0:00

We want to start with a disclaimer that throughout

0:02

this series we feature explanations

0:04

and stories that include some heavy material,

0:07

including early pregnancy, loss, still

0:09

birth, and other traumatic experiences

0:12

of pregnancy, childbirth, and

0:14

the postpartum period.

0:17

There's a lot I could say about the physical difficulty

0:19

of carrying a baby, that

0:21

I'm going to focus on the postpartum because

0:23

that was what was most surprising and unsettling

0:26

to me throughout my pregnancy. I

0:28

always expected that I would start kind of falling

0:30

in love with the baby, like I always heard people

0:32

saying, I'm already so in love

0:34

with you, all those you know, social media posts

0:37

and what people are talking about, and

0:39

I never really felt an attachment. But

0:41

I was especially promised that when

0:44

you give birth, it's the happiest day of your life.

0:46

You look down at the baby and you love them

0:49

instantly more than it's a different love than you've ever

0:51

experienced before. And so after,

0:53

you know, three days of

0:56

pre labor and then fifteen hours of

0:58

labor, I gave birth and

1:00

the baby was put on my chest and

1:03

I just felt this kind of heartbreaking

1:05

missed step feeling because

1:08

it felt the same as it always had.

1:10

There was no immediate love.

1:12

There was a baby on my chest and

1:15

that was it. And then in the hospital

1:17

I kind of was feeling like I had no idea

1:19

how to take care of this baby. There was kind of this

1:22

helplessness. I couldn't feed it, he wasn't

1:24

latching. I could hardly stand

1:26

myself, like I needed help getting to the bathroom.

1:29

I couldn't sit up, I didn't change into clothes.

1:31

I just felt like very sick.

1:34

And when the nurse came with the wheelchair

1:36

and was going to wheel us out, I was like, how the heck am

1:38

I going to go home and take care of this baby. I have no idea

1:41

and I don't even love it. Does anyone

1:43

know around me that I don't love this baby

1:45

and that I don't know how to take care of it? And

1:47

my husband drove us home and

1:49

I walked into the house and it was even

1:52

Actually, when we pulled into the garage, there was this immediate

1:54

sense of everything around me looks

1:56

different than it did, nothing looks

1:59

familiar. It's like we drove into

2:01

this kind of parallel universe that I'd never

2:03

lived in before, and it was very unsettling.

2:06

And my parents were there and everyone was

2:08

so happy, and I was like, something feels

2:10

so off to me. And then my husband

2:12

went to take the dog for a walk because we'd been gone

2:14

for three days, and I

2:16

felt a panic inside me, and I left

2:19

the baby with my parents and I went into

2:21

my bedroom and I cried because I didn't want to be without

2:23

my husband. He was the only person who

2:25

knew what I'd been through the last three days. So

2:28

then I had this kind of like vague

2:31

feeling of desolation for a long time, and I

2:33

would cry for hours

2:35

at a time at night, and I just kind of I'd

2:37

never really felt happy. I

2:39

was always just kind of leaning towards depression,

2:42

I guess, and I'd never experienced depression before,

2:44

so I didn't recognize it. It just felt

2:46

like homesickness, like this nagging sense

2:49

of homesickness that intensified

2:51

or dulled but never went away.

2:53

And the scariest part was when my in laws visited

2:56

and my parents also visited, and they were taking

2:58

turns carrying the babe all day and

3:00

when they finally when they gave him back to me after

3:03

maybe an hour, I looked down and

3:05

I didn't recognize my baby, and

3:07

it could have been any baby I had. I had had him for

3:09

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

3:12

he was. It could have been they could have swapped him

3:14

out and I would have had no idea, and I started

3:16

sobbing. I told my husband

3:18

right away, and he googled

3:22

mother can't recognize baby. And I watched him

3:24

google that, and it was so heartbreaking. And

3:27

I came up with this kind of soothing exercise

3:29

where because my son's face

3:32

didn't look familiar to me, I kind

3:34

of broke it down into pieces and I would say, like,

3:36

there's his mouth, there's his eyes, there's his nose,

3:38

there's his ears, and I would memorize them

3:40

in pieces, and from then on, whenever

3:42

I held him, I would go over and recognize

3:45

each of those small pieces until

3:47

they looked familiar to me. To this

3:49

day, I don't know if it was like mild psychosis

3:53

or depression. By the time I went

3:55

to the doctor six weeks later, it

3:57

had I mean, I was still sad and should

3:59

have been treated with depression, but

4:01

it wasn't so startling that

4:04

the doctors picked up on it. And I didn't

4:06

know how to report it myself because I didn't

4:08

know what to recognize. I wish that

4:10

I had seen a doctor a way earlier. It

4:13

wasn't required and I didn't know to ask for it,

4:15

and I wish that I had

4:17

been treated because that dull sadness

4:19

probably stuck around for six

4:22

months, and if there had been earlier

4:24

intervention, I think I would have had a much

4:27

more enjoyable early motherhood experience.

4:30

I also told my husband that I

4:32

didn't love the baby as much as I loved

4:35

him, and that that seemed wrong to me, and

4:37

he assured me that I'd

4:40

known my husband for ten years, so it kind of made

4:42

sense that I would love him more than somebody

4:44

that i'd only known for two weeks. It

4:47

probably took a year for me

4:49

until I had the solid bond that I was

4:51

expecting to have right away, and

4:53

I wish that other women knew that sometimes

4:56

it's just a bond that has to build

4:58

as you get to know people. And now

5:00

my son is six, and I couldn't possibly

5:02

love him more.

5:49

It has been so incredible to

5:51

hear everyone's stories, and

5:54

we really can't thank everyone enough

5:56

for sharing your stories with us. We

5:59

read hundreds of first

6:01

hand accounts and it truly

6:04

is such an honor and it feels so

6:07

I can't. It feels surreal.

6:09

Yeah, it's amazing. So thank you to each

6:11

and every one of you who wrote in and

6:15

who shared your stories.

6:16

Yeah.

6:16

We tried so hard to include

6:19

as many different stories from as many different

6:21

perspectives and experiences of

6:23

pregnancy and childbirth and the postpartum

6:26

period as we could, and we know

6:28

that as many as we included, there's so many that

6:30

we didn't and we just want to thank

6:32

you all again from the bottom of our hearts.

6:34

We really really appreciate it.

6:35

It means it means the world to us, and this podcast would

6:37

not be the same without all of you.

6:40

Absolutely not. Yeah, it has really been.

6:42

It's such an integral part. It's it's amazing.

6:44

It is.

6:44

Yeah.

6:46

Hi, I'm Aaron Welsh.

6:47

And I'm Erin Allman.

6:48

Update and this is this podcast will

6:50

kill you.

6:51

We are coming to you with the fourth and

6:53

final for now episode

6:56

in our series Pregnancy Now.

6:58

I mean to be continued to continue.

7:00

But this is our season

7:03

finale.

7:06

That was lovely. Thank you.

7:07

I did a drum even though it was more like a

7:09

trumpet.

7:10

Yeah, No, I liked it. I think it's it

7:12

was. It was a really nice touch.

7:14

It's also our last episode recording in

7:16

the exactly right studios. So thank you guys

7:18

for having us here. Yes, we're having

7:20

too much fun. We are having too much fun, too

7:22

much fun, No such thing. We're just relaxing.

7:27

That's been the joke all morning. If you listen to the first

7:29

couple episodes, you get it.

7:32

Oh my god. Okay, okay, we still have an

7:34

intro to get there. We do, we do. We have some.

7:36

Things to discuss. If you've listened

7:38

to the other episodes, you've heard these.

7:40

Before, heard this before. Yeah, we want

7:42

to just sort of briefly go through again

7:44

what we've already covered in the first three

7:46

episodes, what we're going to be covering in this episode,

7:49

talk about some of the language that we'll be using,

7:52

and our goals overall with creating

7:54

the series. And so we decided, like we

7:56

have said early on, to dedicate

7:58

four episodes to pregnancy for each trimester.

8:01

Clearly not enough to actually

8:03

cover this huge experience that is pregnancy,

8:06

childbirth, and the postpartum period. Yeah,

8:08

and so if you are like, hey, I really want

8:10

to hear more about this, I want to learn about this aspect,

8:13

what about this? Send in your questions, Send

8:15

in your topic ideas. We are happy

8:17

to have them. This will not be the last episode

8:20

on anything related to pregnancy

8:22

now, So, yeah, we've got more to go,

8:24

so much more.

8:25

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

8:28

We still have this episode to try,

8:31

but we definitely have not covered every

8:33

possible experience that a person could

8:36

have during pregnancy, childbirth, and

8:38

beyond, because pregnancy is such an individual

8:40

experience. So each

8:42

episode that we have done thus

8:45

far has covered roughly a

8:47

trimester of pregnancy. So

8:50

in our very first episode we talked about

8:52

how you even know whether or not you're pregnant

8:55

and what happens during early development.

8:58

The second episode, we talked a lot

9:00

about the placenta, what an incredible

9:03

organ that is, and we

9:05

also talked about the physiological changes

9:07

and antempal changes that someone experiences

9:09

throughout pregnancy, and we touched

9:12

on some of the complications that can arise.

9:14

Last episode last week, we talked all about

9:17

the process of childbirth itself, Yeah,

9:19

all the different ways that you can do it. Yeah,

9:21

a little bit about labor and modes of delivery,

9:24

and then the history of the cesareans actually about

9:26

C section, wasn't Julius Caesar y'all

9:29

no yeah.

9:30

Tune into episode three to find out more. And

9:33

finally, today, our fourth episode,

9:36

our final episode of the Pregnancy Series

9:38

and our final episode of season

9:40

seven, will be about the concept

9:42

of the fourth trimester, talking

9:44

about what changes are going on

9:47

in your body after pregnancy, and

9:49

we're also going to be talking about this big

9:52

picture of how the medicalization

9:54

of pregnancy and childbirth changed

9:56

that experience and how we moved from

9:58

home to hospital and some of the consequences

10:02

of that.

10:02

Yes, I'm excited for this episode arin

10:04

me too.

10:05

We have intended for this Pregnancy

10:07

Series, as with all of our episodes, honestly,

10:09

to be inclusive of all families, and

10:12

we recognize that not everybody who experiences

10:14

pregnancy identifies as a woman, so

10:17

we try wherever we can to use gender

10:19

neutral language and discuss pregnant

10:21

people. At the same time,

10:23

we know that a lot of what we discuss, especially

10:26

when it comes to medical bias during pregnancy

10:28

and childbirth, historically and today,

10:30

is a result of gender discrimination and

10:33

racism, and so in those context

10:35

we use the term woman or women, and

10:38

throughout these episodes we also use the term

10:40

mother or maternal and paternal since

10:42

these are the terms that are often used in the scientific

10:44

and medical literature.

10:45

Yes, and we also want

10:47

to just you know, recognize that there is

10:50

no such thing as a normal pregnancy.

10:52

There's no This is what is going to

10:54

happen, and this is normal, and that's.

10:57

The only way that it can be, the only way there's

11:00

Differently, you.

11:00

Go gone over that a lot in these

11:03

episodes.

