Huh. Lockea. And 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 blood, like relative to a regular, like if you have more regular periods. What is a regular period, Aaron? If you, for an individual, that doesn't even, that doesn't even track. No, yeah, it totally varies. What I will say is what we, okay, we talked a lot about postpartum hemorrhage last episode. Yeah. Delayed postpartum hemorrhage is also a thing where you can have a hemorrhage that occurs later on after delivery in the days or weeks postpartum. And so what I will say is like the general advice in terms of how much is too much bleeding.

I don't actually like to give medical advice on this podcast. This is not medical advice. We are not your doctors. Please consult your doctor. But usually if somebody is bleeding so much that they're like completely saturating pads for like hours in a row or they're passing very large blood clots, that is usually considered too much bleeding. Okay. So it's kind of, it should be like a moderate amount, but not like heavy, heavy bleeding. Right. But again, can barely 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. Are you 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 has really kind of kicked in in those first couple of days, your body is producing this substance called colostrum. Yeah. And that's that kind of yellowy, like it's a different. texture, it looks different substance. We actually start making that most people during about the second trimester. Some people might notice it. Some people might not. And then it takes usually two or three days on average for your breast milk to come in in people who are going to be breastfeeding. There are a lot of situations that can cause challenges to that, whether it's delayed milk production.

one of the risk factors for delayed milk production might be a C-section. The mechanism there, not fully known. Right, we don't know. But it is the case that C-section is associated with an increased risk of delayed milk production. Also early delivery, whether that's early term, which would be before 37 weeks. Okay. Or like late pre-term, it's like 34 to 36 weeks or so in there. Or even just that like early term, 37, 38 weeks, sometimes people have a little bit of a delay or have like a little bit of a delay.

start in their breastmunk production. And then there is so many individual factors as well that play in. Have you ever breastfed before? Like so many different things. There's also infant factors that can really contribute to like 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 strong. strongly about the rhetoric around breastfeeding today. Yeah, we do. I do feel that it deserves its whole own episode. We will do one. We absolutely will. Because there is a lot to unpack there. Yeah. And the short answer is, in my opinion, and per medical establishment, regardless of whether they admit it or not, Fed is best. Fed is best. 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, you notice them or not, like you might not notice your blood volume changing, but you might notice that you're peeing a lot, sort of a thing. You also have just given birth either vaginally or through a

C-section. So you might have stitches, either in your abdomen or in your perineum or maybe not. In either case, you're probably going to be sore. There's going to be pain that is there because of the whole process that literally just happened. Yep. And then on top of that, you have an infant. or multiple, who needs literal constant care. Constant, round the clock 24-7. Who cannot be left alone for like a minute. Who sucks at sleeping? They suck at it.

Why are they so bad at sleeping? Why are they so bad at sleeping? They suck at pooping. They're not even good at pooping yet. They suck at eating. Yeah. They cannot figure it out. And you are now entirely responsible for them.

Yeah. This is a very difficult to. time period. Yeah. Even if you are good at it or you've done it before or something like that. It's very hard. And we talked in these last few episodes a lot about the risky parts of pregnancy. The postpartum period really often, especially in the U.S., gets dismissed. Oh, yeah. But all of these physiologic changes that we've gone through, they don't reverse themselves automatically. And they are still kind of changing and finding a brand new baseline in this postpartum period, which means that we are still at increased risk of things like postpartum preeclampsia.

Yeah. Okay. Of delayed postpartum hemorrhage like I talked about. There's also the risk of infections like endometritis, which can happen post-delivery. So there is a lot of different topics that I could go into. But what I'm going to now shift to focusing on is one of the biggest contributors to postpartum morbidity, and that is postpartum depression and postpartum anxiety and other postpartum mood disorders. So postpartum depression, which is the one that gets probably the most press these

days and is the most well defined because it does exist kind of in the DSM 5. It is generally recognized as more than two weeks, and sometimes it's like has to be developed in the first four weeks of a depressed mood in the postpartum period. And that's the postpartum period. And that's the, 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. Yeah. I am being anxious for no good reason at all. Right. I've been crying for no reason at all. To ask someone to say, are your anxieties justified or are your worries justified? Yeah, yeah, yeah.

But that's just my personal feelings. These are very well validated tools. for screening. And so this is the kind of first thing that's recommended that everybody during pregnancy and postpartum is supposed to be offered questionnaires like this to try and identify people who are perhaps experiencing postpartum mood disorders or who are at risk of developing postpartum mood disorders. Globally, postpartum depression has an estimated prevalence of 17 percent.

