This Podcast Will Kill You - Ep 73 Puerperal Fever: Seriously, wash your hands

Episode Date: May 18, 2021

Our sign-off, “wash your hands, ya filthy animals”, has never been more appropriate than with this episode on puerperal or childbed fever, now known as maternal peripartum infections. It took us over seventy episodes to get here, but today we finally tell the tragic story of Ignác Semmelweis, the “father of hand hygiene” and “savior of mothers”, whose keen observations and devotion to his patients earned him ridicule in his time and respect in ours. But the tragedy of this episode’s topic doesn’t reside solely in the past. Today maternal peripartum infections are still a major contributor to maternal morbidity and mortality worldwide, and, surprise surprise, the impact is not equally felt across racial, ethnic, and socioeconomic groups. Join us as we dive into this historically rich, medically complicated, and still appallingly prevalent group of infections. See omnystudio.com/listener for privacy information.

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pain in the lower part of the abdomen, attended with a very great degree of fever, the velocity of the pulse being at the rate of 140 strokes in a minute. I had no difficulty in ascertaining the patient's disorder, having had previous opportunities of seeing it both in London and in the course of my practice in Aberdeen, for this was the 15th case I had attended since the epidemic began. And in every respect, this answered the description of that known to practitioners by the appellation of the puperal fever, a distemper which so frequently proves fatal to women in childbed, baffling the skill of the most eminent physicians. On the 21st, when I visited her in the morning, I was happy to find that she had been pretty easy throughout the night and had enjoyed some

hours sleep. She was in a profuse sweat, which I hoped would prove critical, but I was sorry to find that I was disappointed in my expectation. For when I returned in the afternoon, I found that the sweat had disappeared, being succeeded by a diarrhea. The patient now complained of very great pain, and the swelling of the abdomen seemed to increase. On the 22nd, I was sorry to find that the disease was making rapid progress, in spite of all the remedies employed, and that the patient's health was sinking. All hopes of recovery were now totally abandoned. The patient's agony was now extremely great, and she called loudly for relief. I therefore thought proper to administer opium to mitigate pain and, if possible, to procure a rest. I went early in the morning of the 23rd to visit my distressed

patient and found that the storm was lulled into a calm. The friends received me with transports of joy, vainly thinking that her danger was over. The patient, supposing herself perfectly, well, asked my permission to rise, for she seemed to feel no pain, and suffered me to touch and press the abdomen, without showing any signs of uneasiness. A proof that the parts were in a state of gangrene. The friends, ignorant of this circumstance, were quite overjoyed to see the patient so composed after such excruciating pain. However, it was evident from the ghastly appearance of the countenance, from the tumifaction of the abdomen with the absence of pain, from the sunk state of her pulse, and from the coldness of the extremities.

that death was not far off. Accordingly, in a few hours, the scene was closed. Yeah. That was from an account by Alexander Gordon, whom I will talk about later in this episode. It's horrifying. Yeah. Hi, I'm Aaron Welsh.

And I'm Aaron Allman Updike. And this is, this podcast will kill you. It's really going to be an upper of an episode. Yeah, sorry, guys. This week, we are talking about childbed fever, puperal fever. Pupil sepsis, maternal fever. WHO calls it maternal peripartum infection now. There we go.

Lots of different pathogens under this umbrella. Erin, it's... So it's funny because one of the... One of the things that you said to me before we started doing this episode is that you felt like it was more, in some ways, more typical than the ones that we've done recently in that, like, the biology and the history are very separate. There's not a lot of, like, overlap. But for me, this was not a typical episode. I was like, could we structure this like a medical mystery except that it's not a mystery, but it kind of is. Oh, that could have been fun. It could have been fun. I know. No. I mean, as I was, as I was researching it too, I was like, okay, well, my story is very clear. And part of the reason that we wanted to do this episode is because, you know, we had learned about puperal fever in various classes. And it's like such a good, interesting story and so crucial to like the history of medicine. And but I don't think that I realized just.

how difficult a topic it would be to cover. Yeah. But it's fine. It's going to be fun. We'll learn a lot. I'm really excited to hear the whole story in terms of the history altogether because I've only heard bits and pieces. Oh, I, it's been one of my absolute, I think, favorite ones to research for sure. Excellent.

Well, before we can get into the episode, of course, it's quarantini time. It's quarantini time. What are we drinking this week? This week we're drinking the filthy animal. And as you will learn later in the episode, this is because at the end of all of our episodes, if you've never stayed tuned to the final very end, which we can't blame you, we always sign off by saying, wash your hands, you filthy animals. And that's basically what Semmelweis, who's a key player in this story, was saying to all

of the doctors around him to try to stop puperal fever from spreading. Yeah, he was just walking around being like, wash your hands, your filthy animals. And everyone was like, uh, uh, I didn't listen. Exactly. So what's in the filthy animal? Well, it's gym, time simple syrup, and watermelon blended up. It's like a really beautiful drink. It's beautiful and really refreshing.

Very summery. Yeah, I like it. We'll post the full recipe for that quarantini as well as our non-alcoholic, Plyssie Barita on our website, this podcast will kill you.com, and on all of our social media channels. Other business, basically go to our website. You'll find loss of stuff there. Transcripts, alcohol-free episodes, book lists of various sorts, just go there. It's great. It's great. It's really great. Yeah. Okay. Should we get into this episode? Let's do it. Okay. We'll take a quick break and and then dive in. Dinner shows up every night, whether you're prepared for it or not. And with Blue Apron,

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Terms and conditions apply. Visit blueapron.com slash terms for more information. Anyone who works long hours knows the routine. Wash, sanitize, repeat. By the end of the day, your hands feel like they've been through something. That's why O'Keefe's working hands hand cream is such a relief. It's a concentrated hand cream that is specifically designed to relieve extremely dry, cracked hands caused by constant hand washing and harsh conditions. Working hands creates a protective layer on the skin that locks in moisture. It's non-greasy, unscented, and absorbs quickly. A little goes a long way. moisturization that lasts up to 48 hours. It's made for people whose hands take a beating at work, from health care and food service to salon, lab, and caregiving environments. It's been relied on for decades by people who wash their hands constantly or work in harsh conditions because it actually works. O'Keefs is my hand cream of choice in these dry Colorado winters when it feels like my skin is always on the verge of cracking. It keeps them soft and smooth, no matter how harsh it is outside. We're offering our listeners 15% off their first order of O'Keefs.

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is made with premium materials in ethical trusted factories and priced far below what other luxury brands charge. I recently got a pair of Quince's Bella stretch wide-leg jeans, and they are now in constant rotation. They are so comfortable, the fit is amazing, and they come in a bunch of different washes, so I'm about to go order some more. Refresh your wardrobe with Quince. Go to quince.com slash this podcast to get free shipping on your order and 365 day returns, now available in Canada too. That's QI-N-C-E.com slash this podcast to get free shipping and 365-day returns. Quince.com slash this podcast. So like I said already, this isn't a very typical episode because pupeoral fever isn't really one single disease. And in fact, it's not even really a term that we use

anymore. We kind of already mentioned there are so many names for this illness, which really does make it difficult to get a handle on in terms of like the current status too, but we're going to do our best. Some of the names that you can find that we haven't already mentioned, puperal sepsis, maternal sepsis. It's also called childbed fever. There's so many names. But the World Health Organization defined maternal peripartum infections, which means they defined it as a bacterial infection of the genital tract during childbirth, like during labor, even before birth, but after like rupture of the amniotic membrane, but before delivery. Or, in the post birth, the postpartum period, up to 42 days postpartum.