11:04

But it is really important in discussing,

11:06

you know, a baseline of what is expected

11:09

to happen, so that we can understand what happens

11:11

when things happen outside of those expectations

11:13

and some of the complications that can happen as a result,

11:16

even defining what a complication

11:19

is.

11:19

Exactly exactly, And

11:22

we're going to do that today for the postpartum

11:24

period.

11:25

We are.

11:25

We are.

11:26

But first, if I remembered it, this

11:28

time, it's quarantine time,

11:31

Aaron, what are we drinking again

11:33

this week?

11:33

We're drinking yet again, Great expectations.

11:36

Great expectation.

11:37

Which is a plasy burrita that is

11:39

a non alcoholic bev.

11:41

It's really good. It's got ginger ale,

11:43

it's got muddled blackberries and mint,

11:46

it's got lemon juice.

11:47

Is shockingly delicious,

11:49

very refreshing.

11:50

Yeah, super refreshing. I love

11:53

it. I'm thinking of it right now.

11:54

Too, which I actually had one, but

11:57

alas.

12:00

Later today.

12:00

Yes, if you want to see us make

12:03

it. We made a really fun quarantine video

12:05

that you can find on the YouTube tube

12:08

tube. We also were

12:10

very honored to be joined by Georgia Hartstark who made

12:13

us a quarantin ye and alcoholic

12:15

version to go along with these episodes. She

12:17

called it the on teeny.

12:18

The Tenius and it's delicious.

12:20

Yes, and you can find that video on

12:23

YouTube as well.

12:24

YouTube you can also

12:26

find I don't know if we have said this enough,

12:28

but you can find these episodes on

12:30

YouTube, these pregnancy episodes, pregnancy

12:32

episodes with video with video and props.

12:35

Well props.

12:37

We're doing great today. And

12:40

if you would like the recipes for these

12:42

quarantine and place rita for this series,

12:45

check out also our social media make sure

12:47

you're following us or now in Blue Sky. I don't

12:49

know if we've said that sure, And

12:52

also our website Yes podcast will

12:54

kill You dot com which features do you want me

12:56

to this listen?

12:57

Let's skip it today?

12:58

Okay? Check out our website transcer rips.

13:00

I just have to throw that in Okay, I

13:06

think more business.

13:07

Rate review and subscribe. We love you, thanks for listening.

13:09

We'll be back soon with a new season. Yeah, and

13:11

we have so like send us your ideas along

13:13

the way. We are so excited to dig

13:15

more into the world of health, medicine,

13:18

disease biology, evolution,

13:21

ecology.

13:21

Literally like after we start misology,

13:24

we.

13:24

Already have a list of things that were like, Okay, so next

13:26

season booo so like.

13:27

Air quality index, yes, thank you, yeah,

13:30

thank you Kenton. Okay,

13:33

let's begin.

13:34

Let us after a break.

13:52

I found out I was pregnant on New Year's Day twenty

13:54

twenty four. I was thirty three, and this would be

13:56

my second baby. My pregnancy was relatively

13:58

uneventful and actually a little easier than my first,

14:01

but both were low risk. I went into labor

14:03

naturally at thirty nine weeks and went to the hospital

14:06

to help things along. My midwife broke my water

14:08

manually. I felt a huge gush and

14:10

things really intensified from there. At this point,

14:12

my memory is a little blurry, but I do remember feeling

14:14

more big gushes when I had contractions. I

14:17

pushed her about an hour and then my daughter was born.

14:19

When the midwives went to place around my chest. They

14:22

discovered that the cord was very short. They

14:24

could only set her on my belly under my belly

14:26

button. I asked them to go ahead and

14:28

cut the cord so that I could hold her on my chest

14:30

instead. I got to hold her for

14:32

maybe a minute and take some pictures before things

14:34

started to go downhill. I was trying

14:36

to nurse her, and then I started to feel very weak.

14:39

I yelled out for someone to take the baby because

14:41

I thought I would drop her. I had been distracted,

14:43

but then I realized I still hadn't delivered the placenta.

14:46

My midwives sprang to action and told me

14:49

we needed to deliver it immediately. As

14:51

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

14:53

My first thought was that it was amniotic fluid,

14:55

because it felt like when my water was broken. But

14:58

then I realized all that fluid had already been do livered

15:00

with baby, and I said, was that blood. I

15:03

looked at the midwife who had been standing between my legs,

15:05

and she was splattered with blood head to toe, like

15:07

she'd been sprayed with a hose. From there,

15:09

everything was chaos. All of a sudden,

15:11

there were a lot of people in the room. The midwives

15:14

were vigorously massaging my belly, but my uterus

15:16

wasn't contracting and I was bleeding out. I

15:18

was given multiple drugs via different routes at

15:20

the same time. One of these was cide attack,

15:23

also known as misiposal. This drug

15:25

is talked about a lot as it is the second step in

15:27

a medication abortion, but it is also used

15:29

to help stop postpartum hemorrhage in labor and delivery.

15:32

The hospital ob and my midwives were working frantically

15:35

on me for about an hour to try to stop

15:37

the bleeding. Oh my husband was doing skinned

15:39

to skin with the baby. I remember thinking

15:41

that my great grandmother had died from a postpartum hemorrhage.

15:44

I asked one of the nurses if I was going to be okay,

15:47

and all she said was, we are doing everything we

15:49

can. They tried using an intrauterine

15:51

balloon device to apply pressure from within.

15:54

Unfortunately it got clogged with clots and didn't

15:56

work for me. Staff was scooping up

15:58

blood and clots off of the bed and

16:00

and weighing it to see how much I lost. Ultimately,

16:03

they said I lost about two to three leaders and I

16:05

was given two leaders via transfusion. Eventually,

16:08

my uterists did contract and they were able to

16:10

stitch me up. The other day, I was

16:12

looking back at those photos when I was holding my baby,

16:14

and I can see that my face has a weird gray cast

16:16

to it. I'm so glad that I delivered in

16:18

a hospital that had all of the best medications

16:20

and resources available to stop the hemorrhage.

16:23

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

16:27

My name is Dawn and I live in Texas.

16:29

In my mid thirties, I became pregnant

16:31

with my second child. My then husband

16:33

and I were thrilled after having such joy

16:36

from our first one. At my first

16:38

prenatal appointment, everything seemed fine,

16:40

my bottles were good, and we were able to detect

16:43

a heartbeat. Since my first pregnancy

16:45

was uneventful, I assumed this one would

16:47

be similar. One thing that was

16:49

very different about this pregnancy was a nausea.

16:52

Although I had had nausea with my first pregnancy,

16:55

this one was much more intense. I

16:57

felt awful most of the time and struggle

16:59

to do normal things. Nothing seemed

17:01

to help. At my second prenatal

17:04

appointment, the midwife was unable to

17:06

detect a heartbeat. She did an

17:08

in office ultrasound and confirmed

17:10

the fetus was no longer alive. I

17:13

don't believe any other information was gleaned

17:15

from the ultrasound. My midwife

17:17

suggested that I have a DNC soon. We

17:20

were, of course devastated to have lost a

17:22

baby. Shortly after

17:24

the DNC, the midwife contacted me

17:26

and asked me to come back into the office. In

17:29

the appointment, she told me that pathology

17:31

done on the placenta or fetal tissue

17:33

had come back with some concerning results,

17:36

which was that I had had a molar pregnancy.

17:39

I had never heard of this diagnosis.

17:42

She told me that I would need to come in for regular

17:44

blood testing to be sure pregnancy hormone

17:47

levels in my blood were steadily

17:49

decreasing. After the

17:51

appointment, I talked to my aunt, who was

17:53

an OBGI in nurse. She gave

17:56

me the highlights of a molar pregnancy, and of

17:58

course I googled on my own. After time talking

18:00

to my aunt, my basic understanding

18:03

was that amolar pregnancy is an unusual,

18:06

non viable pregnancy that can sometimes

18:08

develop into cancer if all

18:10

the abnormal cells are not removed.

18:12

Years afterwards, my aunt told me she was

18:15

very concerned for me. While

18:17

the intense nausea remained for a few weeks.

18:19

After the DNC, my pregnancy

18:22

hormone levels did steadily decline,

18:24

and after some time I was fortunate

18:26

to have a third pregnancy that resulted

18:28

in a healthy baby boy. Since

18:30

I live in Texas, I do want to mention

18:32

that I'm not sure if the DNC

18:35

my midwife recommended would be possible now

18:37

with the unprecedented removal of

18:40

women's reproductive rights.

19:08

Last week, I took us through the history

19:10

of cesarean sections, a procedure that

19:12

has been used in some capacity since

19:14

at least ancient times, but one

19:17

that physicians weren't able to widely utilize

19:19

until the twentieth century, when antibiotics,

19:21

antisepsis, transfusions, and surgical

19:23

technique transformed it from an almost certain

19:26

death sentence to a life saving tool, and

19:29

we discussed how the high rates

19:31

of sea sections have led people to question

19:33

whether the surgery, life saving though

19:35

it may be, is overused

19:38

and what possible consequences might

19:40

arise as a results. So,

19:42

for many, high rates of sea

19:44

sections represent sort of this dark

19:46

side of the medicalization of pregnancy.

19:48

And childbirth where medical intervention

19:51

is seen as always necessary

19:53

and women aren't trusted to give birth.

19:58

This, of course, is no the complete

20:00

picture, because ultimately, as

20:03

childbirth moved from the home to hospitals,

20:06

rates of maternal and perinatal

20:08

mortality declined as medicine

20:10

developed methods to manage the complications

20:13

that in previous centuries may have resulted

20:15

in tragedy. But this

20:17

rosy picture of modern medicine

20:19

marching onwards with doctors saving

20:22

the day that really fails to

20:24

capture the inevitable and often overlooked

20:27

cost of progress. What did

20:29

we leave behind when we moved from

20:31

the home to the hospital. So

20:33

today I want to take this big picture

20:36

view of how childbirth has changed

20:38

over the centuries, exploring some

20:40

of the factors that have underlaid those changes,

20:43

and ultimately I want to kind

20:45

of just think about this question of

20:47

how can we use the past

20:50

to ensure a better future. Before

20:53

I dig in, I want to shout out a few of the major

20:55

sources that I used to put this together. There was

20:57

a book called Brought to Bed by Judith Walser

20:59

Levitt about childbirth in America from

21:01

seventeen fifty to nineteen fifty. The

21:04

title sounds somewhat dry. It is one of the most

21:06

fascinating books I have ever read,

21:08

very enlightening. The book

21:11

A Midwife's Tale by Laurel Thatcher Ulrich,

21:13

which is so good. Oh my gosh,

21:15

this is the excellent history book about the life of

21:17

midwife Martha Ballard snippets.

21:20

It's such I love

21:22

this book. I could talk about this forever. But the way

21:24

that it approaches history is fascinating

21:27

because it takes like, here's a segment, here's

21:29

a month in her life. Now let's

21:31

think about marriage laws in Massachusetts

21:33

or not in Massachusetts, in Maine the

21:35

late seventeen hundred, so like all the.

21:37

Context of what was happenings.

21:39

Oh, how interesting.