That is so much higher than any of the other complications that we have talked about. Yeah. Like so much higher. That global number, though, is not, like, you can't just leave it there, okay? Because the variation geographically is huge. Okay. Now, low and middle income countries, prevalence is significantly higher, significantly higher than in high income countries. The average, if you just lump all low and middle income countries, which is not a fair thing to do.

But if you do that, then the prevalence is estimated at around 20%. Okay. High-income countries, the average is like 15 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 30 in the 30 percentile. Wow. Yeah. So the range is really, really huge.

And a lot of high-income countries, the prevalence of postpartum depression, is in the single digits, like 8, 9%. Okay. The U.S. and the U.K. are a little bit of outliers in the high-income country bracket where the prevalence is estimated at 18 and 20 percent, respectively. Okay. Okay. Now, pause for a second, because we're going to err in math this a little bit. Yeah, yeah. Because that is, in the U.S., we have an estimated around 3.5 million live births every year.

If 18 percent of those, and postpartum depression is not limited to live births, so this also encompasses, depression post-miscarriage and stillbirth, which those rates are even higher. But even if we just look at those numbers, three and a half million live births, 18% of those people having postpartum depression is over 630,000 people in just the U.S. every year. That's not a small number of individuals or families that are being affected. So that's postpartum depression, which is just one of the postpartum mood disorders. disorders. Postpartum anxiety. I have a question. Wait. Sorry. I know you're like I really want to. I know. I know. I know. Okay. This map that shows the rate of postpartum depression or the prevalence. Prevalence. Previllance. Yeah. Okay. Is postpartum depression? Is this all being defined in the same way? It's all being defined as DSM-5 definitions. Yes. DSM-5 definitions. Yes. Yeah. Postpartum anxiety, another one of the post-partum mood disorders, estimated to affect

8 to 12% of people postpartum. Here's the big problem here. Okay. We don't have diagnostic criteria. There is no such disorder in the DSM. There is no disorder that is called postpartum anxiety. We also do not have a screening test. In theory, the EDS should be capturing people who are at risk for postpartum anxiety type mood disorders and depressive disorders, but it doesn't. Like there's no screening test for for anxiety that is universally administered in the postpartum period. And there is also not a specific like disorder that is recognized as a postpart of anxiety disorder. So then people have to like in to get a diagnosis quote unquote, whether that's important or not is a different discussion. But it would then be a different type of anxiety disorder like a generalized anxiety

disorder, obsessive compulsive disorder, right? Like all these other type of anxiety disorders. Because anxiety is a symptom and not a diagnosis. Okay, a few questions here. So a person could have postpartum depression and postpartum anxiety. Absolutely. Okay. Secondly, then, do postpartum depression, postpartum anxiety? Because I know that in reading about the history, the postpartum, like, there was a huge fight or struggle to get postpartum to be a specific thing.

And part of that was related to insurance and stuff so that it's like, oh, if this was preexisting, we're not going to cover it. Correct. But and so then that postpartum period was shown as a risk factor. And that is how we got postpartum depression as a diagnosis. But then what? 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 60s, do you want to know what, like, I think it was Dr. Spock or something? You know, like the Benjamin Spock who was like, this is how to care for your baby. No, I only know this Spock with like the Live Long and Prosperry.

This is relative. Okay. Okay. Yeah. Not really. Oh. I was like, really? I was like, he's an alien. I know.

That's why I was so confused. Oh, no. No. It was recommended that to pick, to like, oh, if you have baby blues, pick yourself up by getting yourself a new hat or treat yourself to a new. dress. Go get your hair done. Get your hair done. That was literally in, yeah, yeah. Great. Love that. Anyway. Yeah, so lasting more than two weeks. More than two weeks. And then in terms of the onset of development, it's like usually the first year postpartum is all still considered within the postpartum period. Okay. That's what, that was my terribly worded question was trying to

get at. 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-5 title. But this is the onset of hallucinations or delusions and like disorganized behavior and things like that that that usually go along with depression or depressive symptoms during this postpartum period. This is thought. to be relatively rare, though our studies are not as robust on it, but estimated between 0.86 to 2.6 per 1,000 births. So it's commonly cited as like 1 to 2 per 1,000 based on a global analysis from 2017.