Oh, okay. That is associated with childbirth. So bacterial infection of the genital tract associated with childbirth. And what's important about this definition specifically is that it doesn't include some other infections that used to sometimes get lumped in to postpartum sepsis or maternal sepsis, like mastitis, which is an infection of the ducks in the breast, or UTIs, even pneumonia. It also does not include infections in surgical sites. So like a C-section incision, just an infection of the skin would not be included in this

definition. Okay. So it's really both locational and time-specific. Exactly. Right. Okay. Yeah. So now that we have that out of the way.

I'm kind of just going to run through this. It's not going to be super detailed on like all of the bacterial virulence factors and things because it's just too much. But what we will do is go through where in the body these infections happen because the genital tract is actually kind of a large area. We'll talk about why they're problematic, how we know that an infection is happening, like what symptoms are we actually talking about? How do we define this? And then we'll talk about the risk factors for transmission, what pathogens we're actually dealing with, and finally, who gets it or what the risk factors are for transmission. Sounds good. Well, sounds horrible, but yeah, it does. It sounds horrible. It's pretty horrible. So puperal, sepsis, maternal, I'm just going to

call it MPI. Can I do that? Sure. Okay. MPI can mean infection in a number of different organs, but most often probably it could mean endometritis. Endometritis is an infection or inflammation of the endometrium, the lining of the uterus. And so this makes a lot of sense in the context of childbirth. This is not a disease that you can only get after childbirth, but in the context of childbirth, the inside of your uterus is exposed to the outside world in a way that it isn't normally. Right, right, either because the cervix is dilated and then there's a vaginal delivery and bacteria can migrate upwards.

Or if a C-section happens, then the uterus is literally exposed on the abdomen and then put back in place. But on top of that, after delivery, you have kind of a raw surface exposed inside the uterus because the placenta that had been attached has been removed. So there's not only like roots of infection, but there's also a surface that's more susceptible potentially. Gotcha. Okay. So that's one possible infection that can happen post-birth. Another is an infection that can actually start a little bit earlier in pregnancy. It could happen any time in theory during pregnancy, but that's called choreoaminitis or intra-amniotic infection, I-A-I. And this is an infection of any part of like the lining of, like, the lining of, of the amniotic sac, which is what holds all the fluid that cushions the fetus.

It could be an infection of the placenta, just basically any part within there. Okay. And so that can happen during pregnancy, but then result, like, in a continued infection that can continue after delivery as well. But a maternal peripartum infection can have a number of other possibilities as well. a peritonitis is infection of the abdominal wall itself, which can happen as a complication, like if the endometritis spreads outside of the uterus. But it can also just happen in the setting, for example, of a C-section if the peritoneal cavity, the abdominal cavity becomes

contaminated in some way. It can also mean a vaginal infection or a soft tissue infection, especially if you have like a third or fourth degree tear that happens during delivery. It can also mean something that's a lot more rare but called septic pelvic thromboflobitis, which is... Sounds very bad. It's as bad as it sounds. This is an infection that involves bacterial infection of the veins that surround the uterus that cause like hypercoagulability and it spreads. Overall in general, not good infections, but the biggest concern with any of these organ systems or any of these tissues

that become infected is when that infection spreads beyond that single organ or that single tissue and enters the bloodstream. Right. That results in bacteremia, so bacteria in your blood or septicemia, bacteria replicating and growing in your bloodstream and potentially septic shock, which can lead, of course, to death. Okay. So in the context of childbirth, the vagina, the uterus, the abdomen, these are just sites of entry for what can easily become an invasive widespread infection. Right. Also, I did not know the difference between bacteremia and septucemia until this moment.

Well, thank you. I also had to look it up. Because I kept seeing them both and I was like, why is that different? So you can just have bacteria in your blood and technically that's bacteremia. But if they're not like, replicating, growing, that would be when you have septicemia. So septicemia is like extreme scary. Right. It's, yeah. Yeah. Very bad. So that's like all the different types of infections that you can have. And you'll notice those are all like much more specific. And that makes sense because now we can like with medical technology that exists today, we can actually differentiate all of these. So how does having this umbrella term sort of help? Great question. I think it helps in a number of ways. Some of these conditions are quite rare. For example, like septic pelvic thromboflobitis, that's very rare. So if you were looking at stats of only

that, your numbers would be really low. Whereas if you lump it in with all of these other ones, but also some of these conditions, for example, Coriomanitis can happen much earlier in pregnancy and result in pregnancy loss, like spontaneous pregnancy loss. But if it happens around the time of delivery, then it's kind of, it might be. cause different problems down the line. And same thing with endometritis. That's something that can happen outside the context of childbirth. But if it happens within the context, then you'd want to know that that happened within that context. So I think by grouping them together, you're looking at a broad picture of all these different types of bacterial infections that can happen specific to the context

of childbirth. The other thing, though, and it's a good question that you ask that, Erin, because the other thing about all these infections is that even though we can differentiate them all, in terms of symptoms, they're all very similar. Okay. Okay. And so that's the other thing is that for a long time, we probably weren't differentiating them all because does it matter exactly what tissue type is infected when you're looking at someone who just gave birth and all of a sudden they spike a fever, right, up to 102 Fahrenheit or 39

Celsius and they're sweaty and they're pale, their heart rate is elevated, they're breathing hard, they're sick, right? And they're sick probably in the context of this traumatic delivery that just happened or even this non-traumatic delivery that just happened. And so I think that's another reason, too, why you lump it all together. That makes sense. In terms of some of the other symptoms, aside from fever, which of course is kind of the biggest sign, which is why it got the name puperal fever. Other symptoms that tell you that you're dealing with an infection of the genital tract are things like abdominal pain or like tenderness in the uterus and not just the tenderness that's normal after delivery, but like a deeper tenderness and like a more,

I don't know how to describe it, a more painful tenderness. And then also some vaginal discharge is fairly common, especially with endometritis. You can have a very like perulant like pus-filled drainage that can happen from the uterus. And then of course you have all these other general signs of infection. Things like I already mentioned like you have an elevated heart rate, elevated breathing rate. If you were to take a white blood cell count, that would be elevated. And like I said already too, the big concern here is if that infection spreads to the bloodstream. because that can result in shock and potentially death. Yeah.

So I've said already this is bacterial infection. What bacteria are we talking about? It's a lot. It's a lot. And so, Aaron, I think, even though I tried really hard not to read about Semmelweis and not step on your toes at all, I think that largely in that time frame, it's thought that it was group A. Strepta cacus pyogenes, that was the big contributor. Is that correct?