21:40

It's so good not to mention like the aspects

21:42

of midwiffery and childbirth and so on. Okay,

21:45

another book is I use

21:47

snippets of a book called The Midwife Said fear

21:49

Not just about the history of midwiffery in the US

21:52

up through today. That one is

21:54

by Helen Varney and Joyce bb

21:56

Thompson. And then finally there's a

21:58

book Blue by Rachel Moran. Not

22:01

our not our friend friend Rachel Moriann, but

22:03

a different Rachel Moran about the

22:05

history of postpartum depression in the US.

22:08

So you can probably tell based on these titles that this history

22:10

section is mostly going to be primarily focused

22:12

on the US.

22:13

It.

22:14

Yeah, there is no origin story

22:16

for midwives. Their existence

22:18

probably predates written history,

22:20

and assistance during childbirth may

22:22

even be a key part of human evolution. As

22:24

we kind of talked about, the word

22:27

midwife means with women, and

22:30

over the centuries and across the globe,

22:32

midwives have taken on various roles

22:34

that have held different meanings wise

22:37

women all around, healer, which

22:40

to the haters, and so on, but

22:43

there have been a few constants that have persisted.

22:46

Midwife care often focuses specifically

22:48

on women, that training often

22:51

involves models of apprenticeship,

22:53

that scientific knowledge is incorporated

22:55

into practice, and that pregnancy

22:58

and birth are considered normal life

23:00

events. This is not

23:02

a history of midwives. I won't be talking

23:04

about like the profession today, but

23:07

it is a history of childbirth, and the

23:09

two are of course inextricably

23:11

linked. In the early years of

23:13

the US, childbirth was at home, most

23:16

commonly attended by midwives, then

23:19

by midwives with occasional visits from

23:21

physicians, then by physicians

23:23

with a woman's friends and family in attendance,

23:26

and then in hospitals with no familiar

23:28

faces. Husbands weren't even

23:30

allowed in the hospital room until

23:33

the nineteen sixties like the late nineteen

23:35

sixties and non spouses way

23:37

later.

23:37

Wow. Very interesting.

23:40

Yeah, the transition from

23:42

home to hospital and from midwife to physician

23:44

was not uniform across the US. Immigrants,

23:47

the less wealthy, non white women, and those

23:49

living in rural areas gave birth at home

23:51

for much longer than wealthier individuals.

23:54

And so, to give you some idea of this timeline,

23:57

in nineteen ten, about fifty

23:59

percent of all babies were delivered by midwivesteen

24:02

ten nineteen ten. By nineteen

24:04

thirty that number had gone down to fifteen

24:06

percent.

24:07

Wow.

24:07

And by nineteen seventy three about

24:10

one percent of births were attended by a midwife.

24:12

Wow. And compare that to twenty

24:14

twenty one, which is the most recent one that I

24:16

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

24:19

Twelve percent. Okay, we're attended.

24:21

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

24:23

back up. I will say that I know this

24:25

is US centric but that is very different than the data

24:28

today for most other high income countries

24:30

even.

24:30

Yes, yes, and that is part that is wrapped

24:33

up in the history of how the US treated

24:35

midwives, specifically laws.

24:38

Yeah, yeah, the transition

24:40

from home to hospital. This did not happen

24:42

overnight, nor was it simply a hostel

24:45

takeover by physicians,

24:47

as Levitt puts it in brought to bed. The

24:50

process by which this occurred reflected

24:52

the needs women felt to upgrade

24:55

and to control their birthing experiences,

24:57

as well as the increasing medical management

24:59

of birth. What I really

25:02

really appreciate about this quote is what I

25:04

feel like so many histories of childbirth leave

25:06

out that birthing women were

25:08

and are agents of change. They

25:11

were not just passive bystanders of the medical

25:14

and legal attacks on midwifery. They

25:16

held the power to say what they

25:18

wanted their childbirth to be like. Until

25:21

hospitals became the default place to give

25:23

birth, women often chose who would

25:25

be there to help, to support, to

25:28

make decisions when she could not, and

25:30

the people she chose were often midwives

25:32

and her female friends and family. It

25:35

was like a birthing network rather

25:37

than just like here's the hospital staff

25:40

and as obstetrics became a more common

25:42

part of medical training. Many women opted

25:44

to bring a physician into that network,

25:46

believing that his professionalism,

25:49

his tools, and his expertise would

25:51

ensure the safety of mother and baby. And

25:53

I say his because that was almost

25:56

universally the case. Yep, yep. In

25:58

nineteen hundred, only six of

26:00

doctors in the US were women.

26:02

I'm actually surprised it was that high.

26:04

I know, I know. I mean. The

26:06

other thing, the other caveat to that is that, yes,

26:08

there were six percent, but they had

26:10

very few patients because most people didn't want to see

26:12

them, but they were elected like

26:15

a lot of women who were giving

26:17

birth wanted a female doctor.

26:19

Okay, interesting then back then.

26:20

Yeah, And of course most

26:22

medical schools banned women and non white

26:25

men from applying. What

26:28

led to women choosing physicians

26:30

and hospitals for childbirth is wrapped

26:32

up in the professionalization of medicine

26:35

and active campaigns against

26:37

midwiffery. Midwives were

26:39

portrayed as lacking the training in medical

26:41

expertise to safely deliver babies,

26:43

while also being explicitly forbidden

26:46

to seek that training and medical expertise.

26:49

Wow, yeah, okay, and.

26:50

Women wanting to make the safest decision

26:53

for themselves and their baby broaden male physicians

26:55

believing that they would provide protection from

26:58

the dangers of childbirth, which there were many.

27:00

Yeah, all right, so now that we've got

27:02

the big picture of view, let's dig a bit deeper

27:04

to see how this all went down. We

27:07

as a society have a tendency

27:10

to romanticize certain aspects of the

27:12

past, like how much better food must

27:14

have tasted it didn't.

27:17

I feel like I've never thought of that.

27:18

Oh yeah, absolutely. And

27:21

they also though see our book Club episode

27:23

on the poison Squad, like there is a reason that pasteurization

27:27

is hailed as one of the most life saving

27:29

inventions. Yes, and

27:31

I think that this romanticization happens

27:34

to a certain degree also with pregnancy

27:37

and childbirth. A call for less

27:39

medical intervention is understandable,

27:41

especially when you consider how early medical

27:44

interventions during childbirth often

27:46

caused more harm than good. But

27:49

it also fails to acknowledge that childbirth

27:51

can be dangerous. And

27:54

no, it is not a disease, and it's not an unnatural

27:56

state of being, as early twentieth century physicians

27:58

believed, but it is a physically demanding

28:01

experience with potential impact on both

28:03

mother and babies life and health. Although

28:07

I really I did find it interesting that in

28:10

that Diary of a Midwife Life,

28:12

the Martha Ballard, she called like when

28:15

a woman was starting labor, she called

28:17

it her illness is beginning, which I think

28:19

is very fascinating.

28:21

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

28:24

The laborers you're at, which maybe just shows

28:26

how she saw it as like this is a potential

28:28

where like there is a lot of attention thats needed

28:31

here, right right? Yeah.

28:33

Imagining the women of the seventeen hundreds

28:35

giving birth with no fear, as relaxed

28:38

as could be, is erasing the

28:40

experience of so many who approached

28:42

their labors with dread and apprehension. In

28:45

the early eighteen hundreds, women in the US

28:47

had an average of seven children. That

28:50

the number of pregnancies was probably higher,

28:52

yes, because that doesn't include miscarriage,

28:55

stir. Many

28:57

women spent the majority of their

28:59

adult lives pregnant, breastfading,

29:02

recovering from childbirth, and taking

29:04

care of small children. A baby

29:06

every two or three years was kind

29:08

of expected, a routine part of life,

29:11

but that didn't mean that women necessarily

29:13

looked towards childbirth without anxiety.

29:17

It wasn't just the loss of a child, the

29:19

potential loss of a child that weighed on them.

29:21

It was the physical act of childbirth

29:23

that carried with it the threat of death. Diary

29:27

entries and letters written in the eighteen hundreds

29:29

give us a glimpse into these worries,

29:31

as women wrote wills or gave instructions

29:34

on who should care for the baby if she

29:36

died.

29:37

This hurts my heart.

29:39

I know, I know, I'm sorry, but I feel

29:41

like it's such a part that we don't think

29:43

that much about, or at least I don't. Maybe that's

29:45

just putting my own No, I.

29:47

Do think, especially because I think a lot

29:49

of what you're talking about already is like we see

29:51

and we see this in a lot of aspects of medicine. We

29:53

see these pendulum swings, yes, right,

29:56

and we see things going from like absolutely

29:58

no intervention, too far, too m or

30:00

like. And it's not just in obstetrics,

30:02

right, It's in so many aspects of medicine.

30:05

And so I think that that we see

30:07

that playing out a lot of especially in like social

30:10

media right now, where it's like there's

30:12

all the intervention or there's natural

30:15

childbirth, which we talked about last episode of

30:17

like that that mean that word does not have

30:20

meaning, right, And yeah,

30:23

I just I think that that is such an important

30:25

part that isn't ever discussed when we're talking

30:27

about like a low intervention birth

30:29

or something like that.

30:30

Yeah that like it.

30:31

Wasn't all roses back

30:34

in the day.

30:35

Yeah, yeah, So I want to

30:38

I've pulled a lot of these quotes from Brought

30:41

to Bed because I think that

30:43

there they just illustrate this, like

30:45

this idea that it's not There

30:47

are many there's a lot of nuance to how people

30:49

felt about their impending you know, pregnancy,

30:52

childbirth and so on. So Lizzie

30:54

Cabot wrote to her sister in the mid

30:57

eighteen hundreds, I have made my

30:59

will and divided off all my little things

31:01

and don't mean to leave undone what I ought to

31:03

do if I can help it. Sarah

31:06

Ripley Sterns wrote in her diary late in

31:08

her pregnancy, perhaps this

31:10

is the last time I shall be permitted to

31:12

join with my earthly friends. A

31:15

woman described her third birth in eighteen

31:18

eighty five between oceans of

31:20

pain, their stretch, continence of fear,

31:22

fear, of death and dread of suffering

31:25

beyond bearing. Those

31:27

who attended births, midwives and physicians

31:29

felt similar apprehension. Like there was

31:32

a physician writing in eighteen seventy who

31:34

described his feelings of alarm and

31:36

gloomy forebodings after seeing a patient

31:38

die unexpectedly during childbirth. He

31:41

goes on to write about how those feelings stayed

31:43

with him, making it impossible

31:45

quote while attending a case of confinement

31:48

to banish the feeling of uncertainty and dread

31:50

as to the results of cases which seemingly

31:52

are terminating unfavorably. Sometimes

31:56

the dread wasn't isolated to the act of childbirth

31:59

itself, but extended to the long period

32:01

of recovery. Like Agnes Read's

32:03

letter about her second pregnancy, I

32:07

confess I had dreaded it with a dread that every

32:09

mother must feel in repeating the experience

32:11

of child bearing. I could only think

32:13

that another birth would mean another pitiful

32:15

struggle of days duration followed

32:18

by months of weakness as it had been

32:20

before. Yeah.