But it is also the most acutely dangerous of the maternal mental health disorders because this can be, it can be very severe and really disturbing for the mom and the family. And so often results in hospitalization. Yeah. I think I told you this, Aaron, but I listened to a book called A Memoir of Motherhood and Madness by Catherine Cho. And it was about this person's experience with postpartum psychosis. And it was a really insightful and meaningful and also like really, I just, it feels like a really important book. I really appreciated it. But the other thing that I think was really interesting about that was how she talked about she was in the U.S. when this happened and when she was hospitalized. But she was actually like traveling from the U.K. where she lived in the U.K. and the treatment is very different in terms of like the management of like, okay, well, keep mom with baby in the U.K. Keep mom separate from baby in the U.S. And just like interesting.

I just, yeah. Yeah, all the different nuances. 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. Yeah. That's like an understatement. It is very often blamed, especially in like popular media press about postpartum depression on quote unquote hormones. Yeah. Maybe there is some data that that might be true for this quote unquote baby blues period where I also, it's important to say that like 40 to 70 percent of people can experience this like mood liability 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. 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, what is clear from the epidemiological correlates, from the facts that, for example, as we saw globally, the rates are significantly higher in low and middle income countries that lack health infrastructure, that

lack access to health care in the prenatal and postnatal period, or that rates of postpartum depression are significantly higher in lower income households in high income countries that lack access to health care, that they are higher in people who are subjected to additional stressors, such as abusive or unsafe relationships. or unintended pregnancies. What is clear from these epidemiological studies is that a lot of the factors that contribute to an increased risk of postpartum depression and other mood disorders are potentially modifiable and not on an individual level. So important. Not on an individual level.

Yeah. And in fact, the single greatest risk factor for postpartum depression and postpartum anxiety are untreated anxiety and depression. and depression outside or during pregnancy. So if we can actually recognize and provide treatment of mental health disorders outside of the context of pregnancy, we can help reduce the burden of postpartum disorders as well. So I'm going to now shift this to talk about what we know from data about how to improve postpartum outcomes overall. Evidence-based.

Evidence-based medicine. I found a quote from an article from 2016 in the American Journal of Obstetrics and Gynaecology. That said, and I quote, the intense focus on women's health prenatally is unbalanced by infrequent and late postpartum care, end quote. And that in the United States of America is an understatement. Yes. Because postpartum care is not just infrequent for most people in the U.S., it is one singular visit, which 40% of people, especially those on public insurance, do not usually attend, and it occurs at six weeks postpartum, which is when I already said that most of those changes

that are happening are done. They're done. Contrast this with getting weekly visits for at least the four weeks prior to delivery and then every two week visits for the several months prior to that. Yeah. Well, okay, also then, Aaron, and I feel like I'm jumping ahead. Give it. During pregnancy. Who are you? you seeing? And then after pregnancy, who are you seeing? Oh, Erin. Let me tell you as a family medicine physician what my feelings about. That are. Yes. In the U.S., our system is very fragmented. Yes. We are generally seeing OBGYN providers primarily during prenatal period, during all your prenatal visits. And then afterwards, you're seeing a pediatrician. And you are seeing them pretty

frequently, and they are there for baby and not for you. And then you see your OBGYN one time at six weeks. Yeah. Okay. So this concept of a fourth trimester is a recent concept, at least in U.S. medicine. And it really is kind of an admission of our failure thus far to adequately care for people who have recently given birth. In the U.S., an estimated 23 percent of employed women return to work within 10 days postpartum. I'm sorry, 10 days? 10 days postpartum. And if that is not one of the most shocking statistics, then I don't know if you've been

paying attention to these episodes. Now, that is not the case everywhere. So I'm going to walk you through a paper that really was very interesting. It was a comparative analysis that compared and contrasted postpartum care, prenatal and postpartum care in the U.S. and five other high-income countries. because again, this is what we have to compare to like kind of apples to apples, right? And this compared the U.S. to France, Japan, Australia, England, and the Netherlands. And we know from things like the data on maternal mortality that outcomes are very different in the United States

compared to all of those other high-income countries. Our maternal mortality rates are three times as high as France and the U.K. And nearly 10 times as high as Australia. Our maternal mortality rates in the U.S. have been on a rise faster than any other countries, though there has been a rise in the U.K., but it's been at a less substantial rate compared to the U.S. And maternal mortality is incredibly unequal, with black American women dying at nearly three times the rate. In 2022, maternal mortality for black women was 50 per 100,000 live births compared to 19 per 100,000 for 1,000 for 1,000. white women and 16 per 100,000 for Latino women. And I will say the numbers were different in 2021, but we don't know if that was because of COVID or what.