That's also what I read. But I think they didn't know. But it seemed like, yeah, strep pyogenes was the first causative agent to be isolated and characterized from what I remember. That makes a lot of sense because it was so interesting because I kind of knew that context. But today, when you read about like MPIs in general, strep A, so group A strep or strep pyogenes really doesn't even come up as a very big topic of conversation in most of the articles about it, which is very interesting. Caviop that, that you can find like separate articles that are all about group A strep in the peripartum period. Right. But when you read about endometritis, when you read about choreo-eminitis, and when you read about just like general maternal sepsis and you use all these sort of buzzword terms, group-based strep is like, yeah, it's on the list along with a whole bunch of other things.

Why? I don't really know. Let's kind of, let's talk about it. Okay. Okay. I have some guesses maybe, but. I have several guesses. So we'll see if our guesses are the same guesses.

So we'll start by talking about strep pyogenes and what might make it a particularly interesting bug to talk about. And then I'll go through what the other bacteria are too. But I'm not going to get into a lot of detail on strep pyogenes because it's also the causative agent of necrotizing fasciitis, which, spoiler listeners, we're going to be covering shortly in this season. Yes. Yeah. So you'll learn all you want to know about the details of strep pyogenes later. But in short, it's a gram-positive little ball. Forms little chains like beads on a string when you look at it under a microscope.

And it's a pretty common group of bacteria. Strep pyogenes can exist on our skin. It can exist in our throat. I think 25% of kids are colonized in their throat and like 5% of adults. it's what causes strep throat, right? So you've all probably heard of strep hyogenes. It also, like I said, causes deeper infections like necrotizing fasciitis. If it's untreated, strep hyogenes is what leads to rheumatic fever, rheumatic heart disease,

a number of different post-infectious type syndromes. But it's also, of course, a potential cause of MPIs. And one of the reasons likely is that during pregnancy, the postpartum period, people are 20 times more likely to become infected with strepiogenies compared to non-pregnant people. Why? So something about pregnancy makes you far more susceptible to strepiogenies. To answer your question of why, we don't know.

Except that it might have to do with pregnancy in general is a state of immunosuppression. So it might just be that that specific type of amino suppression makes you more susceptible. There are some people that say because being around children is a risk factor for strepiogenies colonization in general, since children are more likely to have it than adults, just like without being sick, just hanging around. So if someone is pregnant, they might also be around kids or have other young kids. So I don't know. That's kind of whatever. But in any case, 20 times more likely to become infected during pregnancy and postpartum, like that short, short postpartum period. Because the thing about people who get strep A postpartum is they often are already colonized.

And then it just becomes an infection postpartum when that bacteria swims into the bloodstream. Right, right. And while it's not the most common cause of peripartum infections today, as far as I can tell, because it's, really hard to get numbers on what is causing all these different MPIs. If you look at all invasive group A strep infections, about two to four percent of them are somehow associated with pregnancy. So that's of everyone in the world who gets an invasive group A strep infection. Two to four percent of those are associated with pregnancy. I don't know the proportion of all MPIs that are due to group A strep. However, when group A strep is the causative agent, it is extremely virulent.

Okay. Yeah. And when and if it progresses to something like toxic shock, mortality can be as high as 30 to 50 percent even today. That's like with the use of antibiotics. Yeah, if it progresses to shock. So that would probably mean that you didn't correctly identify it and treat it before it progressed that far. Okay. Yeah. So it's, I think because of that, because it's so virulent, it often has a very quick onset, like within 24 to 48 hours after delivery, and then people can just get really sick from it. So I think because of that, it's like one of the really scary ones, even though it maybe isn't one of the most common causes of infection. Okay.

So that's group A. There's a whole other group of strep that we get to talk about. And that is group B strep, aka Streptococcus agalacte. I think I probably pronounced it wrong. And what I think is so interesting is that today you hear a lot more about group B strep in the context of pregnancy than you hear about group A strep. And that's because this is something that we actually test for in the U.S. at least during pregnancy because we know that group B strep is a very important cause of meningitis in newborns.

Mm. Yeah. And so we know that by testing for group B strep, because this is another bacteria that just can often colonize the vagina and the rectum. So if you test pregnant people for group B strep and then treat them with antibiotics during labor, it drastically reduces the probability of that bacteria being transmitted to the baby during delivery and then reduces that baby's risk of menagitis significantly. And so is the same treatment used for group B that's also used for group A? The same bacteria. Yeah, you'd use like a penicillin type. So that would treat both. Yeah. Okay. Okay. And so is that part of the reason why we see so few nowadays? It's a good question. I mean, we don't test for group A strep. So. Okay. Yeah. But.

it's a good question. But group B strep, even though we know that it definitely can cause, you know, illness in newborns, it also has the potential to cause a perinatal infection, a parapartum infection as well in the pregnant person. Other bacterial species, E. coli, super common cause in some studies, but also things like anaerobic species like bacteriides. And what's really common overwhelmingly, is that you can have polymicrobial infections. So we're not even looking at a single bacterial species. If you think just about the process of childbirth and that there's so much exposure happening

from so many different potential sources, a lot of these are bacteria that can be found on a lot of different kind of surfaces and skin and things like that. And so it kind of makes sense that you might be able to have polymicrobial, multiple bacterial species, infections. Just a bunch of opportunists. Exactly. Yeah. But really in general, we don't often know what the causative agent is. So most studies, even the ones that kind of looked at it, where they tried to figure out, like, what was the cause of these particular infections? Even when we're

looking, we often only identify like 30 to 40 percent of cases with like a laboratory confirmed organism. Is that just because like, you know, toss some antibiotics and the person gets better and exactly. Right, right. We use like a kind of, for any kind of postpartum fever or fever during delivery and after delivery, anything like that, there's kind of like a standard regimen of antibiotics. And if those don't work within 24 hours, then you add a penicillin in case it's a strep. And then that's it. So it's a pretty, yeah, because you do, you give antibiotics that are going to covered that whole range because you don't know it could be any of those. Right.

Time is of the essence. Exactly. Exactly. And so is there a risk, this might be jumping the gun, but is there a risk of antibiotic resistance? Good question. Of course it's always a potential risk. Right.

Right. The answer is always yes. But I don't have stats on what the rates of resistance. of like MPIs are to the kind of mainstay antibiotics at this point are. One of the big problems is that kind of at least one of the big antibiotics that we often use can be quite expensive. So in other parts of the world, I don't think they use that. They use different antibiotics that are less expensive.