32:23

Yeah, And when comparing historical

32:25

and modern experiences of childbirth, we

32:28

use data, right, Like we're talking about what about

32:31

the data? And our data are limited

32:33

to things like maternal mortality or complicated

32:35

births. They're not that great anyway, and

32:38

we can look at I think it's interesting

32:40

to look at Martha Ballard's eight hundred

32:42

and fourteen deliveries from seventeen

32:45

eighty five to eighteen twelve, so

32:48

five maternal deaths, none during delivery,

32:50

all during two weeks after birth. And that's

32:52

today compared to zero point two

32:55

two per every one thousand, so five

32:57

per one thousand, two point two two. Okay, yeah,

33:00

Martha recorded twenty neonatal deaths.

33:03

That's two point five for every one hundred

33:05

live births, compared today two point

33:07

five to six.

33:09

So that I think also is very often

33:11

left out of the discussion, even when we're

33:13

talking about interventions

33:15

that have reduced maternal mortality.

33:17

I think that it's easy to gloss over how

33:20

much we have improved infant survival

33:22

and reduced still birth and neonatal mortality

33:25

like drastically, not even to mention like

33:27

vaccines and saving life's postpartum and all that.

33:29

Right, right, but during

33:31

childbirth experience itself, yes exactly,

33:34

yeah, yeah, you still birth she

33:36

recorded fourteen. That's one point eight

33:38

for every one hundred today, that's point six

33:41

every one hundred, So yeah, there's a lot

33:43

of I mean, we can use those data to a

33:45

certain degree, but I think also like hearing

33:47

those experiences from the

33:49

women who you know went through this is

33:52

a really fascinating part of it. And

33:56

these data also don't show us what women

33:58

dealt with in other outcomes of pregnancy,

34:01

Like we talked about prolapsed uterus ficials,

34:03

extensive tearing, perinatal mortality,

34:05

and the emotional experience of that late

34:07

pregnancy loss, the range of emotions

34:10

that could accompany having limited

34:12

control over your reproduction. Mary

34:16

Foote described it in the eighteen hundreds

34:18

as a sort of pendulum between

34:20

joy and dread. For

34:23

Hannah Whittall Smith, writing in eighteen

34:25

fifty two, that pendulum swung more

34:27

towards dread. I

34:30

am very unhappy now that trial

34:32

of my womanhood, which to me is so very

34:34

bitter, has come upon me again. When

34:36

my little Ellie is two years old, she

34:38

will have a little brother or sister. And

34:40

this is the end of all my hopes, my

34:43

pleasing anticipations, my returning

34:45

youthful joyousness. Well,

34:47

it is a woman's lot, and I must try to become

34:49

resigned and bear it. In patience and silence

34:52

and not make my home unhappy because I

34:54

am so but oh how hard it is.

34:57

Wow, that's a really heartbreaking

34:59

are Yeah, it's

35:03

it's.

35:05

Yeah, yeah, we have gained

35:07

so much and then now we're losing

35:09

so much again.

35:10

But yeah, I know, yeah, to not because

35:12

like like she said, to not have any control over

35:14

do not have any control, any control over it?

35:16

Right, And it's just like here, it is, it is

35:18

my it is not added life. Yeah.

35:22

So yeah. Even though pregnancy and childbirth were

35:25

much more common historically, that didn't necessarily

35:27

make them more welcome or more looked forward

35:29

to. Just as with today, women's

35:31

experiences were incredibly varied and complex,

35:34

and they created ways to manage their fears,

35:37

whether that was surrounding themselves with familiar

35:39

faces or seeking the latest medical

35:42

advancements or both. The

35:44

choices available to women depended

35:47

on when she lived, where she

35:49

lived, and how much money she had. Early

35:52

in US history, most births were attended

35:54

by midwives, who played a largely non

35:56

interventionist, supportive role. According

35:59

to Levitt, as much as possible, they let

36:01

nature take its course. They examined

36:03

the cervix or encouraged women to walk

36:05

around they lubricated the perenial tissues

36:08

to aid stretching. They delivered the

36:10

child and tied the umbilical cord, and

36:12

sometimes they manually expressed the placenta.

36:15

Historically, at least from my understanding, there wasn't

36:17

a ton of post natal

36:19

care for like mom and baby. She would

36:22

be there for a bit and maybe make another visit, but

36:25

usually the woman had other friends who would

36:27

come and help with like other

36:29

women in her life and that it's exactly yeah,

36:32

And the midwife was typically not alone

36:35

in the like in attendance.

36:37

Often they were like friends and family right as

36:39

well, usually formal friends and family. But

36:42

as the practice of medicine became a formal

36:44

profession, meaning like you had

36:46

to have a certificate, you had to go to show your

36:49

training here at.

36:49

School yep, then they developed residency.

36:52

That's the whole episode something episode

36:54

yep.

36:55

So this active professionalization started

36:58

in the late seventeen hundred early

37:00

eighteen hundreds, maybe even a little bit earlier in the seventeen

37:02

hundreds. Towns. That meant that towns

37:04

and cities had more physicians

37:06

that could be called in during birth, and

37:09

sometimes that call came from the midwife

37:11

who wanted a bit of extra assistance during

37:13

a particularly difficult berth.

37:15

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

37:17

I know, I love love that show.

37:20

I really love that. There are probably seasons I haven't seen

37:22

it, definitely, so yeah, yeah,

37:24

I should watch it. And

37:27

physicians and midwives weren't always in direct

37:29

opposition during this time, and many physicians

37:31

saw the potential for partnership, with

37:34

midwives primarily being the ones

37:36

attending the births and only calling

37:38

in doctors in cases of emergency, and

37:41

these occasions could also lead to tension, though

37:43

if the midwife and doctor disagreed, some

37:46

physicians might defer to a midwife

37:48

with hundreds of berths under her belt, but

37:50

gender and class dynamics ultimately

37:53

put the authority in the hands of the doctor,

37:55

no matter how little experience he had.

37:58

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

38:00

diary. She records a few of these

38:02

clashes, and here's one of them. They

38:05

meaning the parents, They were intimidated

38:07

and called doctor Page, who gave my patient

38:09

twenty drops of laudanum, which put her into

38:12

such a stupor that her pains,

38:14

which were regular and promising in a matter

38:16

stopped till near night when she puked,

38:19

and they returned and she delivered at seven hour

38:21

evening of a son, her firstborn.

38:23

Okay, Aaron, so I told you that I

38:25

read that like fictional Okay,

38:28

that that story is in there, but in like way

38:30

more detail because it's obviously like fictionalized

38:32

version of history.

38:33

It is fascinating to

38:36

hear.

38:36

The actual like diary entry.

38:38

Yes, and then like the like the

38:41

description because this story it's called frozen

38:43

for the book, and it's like they

38:45

go she goes so much into like what she assumes

38:47

that Martha Ballard was thinking during the time and stuff

38:49

like that, which is just so like fun and fascinating.

38:52

Yeah.

38:53

Yeah, but that story isn't in there, so I knew

38:55

that one.

38:55

I want to read that book. I'm very curious because

38:57

like there is her diary entries are

38:59

so so sparse in terms of like rightail,

39:02

that's what she said, very few emotions. There have been

39:05

like a couple times well she'll say like poor poor

39:07

mother because she lost a baby

39:09

or kind of thing. But but yeah, this and

39:12

then I think there's another time she calls out doctor Page

39:14

and she's like, what an unfortunate man or something

39:16

like that. But it's hard to know if she's

39:18

like and who knows is she irritated

39:20

at him or does she actually feel bad because

39:22

he is chosen a profession

39:25

that clearly is not to his skill

39:27

set.

39:28

Yeah, yeah, so interesting.

39:30

Yeah, check out this those books to check

39:32

out those books.

39:34

As doctors became a more regular presence during

39:36

childbirth, so did the doctor's toolkit,

39:39

which probably helped bolster appearance

39:42

of expertise.

39:43

Right.

39:44

If midwives took a largely non interventionist

39:46

approach, nineteenth century doctors

39:48

did the opposite. There was laudanum

39:50

or opium, as Martha mentioned, blood

39:53

letting even in the case of hemorrhage.

39:56

Oh, I still can't get I'm sorry. Yeah,

39:58

but yes, we haven't talked about he are

40:00

blood letting these all these episodes, So.

40:02

I know the humors I didn't. That's the only

40:04

thing that I haven't mentioned is the humors.

40:06

At some point, there was something called tobacco

40:09

infusions I don't know, doesn't

40:11

sound great, surgical separation of pelvic

40:13

bones, which was

40:15

often led to like permanent disability

40:18

yea, And of course forceps.

40:22

By the mid nineteenth century, forceps came

40:24

in all shapes and sizes, and were

40:26

restricted by law to medical professionals,

40:29

like you could not own a pair of forceps

40:31

unless you could prove you were a doctor.

40:33

Wow. Okay.

40:34

One doctor bragged in jama in

40:37

the mid eighteen eighties that I

40:39

hate this quote. Okay quote. I

40:41

take pride in stating that, as far

40:44

as my recollection goes, in no

40:46

case of my own was a woman ever allowed

40:48

to lie in suffering and danger till

40:50

the cervix was completely dilated. Oh

40:53

no, I'm sorry.

40:56

Oh no, yeah, yeah, they would

40:58

like prophylactically use forceps.

41:01

But like before the survices all the way dilated.

41:03

Yes, no, like before the baby

41:05

had even fully entered the berth, that they had the long

41:07

long forceps.

41:08

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

41:10

Yeah, nope, nope, nope, nope, nope.

41:12

Okay, that's not how forceps are used today. I just

41:14

want to put that out there.

41:15

No, no, no, put that over there. We have corrected,

41:17

of course.

41:18

Yeah, are not used in that way today.

41:20

No, Wow, they used to be used.

41:22

Yeah okay.

41:24

So, unsurprisingly, the site of forceps

41:26

was not always a welcome one, and

41:29

so the doctor would just be instructed to like

41:31

he instructed his students to hide them.

41:33

Just wear big gowns so that you can

41:36

hide your tools, because it'll, you

41:38

know, make make the woman nervous.

41:42

If a medical school included training specifically

41:44

on obstetrics, and few actually did

41:47

and the late eighteen hundreds, it mostly

41:49

centered on how to use these tools and

41:51

rarely included hands on supervised

41:53

experience. Awesome, Okay, there,

41:56

So there's one example that I want to share with you.

41:58

I don't want to hear it.

41:58

I hope it's an urban led, but I don't

42:01

know. I would actually believe that it's

42:03

not necessarily that. Okay. Tells the story of

42:05

a newly graduated doctor, official

42:08

doctor in the late eighteen hundreds,

42:10

who examined his first laboring patient,

42:13

only to be horrified at what

42:15

he thought was a tumor blocking the birth

42:17

canal. He figured, Okay,

42:19

no, she's a goner. I just have to wait for

42:21

her to pass, only

42:24

to realize a few minutes later after she gave

42:26

birth that what he thought was a tumor was the baby's

42:28

head.

42:30

Okay, I thought it was going to go a

42:32

different way, and I was getting very nervous.

42:34

Oh no, what did you think I was. I'm not going to say,

42:36

okay, we can we can discuss off camera.

42:40

Okay.

42:41

Yeah. So someone who is a medical

42:43

doctor and didn't know how

42:45

babies were born.

42:46

Well, I mean, I'm that doesn't surprise

42:49

me.