But this trend has been there for decades. Yeah. Okay. And so this comparative analysis was looking at prenatal and postnatal care, not just looking at like delivery method or like one time point. But like let's look at these overall systems of care to see if there are any big themes that come out. And boy, how do you do they? So as a baseline to understand where a lot of other countries maybe are getting ideas from, the World Health Organization recommends immediate postpartum care. So like immediately in that postpartum period, like after delivery of placenta for the first 24 hours, and then care in the first 24 hours.

And then additional visits at three days, seven to 14 days, and at six weeks postpartum. and that should include both maternal and newborn care. And again, in the U.S., our care is divided between specialists in obstetrics and gynaecology and pediatricians. So in this comparative analysis, in every other country that they analyzed, aside from the U.S., postnatal care included home visits, universal home visits, that begin immediately post-discharged from the hospital and are specifically intended to address both maternal and infant health. These programs are typically run Aaron by midwives or nurses who are trained in prenatal care and infant care. Yep. The U.S. has absolutely no such universal system. None.

Yeah. 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 U.S. in this comparative analysis was the only country where the majority of our prenatal care was conducted by OBGYNs as opposed to midwives. Okay. We also, in the U.S., it's not just postnatal care.

It's not just postpartum care. We have huge inequalities in our access to care early in pregnancy because of our ridiculous insurance system. Those are my editorialization. That wasn't in the paper. So that like even though in the U.S., pregnant people are guaranteed access to Medicaid services, however, individuals like from data, individuals that are on public insurance such as Medicaid, start prenatal care significantly later, they in many states lose their insurance at 60 days postpartum. I'm sorry. Yeah. What?

And that, what that means is that in the U.S., more people are coming in. to their pregnancy without any access to health care to address their underlying or chronic health conditions that existed prior to pregnancy. Yeah. Then they have the bare minimum of prenatal care. And in fact, over 6% of pregnant women in the U.S. have no prenatal care 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. Yeah. We know that these things are associated with riskier pregnancies.

and some of these things are in fact on the rise in the U.S. 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 preexisting condition. It's your medical complications. Yeah. It's 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 lifestyle. Lifestyle, yeah. That is a lie, period. Across the globe, not just in the U.S., millions of maternal deaths each decade are due to preventable factors. And this is not just coming from me. This is coming from the Lancet Global Health 2020.

they said, and I quote, these maternal deaths are, quote, tangible manifestations of the prevailing determinants of maternal health and persistent inequities in global health and socioeconomic development. Yep. Yep. So we know, I'm getting like sweaty from how angry I get about this because it's like, I feel really passionate about this. Justifiably angry. We know the things to do to prevent this. We can prevent maternal mortality. We can prevent adverse neonatal outcomes as well by doing what, 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 Laman Updike, saying this, okay? I say this, but this is literally the data that we have on what prevents adverse

sources. We have citations. We need universal access to comprehensive and modern contraception so that people can plan if and when they want to get pregnant. Yep. We need universal legal, safe access to abortion services, which are life-saving medical care. Medical care. We need universal access to high-quality prenatal, intrapartum and postpartum care, which includes midwives and obstetrics and gynaecutive. and family physicians and pediatricians, all of it. All of it working together. Worked together as a medical system. And this particular paper does not get into this like deep of detail, but I have other sources that show that guaranteed paid parental leave, which we also do not have in the

U.S., is in fact associated with reductions in the risk of postpartum depression, depression later in life, lower risk of intimate partner violence, which is at its peak during pregnancy and postpartum. Yep, it is. Paid parental leave also increases the likelihood and duration of breastfeeding. So folks who are all making sure that everyone breastfeeds, that's a thing that can help it. And it is directly associated with decreased infant mortality.

Yeah. Sorry. We have a playbook. The answer is here. We know the answers. We just have to implement them. Yep. I'm done.

No, but it's, it is, 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 the answers. It is hopeful. We have had these answers for so long. I know. I know it. I know it. It's true. It's true.