So there's also always the cost to take into consideration. Mm-hmm. Yeah. So that's kind of the overall picture of infections and what causes it. And Aaron, you're going to talk a lot, I think, in the history about kind of the transmission, how we figured this out, right? Yeah. But like I said, a lot of these bacteria are just bacteria that exist around us, whether on providers' unclean hands or on unclean instruments that are used,

or even just on our skin, just already here, or in our vaginal canal, or even in our throat. or other mucous membranes. So when you add on top that pregnancy is a state of immunocompromise and all of the potential roots of entry that could be opened up during childbirth, and then all of these bacterial species floating around, that's kind of how you get to transmission, if that makes sense. There are some things that would increase the risk of a maternal parapartum infection, and the biggest one worldwide today, of course, is a C-Sexam.

which is not really surprising, considering that that's a much more invasive way to deliver a baby. However, in general, antibiotics are used prophylactically during C-sections, just like with any other surgery, because we know that surgery is such a big risk for infection overall. Right, right. And so with antibiotics prophylactically, that drastically reduces the risk of infection associated with C-section. And so I guess since this umbrella term, well, is it umbrella term? well, is an umbrella term and covers a lot of different things, asking what is the, you know, case

fatality rate is not very easy to answer. It's very, very difficult. We'll talk in the current events section about like what the stats are today. And I think that'll give us a little bit more. But yeah, just like looking at overall, it's almost impossible to get that. I mean, yeah. Yeah. Yeah. I'm sorry, Aaron. I, making you do this one. This is very difficult. I do feel like we put this one off for a while and it was because I was like, oh no, how am I going to even do this? Well, I think it's been great so far. Oh, good, because I'm pretty much done. I do just want to say because I think it's a very interesting fact. If we go back to group A strep for a second, it's far more common following a vaginal

delivery than a C-section delivery, unlike some other infections. Like, from other bacterial species. Isn't that interesting? Interesting. So yeah, that is maternal peripartum infections. Aaron. You want to walk us through this? Oh, I can't wait, but let's take a quick break first. Anyone who works long hours knows the routine. Wash, sanitize, repeat. By the end of the day, your hands feel like they've been through something. That's why O'Keefe's working hands hand cream is such a relief. It's a concentrated hand cream that is specifically designed to relieve extremely dry, cracked hands caused by constant hand washing and harsh conditions. Working hands creates a protective layer on the

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begins more or less with Ignaz Semmelweis. Yeah. And that's reasonable to think because if you had heard of puperal fever before this episode, there was a good chance it was in connection with his name and his story. And I love that story. And I will definitely get to it. But it turns out there's actually so much more to the story of pupil fever. Not surprising, considering that it's like a ton of different bacterial species.

and you can get it a ton of different ways and so on. And also it's this podcast, so I would expect nothing less. So let's begin at the beginning, which also is easier said than done for all the things you have already talked about. I also wanted to say we will also be at some point, whether it's this season or not, probably not, we will be doing Scarlet Fever. So another group A strip situation. But in the interest of time, I'm just going to start with the beginnings of the concept of puperal fever. Okay. Which, as you might guess, goes way back.

Giving birth is not a risk-free activity. It never has been. It never will be. And since at least some of the bacteria that cause infections after childbirth are carried naturally with us, as you said, these infections have been around since, well, you know, as long as humans have been giving birth, so forever. It's, you know, humans, before humans were humans. And so it's probably not surprising that people had long recognized that fever, severe pains, and a swollen abdomen in the days after giving birth often led to death. Hippocrates, for example, wrote about it. And there are also

descriptions in Hindu texts dating back to 1500 BCE. Several English queens died of infection after childbirth, including Elizabeth of York, queen consort of Henry the 7th, and Henry the 8th had two wives that died in the same way, including Jane Seymour, whose death inspired an old ballad that's included in a song in Inside Lewin Davis. I really like the song, it's beautiful. But it was only in 1716 that the term puperal fever was introduced from Pure, P-U-E-R, the Latin for child and Pereira, meaning to bring forth. Why did it take so long for there to be a term for what was obviously known about and probably not that uncommon? In short, hospitals. The 1600s saw the establishment of many so-called lying-in hospitals where women would go to give birth.

And the growth of these hospitals was an advance in some ways, like through the use of forcepts and difficult deliveries and through the beginnings of formalization of medical education and the growth of obstetrics and gynaecology as a separate field. But in so many other ways, they were a perfect setting for the spread of infectious disease. Wards were overcrowded, instruments were filthy. germ theory was still over 200 years away, as was the importance of cleanliness and limiting infection. So no one was washing their hands or the bed sheets or their clothes or their instruments. It was believed that the stiffer the doctor's coat with blood and fluids and pus, the more respected they were because it showed that they had experience. Stop. That really makes me nauseous. I know.

Oh, I can picture that far too well. I know. I know. Yeah. And these hospitals were often used as training grounds for future physicians, which meant that a pregnant person would often be subjected to repeated vaginal exams as student after student came to practice on them. By the way, speaking of that, because that's a thing that still sometimes happens,

I should have probably mentioned that that's one of the biggest risk factors for transmission of bacterial infections is the number of cervical exams that take place, as well as the how long you're in labor, like the longer the duration of labor, especially after the membranes are ruptured. But oh, that, ooh. Yep, yep, that makes complete sense. Yeah, it does. Yep. And so knowing what we know now about the transmission of puperal fever, it's not surprising that it was at one of these lying in hospitals that the first described epidemic of puperal fever happened in Paris in either 1646 or 1746.

Different papers say different things and I couldn't get to the bottom of it. My guess is 1746, but honestly, someone can pinpoint the very original text. That would be amazing. That's so fascinating. Yeah. Up until the development of these hospitals, outbreaks of puperal fever tended to be more isolated with single cases or maybe a few here or there. But this marked the beginning of an era in which puperal fever seems like inescapable, essentially. From that first epidemic, puperal fever never

really left, and outbreaks of the disease were not unique to France, where the first epidemic happened, or even Europe, and nor was the threat restricted just to hospitals. Physicians or midwives may have moved in between hospitals or in between house to house, leaving a string of deaths behind them. Let's put some numbers to the absolute nightmare that hospitals were, though, jumping ahead to the 1800s. In London, between 1831 and 1843, 10 mothers, per 10,000 died of puperal fever at home, while 600 per 10,000 died when they gave birth in the hospital. What? Uh-huh.

These numbers were also not unique to Britain, and in some places or during sometimes, were even higher elsewhere, such as in Paris, where the peak reached 880 per 10,000, which was 17 times higher than at-home births. Oh, my gracious. So many infants lost their mothers to childbed fever that many of these hospitals had like a home attached or a home nearby specifically for the care of these and other infants. Oh, my. Yeah. And so it's hard to believe that physicians or the general public would fail to notice this massive uptick in childbed fever. But what did they think caused it? This was still pre-germ theory, so you can imagine the array of possible causes.

One of the most predominant one was that it was caused by the lokiah, so the fluid that flows from the uterus after a vaginal delivery. It was caused by the lociah being prevented from freely flowing and then stagnating in the body. Another was that it was pregnancy itself, like over the course of nine months, impurities accumulated in the blood, and as the fetus grew, it pressed down on the intestines, and so fecal material was slowly released into that area and then caused peopural fever. I know. Gosh, that'd be terrible. Yeah, it'd be terrible. And why was this, you know, either fecaly contaminated, fluid, or lokiya suppressed?

Well, it could be due to the blood being too thick or cold air inadvertently received into the uterus, was one example, or drinking cold water or fear, terror, grief, any shock to the system. And if you weren't a fan of the lokiah, of the suppressed lokiah cause, you could blame rerouted breast milk. For way too long, it was believed that breast milk was actually menstrual fluid, or it originated from the blood, going from the uterus to the nipple via a duct, despite countless autopsies failing to find any such duct. And so when doctors examined the abdomens of people who had died from childbed fever and found white pockets of pus that kind of resembled breast milk, they thought that it was caused by the failure of milk to route to the nipple. Yes.