42:49

No, I know. Back in the day, yeah,

42:51

yeah, but sorry,

42:54

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

42:57

I don't know, I wasn't in med school in the age.

43:01

They did have like theaters where

43:03

someone the students could watch someone.

43:05

Can you just imagine the horror of that?

43:07

No.

43:08

Yeah,

43:11

But aside from forceps, the other major

43:13

tool that was employed by nineteenth century physicians

43:16

was anesthesia. First

43:18

ether and then chloroform were introduced

43:21

in the mid eighteen hundreds, and pretty quickly

43:23

they exploded in popularity. And it wasn't

43:25

just like popular with doctors. Everyone

43:27

wanted them, especially after Queen Victoria

43:29

had one of her kids with I

43:31

don't know if it was ether or chloroform, but

43:33

it was like made the news. You know who administered

43:36

it, John Snow as

43:39

John John Snow of Color Effe color

43:41

not disgraced Game of

43:43

Thrones. Yeah yeah, wow yeah,

43:47

And so that that really I think allowed people

43:49

to go, oh, I want that, And she was like,

43:51

this was great.

43:52

Yeah, it again,

43:54

I would highly recommend.

43:55

Yes, okay, yeah, and it's I

43:57

think it's pretty easy to see the appeal if you

44:00

if you look at some of them, I mean, even not based

44:02

on today, but like and like people

44:04

you know you have experienced child grouth, but

44:07

the at the time, you know, in these

44:09

diary entries. In these letters, women described

44:12

their labor pains as travail suffering,

44:14

screams of agony, anguish tortures,

44:16

pains from hell, and from

44:19

the doctor's perspective, popular there

44:21

too, right. It made for a much more compliant patient

44:23

whose arms and legs would usually be strapped

44:25

down to the bed. And yeah,

44:28

this is when the bed often became

44:31

the place instead of like a birthing

44:33

stool, instead of leaning on somebody

44:35

else, instead of doing what feels like

44:38

you want to do, you were physically,

44:40

in some cases strapped down to

44:42

a bed. I'm not going to get

44:45

into twilight sleep here, because

44:47

I had a long section that I was like, this

44:49

deserves its own thing when we talk about, you

44:51

know, anthesia, but twilight

44:54

birth was this thing where you would be given

44:57

like scopolamine and something else

44:59

and often the effect was not or the

45:01

goal was not necessarily to believe pain, but

45:04

it was to make you forget and

45:07

it could induce a lot of anxiety

45:10

and delusions, and so they

45:12

would be physically strapped down. And then

45:14

this idea was that you would wake up with

45:16

a baby in your arms.

45:17

Alah Madmen Allah.

45:18

Madmen and Betty Yeah yep.

45:22

By nineteen hundred, ether or chloroform

45:24

was used in fifty percent of births

45:27

attended by a physician. Wow, ether

45:30

or chloroform. And we got better

45:32

lead around in terms of like the safety because

45:34

a lot of doctors did have concerns about the safety of

45:36

like general anesthesia and these in particular,

45:40

and the demand for anesthesia during

45:42

childbirth actually helped to speed up the move

45:44

from home birth to hospital

45:47

because the equipment necessary to administer

45:49

these drugs would be hard to haul around from

45:51

like house to house. The introduction

45:54

of both anesthesia and other medical

45:56

tools changed expectations

45:59

for childbirth in the late nineteenth century.

46:02

It can be done quickly, safely.

46:03

And with no pain.

46:04

That was what childbirth had become, right

46:07

like, this is what medicine promised. This is an option,

46:10

and of course that was not always the reality, Nor

46:12

was it the reality for those who couldn't

46:14

afford to pay for a physician, or

46:16

who felt it was taboo to have a man present

46:19

during labor and delivery. Doctors

46:21

charged more for midwives, so, for instance,

46:24

Martha Ballard charged two dollars

46:26

for her assistance during labor and delivery

46:28

and her contemporary doctor Page charged

46:31

six dollars. Yeah,

46:33

this could be a lucrative job for physicians,

46:35

and as more doctors incorporated childbirth

46:37

into their practice, they increasingly saw

46:40

midwives as competition for

46:42

patients rather than collaborators.

46:45

And instead of this high price discouraging

46:47

people from hiring doctors, it played

46:49

into the psychological phenomenon familiar

46:51

to many of us. All of us were

46:54

higher price is equated with higher quality.

46:56

Yeah, yeah, and that is completely understandable,

46:59

right. Who wouldn't pay whatever

47:01

they could if it meant the best care

47:03

possible for mom and baby? The issue

47:07

was whether it was actually the best care.

47:10

In the last few decades of the eighteen hundreds,

47:12

childbirth became increasingly medicalized.

47:15

Physicians now attended nearly half of

47:17

all births and tried their hands at various

47:20

interventions, none of which had been

47:22

adequately examined. For safety or

47:24

efficacy, and while women

47:26

still held the power in home childbirth,

47:29

doctors were growing more resentful of that conversation

47:33

should be prohibited. Nothing is more

47:35

common than for the patient's friends to object to

47:37

blood letting urging as a reason that she

47:39

has lost blood enough of this, They are

47:41

in no respect suitable judges. Oh gosh

47:44

right, Her friends are probably

47:46

like she is, like,

47:49

she has been drained, stoppedop.

47:51

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

47:54

Yeah, you didn't go to Harvard.

47:55

Medical schools

48:00

were also blamed for high rates of pupil

48:02

fever and sepsis, despite adence

48:04

that it was in fact doctors who

48:06

were more much more responsible for

48:08

the infections due to their proclivity

48:11

to just go from cadaver dissection

48:14

to the labor and delivery room in hospitals.

48:17

Listened to our pupil fever episode. There's so much

48:19

more on that, And

48:21

in fact, maternal mortality

48:23

in the US was on the decline by

48:26

the end of the nineteenth century, but it plateaued

48:28

for a while until the late nineteen thirties,

48:31

which was after most births

48:33

were happening in hospitals. Interesting,

48:36

okay, and that's probably because of all

48:38

of the adjustment we'll

48:40

call charitably call it adjustment for transition

48:43

to the hospital where people were still trying to

48:45

figure things out.

48:46

Well and still studying and learning things because they hadn't

48:48

done that, right.

48:49

Yep, it's all yeah, yeah,

48:52

the field of gynecology being

48:54

built on the backs of people who probably

48:57

did not consent in a way that was meaningful.

49:00

Oh yeah, yeah, Medical

49:02

Bondage. For more on that, Medical Bondage.

49:05

Yes, yeah, that's such a great book. The

49:07

US seemed an especially deadly place

49:09

to have a baby. In nineteen ten, one

49:12

mother died for every one hundred and fifty four

49:14

live births.

49:16

Wow.

49:16

Compare that to Sweden at the same time,

49:18

where the number was one in every four hundred

49:21

and thirty.

49:21

Okay, yeah wow.

49:23

In the early nineteen hundreds, US states introduced

49:26

laws banning midwiffery, and

49:28

all midwiffrey became illegal in nineteen

49:30

fifty nine under a law that redefined

49:32

midwiffery as the practice of medicine.

49:36

Interesting, eron, I did not know

49:38

that.

49:39

Yeah, And I'm not saying that we

49:41

should have like there's like, I'm not advocating for a

49:43

blanket defense of midwiffery.

49:45

At the time, because undoubtedly

49:48

they were unnecessary injuries or

49:50

infections and deaths at the hands

49:52

of midwives, just as there were for doctors.

49:55

But those early bands did not provide

49:57

any pathways for training or certification

50:00

for midwives, and so then that

50:02

disproportionately impacted poor women

50:04

who couldn't afford a doctor or who were

50:06

then forced to go to a hospital,

50:09

which were deadly at

50:11

the time.

50:12

And this is like at the time when becoming

50:15

a physician, and like the process of that is

50:17

becoming very well regulated. Oh even

50:19

before then, yes, and then there's no pathway

50:22

to become a like certified licensed

50:24

midwife the way that we have today with like a registered

50:26

nurse midwife kind of thing.

50:28

And so other countries did have that pathway

50:30

for midwise in the US we did

50:32

not get it, okay, And so then this eliminated an

50:35

entire career path that women

50:37

had. So then what what do you do?

50:39

Interesting?

50:40

Okay, this process

50:44

devalued the contribution of midwives

50:46

and the importance of human

50:49

presence as an essential part of care,

50:52

like familiar human presence,

50:54

not just like a nurse

50:56

or a doctor popping in every hour

50:59

thirty minutes something like that. This

51:01

also furthered the notion of

51:03

pregnancy and childbirth as pathologies.

51:07

The father of modern obstetrics, Joseph

51:09

D. Lee. Does his name sound familiar to at

51:12

all? I don't think I've ever talked about him, Yeah,

51:14

okay, I didn't know if like in med school or something.

51:16

Okay, he wrote in nineteen

51:18

twenty. So

51:21

frequent are these bad effects that

51:23

I often wonder whether nature did not deliberately

51:26

intend women to be used up in

51:28

the process of reproduction in a manner

51:30

analogous to that of salmon, which dies

51:32

after spawning. Oh

51:35

my god, we're

51:38

just fish. That's also also male

51:41

salmon die too. Come

51:44

on.

51:44

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

51:46

Like clearly you don't understand evolution for that

51:48

to make so, because salmon spawned like bajillions

51:51

of fish. Listen, and we're reproducing

51:53

one offspring at a time, who's going to require

51:55

intensive care thereafter?

51:57

Like?

51:57

Come on.

51:57

He's the father of modern obstetric case and

52:00

not the modern synthesis and evolutionary

52:06

Okay, I'm for his part because there's

52:08

nuance to every most people. He

52:11

was aware of the dangers that hospitals posed

52:13

in terms of infections, and he was a big advocate

52:15

for home birth or like birthing centers

52:17

and keeping and like creating new

52:20

different types of maternity wards where

52:22

it would be separate from the rest of the hospital and you had

52:24

different kind of care. Interesting, Okay, okay,

52:27

right, still, thanks for Salmon. But

52:31

pathologizing childbirth was a way

52:33

to send home the message that midwives

52:35

were not qualified. Right, this is

52:37

a dangerous state, and you need someone

52:40

who is has been trained in this

52:42

way and has this you know, diploma

52:46

from this university, right, yea. And

52:49

the way that society saw women

52:52

during this time, especially middle

52:54

and upper class white women, as fragile

52:57

and over civilized in need

52:59

of protection this birth

53:02

exactly, exactly, And

53:05

so all of these factors drove childbirth

53:07

from the home to the hospital. Midwiffrey

53:10

discredited and banned the pathologization

53:12

of childbirth, the growth of hospitals,

53:15

women themselves choosing hospitals

53:17

and physicians. As Levitt writes,

53:19

women who opted for hospital childbirth

53:22

quote gave up some kinds

53:24

of control for others because,

53:26

on balance, the new benefits seemed

53:29

more important. Okay, yeah, yeah,

53:31

that's completely understandable.

53:32

Yeah.

53:33

One woman wrote to her mother in nineteen eighteen,

53:36

I have placed myself in the hands of a specialist

53:38

in obstetrics. I have every confidence

53:41

in him, and it is a great relief.