It's true. It's true. It's true. But we have the answers. We know the answers, right? These answers just have to be enacted. And they are being done in certain places. They are. In this, I mean, the state-by-state mortality data in the U.S. is, like, shocking. If you go to the CDC website and you look at, like, what the rates are in, like, one state versus another. It's like the disparities are very severe. Systemic racism played 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's. is a lot of things that are not easy to fix. I mean, they could be easy to fix because we know how to do them. We can fix parts of most everything. Right. Yeah. But so we've, we've done all your work for you. It requires investment. It does. And that is the hardest thing to convince people. That's our constant theme and it's my favorite thing on this podcast will kill you.

In investment and tradeoffs 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. 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. Often, everything goes just fine. Absolutely.

And it is beautiful and amazing and phenomenal to, like, see that happen and to know that it happens so frequently. It truly is. Like, I really love prenatal care. I really love this whole process. I just love everything about this. And I really loved doing this, even though I know we focused a lot on the bad things. Well, I feel like there's, it's all about contextualizing. 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 let everyone else do the work. It's totally fine. And it's like knowledge is power. It is. And but we also didn't increase my anxiety. And it can increase anxiety. And so I feel like this is, you know, we really did try hard to balance like talking about what are the pieces that we feel are valuable to talk about. And also while not talking about everything that is valuable to talk about. Yeah. So it's, yeah, but it is, it's true.

Like I hope we didn't make everyone be like, oh, God. Oh, God. Never for me. Right. Never for me. Or our, you know, healthcare system and country is broken. Yeah. Totally broken.

I mean. I have no interest in having any of their kids. Definitely not. Absolutely not. I'm done. But there were moments in this where I was like, oh. Like, you know? reading, like re-learning these things. And yeah, it's, it is a, it's a little bit of magic, I feel.

Absolutely. Yeah. I mean, I think, yeah, I have never, I've never wanted to have kids, but throughout the series, I called my mom so often to be like, oh, what about this? Did you take a pregnancy test? Did you, like, tell me about your ultrasound. Tell me about your delivery. What was it like, you know, she waited for one of my brother's 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 it was before DVR. Right. But like that experience, like so many things that we had never talked about before, right, 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, and think about, yeah. Think about so many different aspects of it. Oh, if you want to learn so much more. So much more. We've got sources. Oh, my gosh. I feel like this was a one, this is, yeah, I have a lot of books for this. I know. I'm going to briefly, because I've already mentioned a few of them. Yeah. I'll mention them again. So brought to bed by Judith Walster Levitt.

Tina Cassidy, a book called Birth, the surprising history of how we are born. Barbara, Aaron, Rick, and Deidre English wrote a book called Witches, Midwives, and Nurses. It's like a classic feminist text. Rachel Moran, again, blew a history of postpartum depression in America. Joyce Thompson and Helen Varney Burst, a history of midwifery in the United States, Laurel Thatcher Ulrich, a midwife's tale, The Life of Martha Ballard, based on her diary. And again, that memoir, Inferno by Catherine Schoe. I had a lot of papers for this one.

I already shouted out a couple like that Lancet Global Health 2024 paper. That was a global analysis of the determinants of maternal health and transitions and maternal mortality. Such a good read. There was also the paper I mentioned. It was from the American Journal of Obstetrics and Gynaecology titled the Four trimester, a critical transition period with unmet maternal health needs. I think I might have said 2016. It was actually 2017. And then the paper where the map of postpartum depression trends came from was from translational psychiatry from 2021. That was titled Mapping Global Prevalence of Depression

Among Postpartum Women. But we have so many more on our website, this podcast will kill you.com, where we list all of the sources from this episode and every one of our episodes from all seven seasons. So many sources. So many. You know, we've said thank you every single episode and we mean it every single episode. And thank you to every single person who provided a first-hand account, who sent in their first-hand account, who thought about sending in a first-hand account. Like, we appreciate you. This is, this series would have not been the same by any means without you.

No, it means the absolute world to us. Thank you. Thank you. Thank you, thank you, thank you, thank you. 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 to Bloodmobile for providing the music for this episode and all of our episodes. And thank you to you, listeners. Seven seasons in four whole episodes on pregnancy. Thank you for sticking with us. Yes. In this short break between seasons, tell us what you want to hear more of.

Mm-hmm. Always, we love to hear it. Yeah, we do. And a big thank you, of course, to our generous, beautiful, fantastic patrons. We appreciate your support so very much. We really do. Thank you. Until next season, wash your hands. You filthy animals.

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