There was always my asthma to blame or poorly ventilated rooms. But before we feel too smug about how dumb people in the 1600s were, that, you know, we would have seen the connection right away. Let's like remind ourselves how little we know about autoimmune disease. or even just how our own immune system works or what dreaming is or like all these things. A hundred percent. I mean, but yeah. So back in the 1600s, 1700s, even 1800s, you know, doctors lack training in statistics

and they were working under the assumption that the cause of childbed fever was already known. You know, just pick whatever cause you want to believe in. Right. And so it's kind of understandable that many doctors would focus their efforts on developing treatments for childbed fever rather than trying to control what seemed inevitable. I mean, we do the same thing today in science and medicine. Like we are all trained on a foundation of knowledge that we're almost taught not to question that these facts have been established and we could and we should focus our efforts elsewhere to expand this body of knowledge, which we often do for very good reason. because that's how most progress is made, and that's also the path that is the most rewarded. And so it makes it all the more remarkable when someone doesn't just question the established knowledge,

because that's easy enough to do, but they collect and present solid evidence in defense of their questions, despite the resistance that they are often met with. Ooh, it's going to get good. Semmelweis was one of these questioners in this. story of puperal fever, but he wasn't the first. The person who wrote the account that I read at the beginning of this, a Scottish obstetrician named Alexander Gordon, he recognized the contagious nature of puperal fever in the 1790s, about 50 years before Semmelweis. Oh, wow. And before germ theory. So contagion as a concept, as we've talked about, is pretty old,

and it had some pretty strong consensus in at least some areas like long before germ theory. But this concept of contagion, where a disease could be transmitted from person to person through skin or contaminated clothing, was disease specific. You touch someone with smallpox, you get smallpox. Same with measles. Pupril fever didn't follow this pattern, so myasma or lokiah suppression seemed more likely. But Alexander Gordon rejected them. those. He noticed that what linked the affected individuals in a pupural fever outbreak was not some characteristic of the mothers or the weather, but rather that they had all been treated by the same person, nurse, midwife, physician, and the cases appeared in succession. And he became

convinced that it was a contagious disease, one that the medical caretaker played a direct role in, which really like shook him to his core. Quote, it is a disagreeable declaration for me to mention that I myself was the means of carrying the infection to a great number of women. He traced an outbreak of the disease to several midwives employed in his practice

and he published his findings in 1795. And in this treatise, he recommended airing out the room, burning contaminated clothing, and scrubbing hands and the arms of people, who delivered the babies as a way of preventing the spread. And he didn't stop there. He went on to say that he could predict who might be at risk of developing the disease based on who their practitioner or midwife was. And then he kind of published this like list of the names of 17 midwives who had

exposure to the disease. And so basically he became an unwanted person in the town. And he left obstetri. and joined the Navy. Oh, goodness. Yeah. And yeah, and he died at 47 of tuberculosis. Oh, gosh. Burned a few bridges on his way out. Yeah. And for the most part, his contributions would not be recognized until way later. Huh. So into the early 19th century, many physicians, especially British and American, had started to maybe consider that puperal fever might be a contagious disease, but the exact nature of this wasn't clear. Like, how was it contagious? What was being transported, you know, here and there. Oliver Wendell Holmes, Sr., an American physician, but probably better known as a poet, set out to compile all of the evidence for the

contagiousness of puperal fever in such a way that it could not be denied. He didn't speculate on the exact mode of transmission, whether it was through the air carried by a physician or through the instruments that they used, but he did firmly state that, quote, the disease known as puporal fever is so far contagious as to be frequently carried from patient to patient by physicians and nurses. He also recommended that physicians should not perform autopsies prior to delivery and that if they had to do so, they should change their clothes and wait 24 hours before treating a patient. If a case of puperal fever develops, that doctors should consider their next patients at risk and shut down their clinic if necessary.

He didn't necessarily suggest any form of washing or sanitation specifically, but his conviction of the contagiousness was so strong that he said in one talk, quote, whatever indulgence may be granted to those who have heretofore been the ignorant causes of so much misery, the time has come when the existence of a private pestilence in the sphere of a single physician should be looked to-for-been-for-been-lawed. upon, not as a misfortune, but a crime. And in the knowledge of such occurrences, the duties of the practitioner to his profession should give way to his paramount obligations to society. I mean, that's pretty bold. Very bold. Bold words and bold, strong evidence. But guess what?

Not really listened to at that point? Yeah, completely dismissed. Completely. A lot of physicians were like, they took great offense to his claims that they were responsible for the sickness, since as was commonly believed, and as one of his main opponents said, a doctor is a gentleman and a gentleman's hands are never dirty. Oh, no. Yeah. So are we seeing a pattern yet? Yeah. If two is not quite a pattern, here comes the third. Here comes the third. Semmelweis. Ignaz Semmelweis was born in Budapest, Hungary, then controlled by Austria on July 1st, 1818. After finishing school in Budapest, he enrolled as a law student in Vienna, but changed to medicine after attending an anatomy lecture. After graduation, Semmelweis found himself in obstetrics after his first two choices had fallen through.

Oh, gosh. And so on March 20th, 1847, Semmelweis began a two-year appointment as assistant in obstetrics, basically like a residency, in the Vienna General Hospital, First Division. He came into the medical profession at a very unique time and at a unique place. In these circumstances, in a way, set him up almost perfectly to make the observations that he did. So let's do a little bit of context. Yes. In the early 19th century, the field of pathological anatomy had really taken off.

And autopsies were seen as essential instruction for medicine, with each cadaver holding an incredible wealth of knowledge. And there was no better place to do autopsies than at the hospital in Vienna, where one of the field's leaders, Carl von Rokitanski, had been appointed director of pathological anatomy. in 1844. And if you were an obstetric student under Johann Klein at the Vienna General Hospital, you were expected to practice on cadavers every chance that you could, especially in the mornings before rounds began. Just make sure to wipe your cadaver juicy hands on your coat before walking upstairs. Please don't ever say cadaver juicy hands.

I'm sorry. And this was a big change from the previous director in the obstetrics ward and this Vienna General Hospital, who felt that autopsies should only be performed if absolutely necessary, and he never allowed an autopsy on a woman who had died after or while giving birth. And so I think it's interesting knowing what we know about the transmission of puperal fever to look at some numbers. about how these two different approaches might have affected the rates of puperal fever. Okay. Okay.

So under Boer, who was the earlier guy who was like not a fan of autopsies, the mortality rate of childbed fever in the first division lying in Ward hovered around 1%, mostly lower. Wow. That's pretty good. In autopsy superfan Klein's first year as director, first year that, first year that number shot up to 8%, which was probably the lowest it ever was during the entire time he was director. Oh my God. And so this is the guy, Klein is the guy that Semmelweis started his

assistantship under in 1847. Okay. And he entered this hospital then. He started his assistantship during a time when one out of every six women that gave birth in that first division died of childbed fever. One in six? That's what was a very common rate, and it was nearly standard all over the world. Oh, my. Yeah. Oh. Yeah.