53:44

Another described her hospital stay as

53:46

a quote unquote lovely vacation, but

53:51

some women felt the loss of familiar

53:53

faces keenly quote.

53:56

The cruelest part of hospital childbirth

53:58

is being alone among strangers.

54:00

Another called it a nightmare of impersonality.

54:04

Another quote months

54:06

later, I would scream out loud and wake up

54:09

remembering that lonely labor room

54:11

and just feeling no one cared what happened

54:13

to me. No one kind reassuring

54:16

word was spoken by nurse or doctor.

54:18

I was treated as if I was an inanimate

54:20

object.

54:21

Oh my god, Yeah, awful.

54:24

Awful, truly like dehumanizing.

54:26

You are just a machine to make babies,

54:28

so no one cares about your mental well being. We

54:31

know best. This period

54:34

from the nineteen thirties to the nineteen sixties

54:36

is marked by tremendous gains and our

54:38

understanding of the physiology of childbirth,

54:41

which is clear from the drastic drop

54:43

in maternal and neonatal mortality during

54:45

this time. But along

54:47

with those gains came losses,

54:50

the loss of control and choice

54:52

that women had in previous centuries, the

54:54

loss of friends and family in the birthing

54:57

room and the loss of a voice.

55:00

This was just how it was. Deal with it. This

55:02

is what you get. And

55:05

it took women years

55:07

to reckon with those losses and to put

55:10

words to them. And of course not

55:12

everyone felt those losses to the same degree.

55:14

Right, Some women didn't think twice about their hospital

55:16

experience. It was a lovely vacation. Others

55:19

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

55:21

and it was like, yeah, okay, that was.

55:24

Sure, was what it was, and now it's done right exactly.

55:26

And then some were completely traumatized and

55:28

everything in between. Yeah, as

55:30

we've said a million times, there is no universal

55:33

childbirth, pregnancy, postpartum experience.

55:36

In the nineteen sixties and the nineteen seventies,

55:38

those who did feel the losses began to

55:41

fight against them. To reclaim

55:43

a voice in the birthing room. They

55:45

demanded that their partners be allowed in that

55:47

they could breastfeed on their own schedule

55:49

rather than the hospital mandated one.

55:52

Oh that is really really

55:54

interesting. Yeah, and they would be like, oh

55:56

no, not here two hours.

55:58

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

56:01

and so your baby was taken away and put in a nursery,

56:03

which is like the opposite of what we do now, which

56:05

also people have opinions about because then it means a mother

56:07

doesn't get any rest.

56:08

Oh my god, there's so much I don't.

56:09

Know, right, I mean, we have this

56:12

is like jumping ahead a little bit. But the

56:15

history of this, this whole

56:17

series, yeah, just shows us that,

56:19

like we don't have everything figured out. And

56:21

that's I mean, that's okay. It is things are

56:23

really overall good, yeah,

56:26

and which people are talking about

56:28

them, are researching them, are writing about them,

56:30

are sharing their experiences. I think

56:32

it just gives such

56:35

hope that things will continue

56:37

to improve. But it is really also

56:40

that is not to erase the experience of people

56:42

who are like I did not have

56:44

a good.

56:44

Time, right, yeah, right, And I think I

56:46

think it is just so interesting to do what

56:49

you're doing right now, Aaron, which is like look back

56:51

at like how did it used to be, How

56:53

did people feel about that at the time, How

56:55

did we get from there to here? Why did

56:58

the pendulum swing this way? Where are we

57:00

in this pendulum arc right now?

57:03

It's so interesting to go back and try

57:05

and kind of piece it together on like, because

57:08

it gives you so much context that sometimes might make

57:10

something that feels horrible today

57:12

make more sense and then make it

57:15

more like you you can, Okay,

57:17

I understand why this thing happened, right,

57:20

I think that's so important.

57:21

Why why are we here today?

57:23

Why are we here today?

57:24

Yeah?

57:28

Did not mean to get that existential, although I'm

57:30

surprised, given that this is a series on pregnancy

57:32

that we haven't gotten that existential for

57:36

that. Yeah, putting it all on the

57:38

table, all on the table. But yeah,

57:40

all of these, all of these new

57:42

choices or choices that previously

57:44

had not been available, things like having your

57:46

your partner in the room, right, breastfeeding whenever

57:48

you want, do I want an epidural or not?

57:51

And so many other choices that simply

57:53

probably were not available. Right, And we

57:56

are now, I think, coming to terms

57:58

with some of these, like the voices and

58:00

the range of choices. And

58:03

I will say too that that is a double edged

58:05

sword.

58:05

Right.

58:06

Since the nineteen seventies, women, along

58:08

with researchers, doctors, nurses, midwives,

58:11

dulas, partners, parents, have examined

58:14

the childbirth experience from every angle,

58:17

asking what do I want what's

58:19

best for me, what's safest for baby?

58:22

How do we balance everyone's needs?

58:25

And today there are so many

58:27

choices, there are so many options, and

58:29

there are so much information out there that

58:31

it can feel overwhelming. How

58:34

do you make the right choice, especially when the internet

58:36

has very strong opinions about

58:38

everything. What happens

58:41

when you are not able to

58:43

choose or if the choice is made

58:45

for you. Navigating

58:47

pregnancy, childbirth, and the

58:49

fourth trimester is a huge

58:52

challenge, which is the understatement of

58:54

this series.

58:55

I'm getting like so many flashbacks right

58:58

now.

58:58

It's a lot from you.

59:00

Yeah, yeah, yeah, yeah, yeah,

59:03

keep going home?

59:04

Is this the right strugg the right choice?

59:07

Is that the right choice?

59:08

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

59:10

this happens?

59:10

Yes? And what if there's a choice

59:12

that like, did I have a choice? I'm not sure?

59:15

Yeah that yeah?

59:17

And there are a million voices telling

59:20

you yes, no, maybe

59:22

in conflict, maybe not in conflict? Do this

59:24

do that that we have more

59:26

choices and more knowledge today than we did

59:29

sixty or one hundred years ago is a

59:31

powerful testament to the work of

59:33

countless women and modern

59:36

medicine striving to make this a

59:38

safer and better experience, and

59:40

of course there's still room for improvement. There

59:42

will always be room for improvement.

59:45

But understanding our past, understanding

59:48

what we lost during the medicalization of pregnancy,

59:50

as well as just how much we've gained, is

59:53

crucial for creating a better future. Recognizing

59:56

those gains is especially important

59:59

because I think sometimes we take them for granted,

1:00:01

yes, or we lose sight of them. Next to

1:00:03

the negative impacts of medicalization, that

1:00:05

is what stands out the most to us.

1:00:07

Yeah.

1:00:08

For instance, take postpartum depression and

1:00:10

other postpartum perinatal mood disorders

1:00:13

from pupil insanity in the late nineteenth

1:00:16

century, which is what it was called, well, which is

1:00:18

what it was a diagnosis, so it's not

1:00:20

necessarily there's more. There's more

1:00:22

nuance to pupil insanity, yes,

1:00:24

yea, to what was called

1:00:26

baby blues post World War two, to

1:00:29

postpartum depression finally making

1:00:31

it into the DSM four in nineteen

1:00:33

ninety four. Nineteen ninety four, I

1:00:36

told my mom that she was like, really

1:00:39

wait, oh, and it's not even I know.

1:00:41

And then in there there's like a whole journey

1:00:43

about how it got in there, and it was it actually

1:00:46

put place in there in an appropriate way.

1:00:48

And what we don't have in there today.

1:00:49

They don't have in there today. And

1:00:52

then also like there's the

1:00:54

book Blue is really fascinating too because

1:00:56

it talks about how postpartum

1:00:58

depression became like aiined more awareness

1:01:01

and it was through the work of a lot of people

1:01:04

advocates who worked really strongly to

1:01:06

make people more aware of this potential

1:01:08

outcome. But the way

1:01:10

that popular media often seized

1:01:13

on postpartum depression was through

1:01:15

the most sensationalist news stories

1:01:17

possible. And so then that was like

1:01:20

I think in some ways had this effect

1:01:22

of oh, well I didn't

1:01:24

I don't think I had postprime depression because it

1:01:26

was you know, exactly,

1:01:28

wasn't that bad? So the extreme scenarios

1:01:30

right, right, And I think that we have now like

1:01:33

there's been such incredible representation

1:01:35

in the media, and it's still again room

1:01:38

for improvement. But

1:01:41

yeah, I mean, I think it's safe to say that since

1:01:44

the late eighteen hundred's postpartum

1:01:47

depression post part of mental health has really

1:01:49

been on a journey and ultimately

1:01:51

creating a clinical definition for PPD

1:01:54

imperfect, though it may be, it opened up

1:01:56

research areas for treatment. It raised

1:01:58

awareness and established ways

1:02:01

to treat people or reach people

1:02:03

who might need help, and it removed

1:02:05

some of the blame that had been so central

1:02:08

to postparti mental health for decades. Oh,

1:02:11

she's depressed because she hasn't accepted her

1:02:13

role as a mother, thanks Freud. She's

1:02:16

got PPD because she had a C section.

1:02:19

Working moms bring on PPD themselves

1:02:21

because they're just not equipped. Yeah.

1:02:25

Yeah, blame certainly

1:02:28

remains. It is not gone by

1:02:30

any means. But turning

1:02:33

this into a more having a more

1:02:35

biological framework for understanding

1:02:37

this has helped to remove some of

1:02:40

that to some degree. And

1:02:42

there is, of course downside to this medicalization,

1:02:45

right it has discouraged to some degree

1:02:48

consideration of systemic and societal

1:02:50

drivers that might underlie PPD that

1:02:52

I know you're going to talk about, sure, am By,

1:02:55

because if you're treating it just as a hormonal

1:02:57

or chemical imbalance, and it's like so,

1:02:59

but it's not happening in a vacuum.

1:03:01

Oh my god, Aaron, I literally can't believe

1:03:03

how well this is like segueing in.

1:03:05

To what I'm going to talk about, Like

1:03:07

we do this, it's like it's our job.

1:03:11

But yes, yes, And

1:03:14

it creates boundaries around

1:03:16

what is normal, right, And those

1:03:19

boundaries might be different for different people,

1:03:21

But it's really hard to incorporate

1:03:24

that into a medical definition,

1:03:26

right. And I will say also those boundaries

1:03:28

are a necessary part of any medical

1:03:31

definition. But having

1:03:33

that lack of nuance in understanding

1:03:35

the individual can also be really have consequences

1:03:38

associated with it. Yeah, personalization

1:03:41

of care is a crucial aspect,

1:03:43

not just for PPD, but also for childbirth

1:03:46

and pregnancy more broadly. And

1:03:48

I want to end with yet another quote

1:03:50

by Judith Walser Levitt. I really loved this book.

1:03:52

As you can tell quote, throughout

1:03:55

American history, women have wanted

1:03:57

and have worked to achieve their own deals

1:04:00

of childbirth, ideals that have

1:04:02

developed and been nurtured within their own

1:04:04

communities in conjunction with the rest

1:04:06

of their life experiences. Childbirth

1:04:09

remains as it has always been a

1:04:11

cultural event as much as a biological

1:04:14

one. Problems emerged during

1:04:16

the middle of the twentieth century because the hospital

1:04:18

acted to homogenize the birth experience

1:04:21

and make it similar for all women. But

1:04:24

childbirth cannot successfully be reduced

1:04:26

to one kind of experience, and at the

1:04:28

same time, satisfy the wide range

1:04:30

of expectations women bring to it. The

1:04:33

diversity that women seek will continue

1:04:35

to reflect the differences of the women themselves.