Every day, almost every hour, it seemed, that you could hear the ringing of the priest's bell as he walked down the rows of beds in the first division, giving absolution to those who were dying of puperal fever. It became like a haunted noise for everyone who was there and also for semilful. And I also want to throw in one more piece of information about this hospital and about the obstetrics ward. So as I mentioned, Semmelweis was an assistant, was appointed an assistant in the first division. There was a second division and a third division, but I won't talk about that. But the first division and the second division were very different. They were both lying in wards where pregnant people would go to give birth.

First Division was composed of male medical students, and that's where they received training. And then the second division is where the midwives received training, which importantly, did not include autopsies. The death rate in the first division was always at least three times higher than that of the second division. And this super high death rate earned it urban legend status. So if a woman came to the hospital was about to give birth, she would beg and beg not to be admitted to the first division. Oh my God. Yeah. And Semmelweis was not blind to this horror.

He couldn't bear it. He vowed to do something about it. First, he was like, all right, I have to get a handle on what exactly puperal fever was. Because despite having many texts and articles written about it, a precise definition was just not there. And so to do this, Semmelweis would start off each day by dissecting cadavers. Gosh. Just, I know. And there was never any shortage.

Some months, as many as 30% of postpartum mothers died of the disease. Semmelweis became convinced that the high incidence had to do with the way that the hospital managed its patients. So he began to make small changes, things like the way that medicine was administered, increasing ventilation, having the women deliver on their sides as he had seen the midwives do, but nothing seemed to help. So he began to look for patterns in the hospital records, and he made six key observations. Number one, even though the first division, so med students and the second division, midwives, had the same number of deliveries per year, so 3,000 to 3,500, in the first division, 600 to 800 women died of childbed fever on average, whereas only 60 died in the second division. Oh, my.

Yeah. Number two, the epidemic of childbed fever was localized to the hospital. There was no similar rate of childbed fever cases seen outside the hospital walls. And he actually found that you had a better chance of surviving if you, gave birth in the street on your way to the hospital. Number three, the incidence of puperal fever was definitely not related to the weather. Okay. Pretty easy to conclude.

Number four, the more trauma experienced during delivery, the more likely it was that the person would develop childbed fever. Okay. Number five, closing down the ward always stopped the epidemic. Huh. And number six, infants delivered by mothers who developed childbed fever also often died of a similar disease. Uh-huh.

Uh-huh. And these observations seemed to semelvice very strong evidence that practices at the hospital and specifically the first division were contributing to or even causing the puperal fever epidemic and that the disease was transmitted through direct contact. But where did it come from? And as he prepared to deliver this information to his director at the hospital, he was given tragic news that would lead to a eureka moment. He learned that his friend, Professor Jakob Kalechka, had died after being stuck in the finger

by a med student wielding a scalpel during an autopsy. Death by cadaveric poisoning, as it was called. Semmelweis, who was horribly sad about the death of his friend, went to consult his autopsy report, which described fever, pain, swelling, and organ. and tissues inflamed and filled with pus. And this sounded awfully familiar to him. Quote, totally shattered. I brooded over the case with intense emotion

until suddenly a thought crossed my mind. At once it became clear to me that childbed fever, the fatal sickness of the newborn and the disease of Professor Kalechka, were one and the same, because they all consist pathologically of the same anatomic changes. If, therefore, in the case, of Professor Kalechka, General Sepsis arose from the inoculation of cadaver particles, then puporal fever must originate from the same source. Now it was only necessary to decide from where

and by what means the putrid cadaver particles were introduced into the delivery cases. The fact of the matter is that the transmitting source of these cadaver particles was to be found in the hands of the students and attending physicians. This was an incredible lightball moment. Right. Linking not just the fact that like cadaveric poisoning and puperal fever were the same thing, but that cadaveric material introduced into the body of someone who had just given birth, that is what led to puperal fever. Yeah. And that was on the hands of the students and the residents and the physicians. Yeah. Yeah. And as he later, you know, learned and talked about, it wasn't just particles from cadaver. It was also, like he noticed if someone came in with an infection on their knee or on their hand or something like that.

Right. That could also be a way to introduce an outbreak of puperal fever. Okay. Yeah, that makes sense. But this, so this moment where he was able to link this material to puperal fever, like, you know, the bits of cadavers to puperal fever, it also led him to come up with a very simple solution for preventing the disease. because if you rid the hands, the contaminated hands or instruments of the cadaveric material, you would prevent blood poisoning.

Yeah, wash your hands. Wash your hands. And I can't emphasize enough how it was really in the mornings. Whenever you had a spare chance, you cut away, you do autopsy. Right, so you're down in the cadaver lab and then you go straight up. Just wipe your hands on your coat and you bring the instruments that you were using upstairs. Not cleaned, nothing. And you could see, like some of I observed that during holidays, for instance, or during the summer,

the rates of puperal fever would decline because students weren't there. Because they did really nice outside. And they were spending more time not in the autopsy lab, but hanging out. I, yeah. But like, this is still pre-germ theory. So how do you, what's like the concept of contamination? Right. And I think it's really fascinating because, like, of course it should come as no surprise

that cadavers don't smell that great. Uh-huh. And so measures had been taken before to control the smell so that physicians and students could work without the horrible odor. and chloride solutions were commonly used for this. And so some of us figured that, hey, if this stuff, this chloride stuff gets rid of the bad smell, maybe it gets rid of the bad stuff itself. And so he placed a bowl of diluted chloride solution outside of the first division

and made every person who would be treating someone wash their hands in it and also do regular hand washing. And then later, he was forced to switch to chloride of lime because the Klein, the head of obstetrics, was really annoyed at how much money he was spending. Simmelweis was spending. And within a few weeks of Semmelweis implementing this hand-washing solution, the effect was immediate. The mortality rate dropped from where it was around 7 to 8%, but also there seems to be

like Klein might have doctored his records quite a bit, to 3%. and that was close to that of the second division, where just the midwives were, and after a month of the practice, it dropped down to 1.2%, with the second division clocking in at 1.3%, where handwashing had also been instituted. Wow. The only other change that had been made besides the handwashing during this time was a new ventilation system. So guess what Klein, the head of the unit, felt was responsible for the drop in deaths. Obviously the new ventilation. Yep. Klein was a member of the old guard at the hospital who believed that new ideas were dangerous.

Like he tried to get a professor kicked out for using a stethoscope, which were new at the time. And that you shouldn't ask why things were the way they were. They just were. You just had to accept that. And on top of this, Semmelweis was foreign. He was from Hungary. And so his Hungarian-tinged accent made him. a target for the xenophobic and superior Klein.

And then came the revolutions of 1848, which made Semmelweis an even, you know, further scary, free-thinking liberal because he participated in the revolutions of 1848. But this, all of this, like, resistance that he faced within his own department, some of us just kept at it. He was like evangelical about his hand-washing doctrine. Yeah. And the incidence and mortality rates of puperal fever continued to fall. And he became like on fire with this knowledge that this practice had the potential to change the world for the better. And he, as a result of this, maybe his personality seems to have changed a bit from being lighthearted and friendly and popular as a young student to sarcastic, suspicious, contemptuous, how later accounts describe

him. If a case of childbed fever popped up, for instance, he played detective to pinpoint who had lapsed and then he would chew them out publicly. His identity began to be wrapped up in this so-called Semmelweis doctrine, and a rejection of the doctrine meant a rejection of him. At the end of his two-year assistantship, he applied for renewal, which was really a formality because they were like always granted. But Klein denied. He denied him re-renewal. Wow. And so suddenly Semmelweis found himself not only without a job, but also without any ability to institute his life-saving doctrine. And he was devastated. Yeah.

His professor friends, who were part of the new school at the hospital, urged him to present his findings. But then Semmelweis met with a little more difficulty because Klein had barred access to the division's records. He wouldn't let Semmelweis have them. But fortunately, Semmelweis had kept some of his own, and he finally agreed to speak publicly about his work in 1850, which is three years after first developing this hand-washing doctrine. His lectures were largely met with success, although there was some debate, especially from doctors who refused to believe that they could be the cause of such widespread disease and death. But Semmelweis knew that feeling. He felt horribly guilty for the role that he had once played.

I'll read another quote from him. Because of my convictions, I must here confess that God only knows the number of patients who have gone to their graves prematurely by my fault. I handled cadavers extensively. As painful and depressing, indeed, as such an acknowledgement is, still the remedy does not lie in concealment, and this misfortune should not persist forever. For the truth must be known to all concerned. And it just seemed like so many of the doctors couldn't look that, they couldn't even consider that possibility, because it is horrifying to think about. Right, because then it's, it's you. You have done this.

Right. Like, yeah. To countless humans. Yeah. And their families and their babies. Right. Yeah. But it seems even more difficult to imagine not considering that, like not trying this out.

Right. Like, what's the harm? It's a lot. It's also, it's just so interesting because like, you know, hindsight, 2020, whatever. Like, it's so painfully obvious. Yeah, it is. When you look back on it. And so it's almost difficult to put yourself in that mindset of, you know?

Right. How could you not? Well, which is why, like, I had thought a lot during this research about how it's so easy to fall into the trap of we know everything. And yeah, there are a few things left to be uncomfortable. covered, but like, uh-uh, there are going to be incredibly huge paradigm shifts or whatever in the future. Things that we look back on and we're like, how? How did we not see it? Right.

Or just things that like you can't even, like, how do you even predict what the next paradigm shift might be in medicine or ecology? Yeah. Like we just don't know because that's not the way that we're trained to investigate problems. That's just interesting. But anyway, besides the forced denial of these doctors and the guilt that they may have felt, another thing that kept the Semmelweis doctrine from gaining traction more broadly was the fact that he wouldn't publish. He hated writing. He hated it.

Oh, goodness. And so a few of his professor friends and some former students tried to write it up, but they lacked all the data and they couldn't capture. capture Semmelweis' thought process that led him to his conclusions. So it was more just like, hey, here are results that we found. That's it. And so he continued applying for jobs where he could put it into practice. And when the job that he had finally been given, which he was actually first denied, and it was a teaching position in midwifery, it was changed at the last minute. And he took it to be a personal affront.

And, you know, it was basically he was like, you know, my colleagues refused to see my great accomplishments. I'm surrounded by enemies. I'm being told to publish despite the evidence being so clear, like you shouldn't need a thorough paper. It should be obvious. How do you not see it? And then now this like the disrespect he felt from this job thing was the final straw.

So he left Vienna. He packed up and left to return to Budapest. without so much as a goodbye to any of the friends who had supported him and championed his cause for so long. Wow. Back in Budapest, Semmelvice seemed to be at least a little bit reinvigorated when he learned of an outbreak of puperal fever at the hospital nearby. And so he visited the hospital and found that the obstetric ward was under the management of the chief of surgery, who was also responsible for doing all forensic autopsies. Uh-huh. Uh-huh.

Uh-huh. And so Semmelweis was like, okay, I will be the unsalered director of this lying in ward at the hospital. Wow. And that came through. He was given that position. And he immediately implemented the same hand-washing practices and saw a similar immediate drop in puperal fever cases and deaths. But his constant watchfulness and tendency to play detective when someone died of puperal fever didn't exactly. make him popular among his employees and students, many of which went to great length to avoid washing their hands just to spite him. Oh, my. I know.

It's so difficult. The story is so wrenching because you're just like, wha. And then he made enemies with the hospital administration. Like the sheets weren't being washed frequently enough in his eyes. So we gathered up a bunch of dirty sheets and dropped them into the office of the hospital administrator. Oh, my God. And so the hospital administrator then it started immediately looking for ways to fire him.

His personality didn't really endear him to people around him. And he seemed to leave enemies a lot of places. That's a real bummer. He made enemies more easily than he made friends, for sure. But eventually he did reach a sort of like point where he was like, you know what, this is too many years of being met with ridicule and scorn. and he finally decided to sit down and write. Finally.

And so in 1861, just 14 years after he first developed the handwashing technique, he published his book, The Edeology, the Concept, and the Prophylaxis of Child Bed Fever. Unfortunately, it turned out to be densely written, difficult to follow, and he included many personal attacks on doctors who had rejected his findings in the past. He's killing me. I know. This is absolutely killing me. He's his own worst enemy.

So his book did little to increase acceptance of his doctrine. Although I will say it had picked up a couple of supporters in some places who wrote grateful, joyous letters to Semmelweis. But maybe the saddest part of this story is that Semmelweis himself wouldn't live to see his doctrine vindicated. In the early 1860s, it became clear to those around him that his mental health had begun to decline. His moods were becoming increasingly erratic and he had trouble taking care of himself or performing his job. There are retrospective diagnoses ranging from tertiary syphilis to Alzheimer's pre-senile dementia. But in any case, by the summer of 1865, his wife realized that she could not take care of him by herself. So she took him to a state-run insane asylum, as they were called then.

Two weeks after he walked through the doors, he was dead. The cause of death was determined to be a septic infection. Oh. I know. Much like the ones that caused puperal fever. Oh, my gracious. However, it was not from a wound during a gynecological surgery. as the facilities officials told his wife,

but rather from an infection following violent beatings by the asylum staff while trying to restrain him. Oh, my God. I know. It is horrific. It is, yeah. What? The year that Semmelweis died, a guy by the name of Joseph Lister came across a series of papers by Louis Pasteur and began to study. under the microscope, the pus from amputation wounds.

He realized that the microbes he was observing may be causing the systemic disease that he was seeing and that spraying them with carbolic acid could prevent it. After he did this, mortality dropped by almost two-thirds, and he published a description of his new technique, which he called antipsis. With this recognition of the germ theory of contaminated wounds, came the realization among the medical community that Semmelweis was right.

And starting in the late 1800s, his story as a martyr to medicine was being rewritten. Wow. What prevented the Semmelweis doctrine, which seems so clear in retrospect, what prevented it from being readily adopted? I mean, could be personality stuff, could be that he didn't write about it. but I think it's kind of the same thing that it always is. Like this isn't the first, this might be one of the most like heart-wrenching stories, but it's not the first time we've seen similar things.