1:04:38

End quote and chills

1:04:43

and with that, err and oh turn

1:04:45

it over me right there. Tell

1:04:48

me about the fourth trimester.

1:04:49

Okay, you might need a little

1:04:51

breather after that.

1:04:53

Okay, we can do that.

1:04:54

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

1:04:56

Sho, let's do it.

1:05:11

At thirty two years old, I got pregnant

1:05:13

for the first time. I had what you'd call a textbook

1:05:15

pregnancy, healthy baby, low risk, and a

1:05:17

noticeabook low.

1:05:19

But there was a lot of.

1:05:19

Things that I wasn't warned about, and things that

1:05:22

just weren't talked about unless I brought them up harmy

1:05:25

and I started trying for a baby in September, and luckily

1:05:27

enough, by November, I was pregnant. My

1:05:29

first symptom wasn't warning sickness or anything like

1:05:31

that. In fact, it was excruciating

1:05:34

period pain. I genuinely thought I

1:05:36

was about to have the worst period ever, as some kind

1:05:38

of cruel joke. Turns out, it was implantation.

1:05:41

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

1:05:44

labor within two weeks of

1:05:46

conception, my body already started changing.

1:05:48

My boobs went from an age with seacup almost a night

1:05:50

overnight, and they continued to grow throughout my pregnancy

1:05:53

and got pretty big during breastfeeding.

1:05:55

My stomach also grew quickly. I

1:05:58

was mostly water because the baby

1:06:00

boy was measuring perfect the entire time. I

1:06:03

was very lucky when it came to nausea. I only experienced

1:06:05

it for about a week and cardamin tea helped a lot.

1:06:08

I only vomited twice, once from a bad

1:06:10

meal which my husband also got sick from, and once when

1:06:12

I accidentally ate bacon. Because pork

1:06:14

was a major food version for me, which is

1:06:16

kind of surprising giving my Italian Australian

1:06:18

background. Thankfully, since my

1:06:20

husband is Muslim, pork wasn't something I had to deal with in

1:06:22

the house. The cravings did start

1:06:25

really early at first, to as salt, venigo, chips,

1:06:27

and anything sour, especially lemon ice cream.

1:06:29

In a second trimester, I craved corn and coffee.

1:06:32

Of course, I only ate drank decaf, but I never drank

1:06:34

coffee before pregnancy. Funnily enough, I'm still

1:06:36

drinking it now after giving birth. By

1:06:39

the third trimester, my cravings had evolved to steak

1:06:41

with an egg on top. On the flip

1:06:43

side, I couldn't stand chicken or pork. Even

1:06:45

the smell of chicken maybe nauseous, to

1:06:47

the point that if my husband ate it, he had to brush

1:06:49

his teeth before coming miming. Pregnancy

1:06:52

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

1:06:54

prepared for. Blood noses, gray

1:06:57

hairs, loose ligaments, ligament pain triggered

1:06:59

by sneezing, dry skin, exhaustion

1:07:01

that left me sleeping for ten hours at night and then

1:07:03

still napping for four hours during the day, acid

1:07:06

reflux, and reoccurring thrush, which

1:07:08

I had never experienced before pregnancy.

1:07:11

The physical strain was pretty intense. At

1:07:13

times, it felt like I'd done a hardcore leg

1:07:15

day at the gym, or I'd been riding a horse

1:07:17

bearback for hours. I had to give up

1:07:19

weightlifting and running because I was just too exhausted.

1:07:22

But I did manage to do a little bit of yoga a couple

1:07:24

of times a week, and maybe that's why I could still time

1:07:26

my own shoes at nine months pregnant.

1:07:28

Who knows.

1:07:29

In my third trimester, I needed an iron infusion.

1:07:31

My iron levels were actually fine, but my hemoglobins

1:07:34

were slightly load, so it was recommended that I do

1:07:36

it. Around this time, baby boy started

1:07:38

moving into position and I could feel every

1:07:40

shift. There was a moment when I

1:07:42

genuinely thought that he might just fall out because

1:07:44

of how low he moved. Despite

1:07:47

all the unexpected symptoms, I got the birth experience

1:07:49

that I wanted. I had a pain relief water

1:07:51

berth, and in the final moments, I reached down and

1:07:53

pulled my baby at myself. It was an intense

1:07:55

and transformative experience

1:07:58

and one that I'm really grateful for. Looking

1:08:00

back, I know I was lucky to have such a smooth pregnancy,

1:08:03

but that doesn't mean it was easy.

1:08:06

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

1:08:08

of discomfort. Through it all,

1:08:10

my body did exactly what I needed to do, and

1:08:12

I'm so grateful for

1:08:15

my body for doing that and for giving me my beautiful,

1:08:17

healthy baby boy.

1:08:20

Hi, Aaron's. My name is Miranda,

1:08:22

and I want to thank you for allowing me to

1:08:24

share my pregnancy and birth journey.

1:08:27

I have to say that overall, my pregnancy journey

1:08:30

was relatively uneventful and

1:08:32

I'm very thankful for that for the health

1:08:34

of myself and of my baby boy, who

1:08:37

is now eighteen months old. I

1:08:39

will say the most annoying

1:08:43

and most prominent pregnancy

1:08:45

symptom I had was actually carpal

1:08:47

tunnel syndrome, which going

1:08:49

into pregnancy I had no idea

1:08:52

that that was a common symptom. I

1:08:54

spent probably the second half of my pregnancy

1:08:56

with my hands being numb

1:08:59

or tingling, or painful, almost

1:09:02

twenty four to seven, so that was definitely frustrating.

1:09:05

Other than that, towards the end of my pregnancy, I

1:09:07

started to have some gestational

1:09:10

hypertension, so we did a

1:09:12

few non stress tests in biophysical

1:09:15

profiles to make sure that I

1:09:17

was safe and that my little guy was safe. On

1:09:20

the fourth of July, maybe I had a little

1:09:22

too much fun on the lake and enjoyed

1:09:24

some salty snacks, but my blood

1:09:26

pressure did go pretty high, so they ended up deciding

1:09:29

to induce me when I was due in mid

1:09:31

July, so it was not too early. I

1:09:33

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

1:09:36

Thankfully, I started

1:09:38

labor pretty darn quickly without

1:09:40

even having any potocin. Unfortunately,

1:09:43

I did not progress

1:09:46

in labor as we'd hoped. I

1:09:48

was in labor for eighteen hours and I

1:09:50

was dilated to nine and a half centimeters

1:09:53

and I was stalled out. So after

1:09:55

about six hours stalled out, my

1:09:57

son's heart rate started dropping, and

1:10:01

my doctor advised us that we

1:10:03

could wait a little bit longer and

1:10:05

potentially have to have an emergency sea section,

1:10:08

or we could just do a sea section now,

1:10:11

And after eighteen hours of labor, I

1:10:13

was on board with that. We had

1:10:15

a beautiful and wonderful sea section experience,

1:10:18

and I'm so thankful for all of the staff

1:10:20

and my husband and my mom for being there to

1:10:22

support me. I

1:10:25

was very surprised by the swelling after

1:10:27

the sea section. I couldn't wear shoes

1:10:29

for two to three days, But

1:10:32

other than that, my little

1:10:34

guy was happy and healthy and

1:10:36

I had an overall great experience.

1:10:39

Thank you.

1:11:05

So last week, at the end

1:11:08

of episode three, I ended where

1:11:11

most conversations regarding pregnancy

1:11:14

end, and that is once.

1:11:15

The baby's delivered, right, everything's over. Yeah,

1:11:18

But that's not where pregnancy ends.

1:11:21

At all.

1:11:23

So Aarin, you just walked us through a

1:11:25

lot of the kind of social and

1:11:27

institutional, high

1:11:30

level factors that have

1:11:32

caused this shift in

1:11:35

where delivery happens,

1:11:37

and how these things have kind of contributed

1:11:39

to a lot of the big picture postpartum

1:11:42

outcomes. Those big picture things

1:11:44

are like maternal mortality rates, even

1:11:47

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

1:11:50

And so that is where I'm I'm kind of picking

1:11:52

up your threads right there, perfect, but

1:11:55

then I'm gonna unravel them a little bit more

1:11:57

to also remind us

1:12:00

of what is going on biologically

1:12:03

in this so called fourth trimester,

1:12:06

why it might be rocky for

1:12:09

some of us. And my

1:12:11

favorite, what do we know about

1:12:14

evidence based ways to improve

1:12:17

outcomes?

1:12:19

Evidence based? What a beautiful phrase.

1:12:21

Oh, I just love it.

1:12:22

You want a spoiler alert on what it is we

1:12:25

don't know public health?

1:12:26

Oh, okay, don't worry. We know

1:12:29

we don't know.

1:12:30

No, we do know health.

1:12:31

But then, yeah, do we invest

1:12:33

in public health?

1:12:34

Maybe we will.

1:12:35

Someone will listen to this episode and be like,

1:12:37

aha, I didn't want to read the Lancet

1:12:40

Global Health article, but I listened to this podcast will

1:12:42

kill you, and.

1:12:42

Now I have all the answers.

1:12:43

Okay, I do also want

1:12:45

to quickly acknowledge what I Am not going to

1:12:47

talk about in this episode, even though

1:12:49

it's so cool, And

1:12:51

that is the physiology of the newborn.

1:12:54

Just like I kind of breezed through early

1:12:57

embryonic development and I didn't talk

1:12:59

at all about the rest of fetal development.

1:13:01

I am not going to talk about the physiology of the

1:13:03

newborn, but it is really cool and fascinating.

1:13:05

We'll do it someday. Second fourth trimester

1:13:08

exactly.

1:13:08

Yeah, yeah, but this is pregnancy,

1:13:11

and so this is the fourth trimester of pregnancy.

1:13:13

Yeah, pregnant person, Yes, Okay.

1:13:16

Physiologically, there is still a

1:13:19

lot of changes to take place after

1:13:21

the baby and placenta have been delivered. Now,

1:13:24

the placenta, our favorite,

1:13:27

is the primary organ that was

1:13:29

making all of the hormones that kept the

1:13:31

pregnancy going. So once

1:13:33

that placenta has been delivered, you

1:13:35

have a rapid withdrawal of placental

1:13:38

hormones, and that results in significant

1:13:41

decreases because the placental hormones are

1:13:43

like there's a whole bunch of different things, and

1:13:45

a lot of them. It's not necessarily just

1:13:47

like estrogen and progesterone alone, but it's

1:13:49

like hormones that are telling us to make more

1:13:51

estrogen and progesterone and stuff.

1:13:53

It's it's like both a radio

1:13:55

tower. It's not just like a trans Okay,

1:13:58

here's what I was thinking. Love

1:14:00

is blind. It's not just the

1:14:02

window between the two,

1:14:06

right, It's like if the window we're also saying

1:14:08

now go get flat. Also

1:14:10

the producers, Yes, the producers. Analogy

1:14:18

does not need to exist, but I like it. Love

1:14:20

a bad analogy. Yes,

1:14:23

Okay, it's that. Okay, it is

1:14:26

the producer, the director, whatever.