No. It always takes, what, 20 years to get a new idea into textbooks. And then when it's outdated, 20 years for it to be removed. Right. Yeah. And so in the 1860s and the 1870s, about 20 years after Semmelweis first proposed, his doctrine, the causative agents of puperal fever began to be characterized, and the next big milestone came in 1935 with the development of the sulfonamide prontazel, which greatly reduced mortality due to puperal fever. The link between scarlet fever, erasipolis, and pupural fever

was recognized, and steady increases in hygiene continued to drive down the rates of the disease. but Aaron, this is not a disease of the past by any means. Can you bring us up to speed on what's going on with puperal fever today? I'd love to. Let's take a quick break first. Worldwide, this, by the way, it's kind of just a depressing story, so I'm just going to leave it out there. Great. Maybe we'll find a way to find some light in this tunnel.

but worldwide bacterial infections during labor and the immediate postpartum period, so MPIs, account for an estimated 10% of the global burden of maternal deaths. Oh, my God. So of all maternal deaths, about 10% are associated with bacterial infections. The World Health Organization, the most recent, data that they have on their site is from 2015. They estimate that there are about 75,000 deaths every year due to these infections. Wow. Wow. Yeah. That's a lot. It is. And the thing is that that that's not the whole story.

It's not just death. These infections also carry with them the potential for long term disability, including chronic pelvic pain, secondary infertility due to infection. And on top of that, like you kind of mentioned, Erin, maternal infections can have a big impact on newborn mortality as well. So that same World Health Organization report from 2015 estimates that over one million, one million newborn deaths are associated with maternal infections. What? Every year? That's what it said in 2015.

I was, I was still shocked by that number. Oh my gosh. Yeah. While today, overall rates of maternal infections are still, like, even though these numbers are shocking, they're drastically, drastically lower than in the past. I mean, 8801 per 10,000? Yeah, and that's just deaths, right? That's not even looking at it.

That's just deaths. That's not incidents, yeah. But, however, even though we've come a really long way, there's still some huge disproportionate impacts. Yeah. Not only between countries, so high-income countries have drastically lower infection and maternal death rates compared to lower income countries. But even within higher income countries, like the U.S., there's a huge disparity in terms of race. So in the U.S. in general, we're not great

when it comes to maternal outcomes. We can look not only at deaths, but severe morbidity, so like serious complications, as well as mortality rates, are very, very, very, very, you know, high in the U.S. compared to a lot of other high-income countries. But the racial and ethnic disparities in the U.S. are also atrocious. So in this country, black women are three to four times more likely to die from pregnancy-related causes than white women. Three to four times. Wow. So I kind of just want to read you like the overall numbers of pregnancy-related more. mortality in the U.S., and this is averaged from 2014 to 2017. In the U.S., 41 deaths per 100,000 live births, which is the standard metric of measure,

41 per 100,000 for non-Hispanic black women, 28.3 deaths per 100,000 live births for non-Hispanic, Native American, and Alaskan native women. 13.8 deaths per 100,000 births for Asian or Pacific Islander women. 13.4 deaths for non-Hispanic white women and 11.6 deaths per 100,000 live births for Hispanic or Latino women. Those are very different numbers. They're very different. I mean, I would say all of them are too high. Yes.

But they're very, very different. So just sit with that for a minute. Yeah. Because like I said, it's not just death. That's the worst possible outcome. It's estimated that in the U.S., for every maternal death, there are 100 other severe events, whether that means infection or severe hemorrhage or emergency surgery that takes place.

So that means that over 60,000 people every year in the U.S. are having these severe, likely very traumatizing complications that in so many cases are preventable. And it's not just the U.S. In the U.K., if you look specifically, even just specifically at maternal sepsis deaths, for every one maternal sepsis death, there are 50 other pregnant people that have life-threatening infections. Wow. If we want to look at disparities across the globe. We do. The World Health Organization estimates that 810 people, so this is looking more broadly than just maternal infections,

but 810 people die every day from preventable causes related to childbirth and pregnancy. 810 every day. 810 every day. That's 295,000 lives lost every year. in low-income countries, that maternal mortality ratio, the number of maternal deaths per 100,000 live births, you said, Aaron, sometimes it was like 800 in like the 1700s. Today, in low-income countries, it's 462. 462 deaths per 10,000? Per 100,000.

Oh, per 100,000? Yeah. Wow. Yeah. Semmelweis would be appalled. Yep. In high-income countries, it's 11 on average, though in the U.S. as of 2017, on average, 17.3. And we know that those averages don't tell the whole story.

Right. So what's going on? I mean... It's such a good question, Aaron, because the other thing is it's not getting better. It's getting worse, at least here in the U.S. Worldwide, from 2000 to 2017, the maternal mortality ratio has actually decreased by like 38%. So worldwide, the trend is going down. Okay.

But in the U.S. specifically, our maternal mortality ratio has been increasing year after year. What's happening? Yeah, I don't. It's a great question. I don't have an answer for you. I mean, I guess it's really difficult because, like, because there are so many different causes, prevention is not a one-size-fits-all type of thing. It's a lot of different things you have to do. Absolutely.

And it's definitely not, I want to just be clear, this is not all infection related. In fact, infection is a 10% or less contributor, at least when we look at deaths overall. But that doesn't change the fact that thinking. like hemorrhage, preeclampsia, eclampsia, cardiac issues, worldwide unsafe abortion practice is another major contributor to pregnancy and childbirth-related deaths.

So we have a lot of work that needs to be done still. And I think, like some of ICE, we need to start by figuring out what the root cause of a lot of these problems are so that we can actually fix them. Yeah. But, you know, racism is a big part of it here. For sure.

There's a lot of... Yep. Yeah, it's a multifactorial problem. Sure is. Gosh, I wish I had something more uplifting to end it on. Sources. Yeah, I was like, I can't really think of anything. Sources.

Yeah. So I relied on primarily, I have some articles, but primarily I relied on two books, both of which I highly enjoyed. One is called The Doctor's Plague by Sherwin-Newland, and that is a nonfiction book mostly about Semmelweis, but also more broadly about puperal fever. And then another is a fiction book, which was really fun. I get to read fiction for not that often for the podcast. And it's called The Cry. in the Covenant by Morton Thompson and it's out of print actually oh wow how'd you get it at library oh okay libraries i of course because this episode was kind of a mess of a biology there's a lot of different papers that you could read some specific to group a strep some just looking at you know maternal peripartum infection overall i will say that you know to add to a slightly happy ending. The CDC has a number of new campaigns specifically to try and address a lot of this, and a lot of it is just paying attention to the person who is pregnant and actually

listening to the symptoms that they're having. One of their big campaigns is called Hear Her. So I, yeah. Because that's, I mean, that's a big part of it, right? is not paying attention to the person who's experiencing what they say they're experiencing. Yeah. And we've seen that time and again. It's a little bit frustrating that it needs to be a public health campaign, that like this is not something that is inherently taught or learned.

But. Yeah. So we will post the, all of our sources on our website, this podcast will kill you.com. Yep. Thank you to Blood Moved. for providing the music for this episode and every one of our episodes. And thank you to the Exactly Right Network, of whom we are a proud member. And thank you to you, listeners.

This was, I mean, it was an very interesting journey, very depressing ending, but thanks for sticking with us. Yeah, thank you. And I guess we've been just stealing this line from Semmelweis all along, but I feel... We really have. I feel very excited to sign off this episode with... A. Wash your hands. You filthy animals. Success starts with your drive.

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