1:14:29

But so once this.

1:14:30

Placenta is gone, you have a

1:14:32

significant and pretty rapid,

1:14:34

like in a number of days weeks decline

1:14:36

in estrogen and progesterone especially,

1:14:39

And this cascade is

1:14:42

what results in a lot of the

1:14:44

physiologic changes that we see. So

1:14:47

I'm going to kind of walk through again a little bit system

1:14:49

by system about what some of these changes are.

1:14:52

Most of these changes kind

1:14:55

of get you back to and I

1:14:57

hate to say back to because it's.

1:14:59

Really a new normal.

1:15:01

Okay, But in terms of your physiology, a lot

1:15:03

of it is closer to pre pregnancy

1:15:05

levels of the stuff that we're

1:15:07

going to talk about by about six weeks.

1:15:10

Some of it takes about twelve weeks.

1:15:12

So can I ask a question about, like, what

1:15:15

how different are those changes?

1:15:17

Like is there just a way, so I can in my

1:15:19

head quantify what

1:15:22

that looks like. And I guess it's hard

1:15:24

to know, like how much estrogen is actually.

1:15:26

Yeah, those numbers, Yeah, I don't

1:15:29

know. I think one of the graphs that I had

1:15:31

in last episode showed like hormone

1:15:33

concentrations and stuff like that, But there's also

1:15:36

such ranges. And especially like

1:15:38

anyone who is menstruating, your

1:15:41

levels fluctuate so much with your menstrual

1:15:43

cycle. I will say that after

1:15:45

like in postpardum, you have

1:15:47

a withdrawal of these hormones, so they go down to

1:15:49

very low levels, and if you

1:15:51

are breastfeeding, they remain

1:15:54

suppressed because of prolactin.

1:15:56

That's being so like the withdrawal of progesterone,

1:15:59

skipping around to my notes, the withdrawal

1:16:01

of progesterone causes an increase in prolactin,

1:16:04

which is the hormone that stimulates milk production.

1:16:07

So if you are then breastfeeding, you

1:16:09

continue to have high levels of prolactin,

1:16:12

and that suppresses the release

1:16:15

of LH which is lutinizing

1:16:17

hormone, and FSH which is follicle stimulating

1:16:19

hormone, and those are what would induce

1:16:21

a normal ovulatory and menstrual

1:16:24

cycle, and that is why you

1:16:26

see suppression of mensis during breastfeeding,

1:16:28

and why that is for a lot of

1:16:30

people a good form of contraception.

1:16:33

But doesn't always it

1:16:35

doesn't.

1:16:35

But okay, in no way. But I mean it is like it's

1:16:37

more effective than condoms.

1:16:39

Okay, that's interesting.

1:16:40

It does not get I had a whole paragraph on

1:16:42

this somewhere, but I can't even find it, so I'm gonna just talk

1:16:44

to you from my brain. Yeah, it is, I

1:16:47

forget the exact number, but it is actually quite effective.

1:16:49

But it's only for the first six months

1:16:52

postpartum that we have good data on it, and it's only

1:16:54

when people are exclusively breastfeeding,

1:16:56

which does not include pumping, because

1:16:58

it is also breastfeeding on demand, which

1:17:00

means that you are breastfeeding based on your newborn's

1:17:03

cues and not necessarily on an

1:17:05

hourly schedule, which is what you end up having to do if

1:17:07

you're exclusively pumping. Not everybody

1:17:10

is going to remain a menner reec which means they're

1:17:12

not having mensis. But it is it as

1:17:14

actually, as per the World Health Organization

1:17:16

guidelines, it is an effective and recommended

1:17:19

form of birth control for a lot of people.

1:17:20

Oh my god, Okay, I didn't know that there's

1:17:22

more nuance because I know a number of

1:17:24

people who have gotten pregnant. Absolutely

1:17:27

absolutely, and.

1:17:28

So there's more nuance too because if you are sort of

1:17:30

supplementing with formula, or if you're having

1:17:32

to be away and then you're pumping and things like that, then

1:17:34

absolutely your mensies can come back earlier

1:17:37

than that six months. They can come back in a

1:17:39

matter of weeks. Again, it's going to be different

1:17:41

person to person. That's why it's not one hundred percent

1:17:43

effective what it means, but

1:17:45

yeah, it is.

1:17:46

This is really interesting. Yeah, how

1:17:48

about that tangent

1:17:51

for us there?

1:17:52

I love a tangent me too.

1:17:53

So, yes, we see this big hormonal change,

1:17:56

and then a lot of those physiologic changes

1:17:58

that happened to sustain the pregnancy

1:18:01

are going to kind of unravel themselves.

1:18:03

So your blood volume, which.

1:18:05

Again had increased by about fifty percent

1:18:08

during pregnancy, is going to return to

1:18:10

pre pregnancy baseline within

1:18:12

a matter of weeks. And what that

1:18:15

means is that you immediately

1:18:18

after birth have way more fluid

1:18:20

on your body than your body thinks

1:18:22

that it needs. Now that there's no placenta there secreting

1:18:24

hormones to say, keep up this blood volume, so

1:18:27

your kidneys have to take over the work

1:18:29

of excreting all that extra fluid, and

1:18:32

so your kidneys have to further increase

1:18:34

their diuresis, and so you have this physiologic

1:18:37

diuresis. So a lot of times you'll you'll

1:18:39

be very kind of puffy immediately

1:18:41

postpartum, and that's because of all

1:18:43

this excess fluid that your kidneys

1:18:45

are now just trying to like shunt out, and then you're peeing

1:18:47

all the time because of that.

1:18:49

And how long does that last?

1:18:50

A few days usually for like the physiologic

1:18:53

diuresis, I think it. I don't remember the exact

1:18:55

days that it peaks, but it's like a few days and then you kind

1:18:57

of go back to your pre pregnancy baseline.

1:18:59

Ish your GI tract,

1:19:02

which remembers slowed down a lot during pregnancy

1:19:04

because of progesterone, It

1:19:06

actually slows down even further during

1:19:09

labor, and it will start to

1:19:11

return to a pre pregnancy

1:19:13

type of functioning, like mobility will come back

1:19:15

within a few days. But in those first

1:19:17

few days immediately postpartum, you

1:19:20

can have that continue like it's a little

1:19:22

bit more slow, and that can result in constipation.

1:19:25

This is exacerbated by c sections

1:19:28

because those are again abdominal surgeries

1:19:30

where it can cause the bowels to kind

1:19:32

of like go to sleep a little bit, and

1:19:35

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

1:19:37

Plus, opioids are often used, and

1:19:40

so those slow down the bowels even more.

1:19:43

So that can make people either very nervous

1:19:45

about their first bowel movement postpartum

1:19:47

because if whether you had a vaginal

1:19:49

delivery or a C section, you might be worried about

1:19:51

a hard stool that might be harder to pass.

1:19:54

So, yes, that's the thing that can happens. Constipation

1:19:56

postpartum usually gets better within a few

1:19:58

days unless you're on opioids

1:20:01

continuously. Okay, Yeah,

1:20:03

Your uterus, which of course had to

1:20:05

grow so large that it displaced all

1:20:08

of the rest of your organs, like

1:20:10

we talked about last episode, has to shrink back

1:20:12

down, and it does this very quickly,

1:20:14

except that it doesn't go all the way back

1:20:17

to pre pregnancy baseline

1:20:19

until a number of weeks later, closer

1:20:21

to like six weeks later, because it

1:20:23

just has to like continue to shrink. Part

1:20:26

of that process also means a

1:20:28

couple things are happening to encourage

1:20:30

that process. One is that

1:20:33

the release of oxytocin, which

1:20:35

is triggered by breastfeeding. So for people

1:20:37

who are breastfeeding, they're going to have an increase

1:20:39

in the release of oxytocin. That oxytocin

1:20:42

is the hormone that stimulates uterine contraction,

1:20:45

so that's going to cause further uterine

1:20:47

shrinkage back down to like the size of a

1:20:49

fist, which is what it is pre pregnancy.

1:20:52

And is that pumping

1:20:55

or.

1:20:56

Pumping or breastfeeding either one. And then

1:20:58

even if you are not breastfeeding, it's still

1:21:00

going to shrink on its own. It just might

1:21:02

maybe take a little bit longer or things like that. But

1:21:05

yeah, so that it's going to take a few weeks before

1:21:07

it really goes back down. It's not like a automatic

1:21:10

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

1:21:12

back takes time.

1:21:13

Yeahs sense.

1:21:15

And as part of all of this, as this uterus

1:21:18

is continuing to shrink and contract, it

1:21:20

also means that you are going to be shedding

1:21:22

all of the remnants of your endometrium.

1:21:25

Regardless of your mode of delivery,

1:21:28

you are going to be shedding this lining of

1:21:30

your uterus, and your uterus is remodeling

1:21:33

its whole inner lining. So you have a

1:21:35

lot of vaginal bleeding. This is called lokia.

1:21:38

That's like just what we call the postpartum

1:21:40

heating l o

1:21:43

chia.

1:21:44

Huh lokia. And how how long

1:21:46

does that last? How much blood?

1:21:48

Like, yeah, so how much blood can vary?

1:21:51

Of course, it usually can last

1:21:53

anywhere from like a couple of weeks to a month

1:21:55

or more, totally person dependent, okay,

1:21:57

Yeah, and.

1:21:58

The amount of like relative to a

1:22:00

regular like if you have more

1:22:02

regular periods.

1:22:04

What is a regular period.

1:22:06

For an individual that

1:22:08

doesn't even that?

1:22:10

No, yeah, it totally varies.

1:22:12

What I will say is what we Okay,

1:22:14

we talked a lot about postpartum hemorrhage last episode.

1:22:17

Yeah, delayed postpartum hemorrhage

1:22:19

is also a thing where you

1:22:21

can have a hemorrhage that occurs later

1:22:24

on after delivery, in the days or

1:22:26

weeks.

1:22:26

Posts or weeks okay.

1:22:27

And so what I will say is like the general advice

1:22:29

in terms of how much is too much bleeding?

1:22:33

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

1:22:35

This is not medical advice. We

1:22:38

are not your doctors. We can hould your doctor.

1:22:41

But usually if somebody is bleeding so

1:22:43

much they're that they're like completely saturating

1:22:46

pads for like hours in a row, or

1:22:48

they're passing very large blood clots,

1:22:50

that is usually considered too much bleeding.

1:22:52

Okay, so it's kind of it should be like a

1:22:54

moderate amount, but not like heavy

1:22:57

heavy bleeding, right, But again can farely

1:22:59

vary. Some people have very little bleeding, okay.

1:23:01

Yeah, And then we

1:23:03

of course have milk production, which we kind of already talked

1:23:05

about, so I can skip it unless

1:23:08

you have any other questions about that.

1:23:10

When does it really like, of

1:23:13

course I have questions about that? Kidding

1:23:15

me.

1:23:15

So the first milk quote

1:23:18

unquote that you produce. All

1:23:20

of this is stimulated by again this withdrawal of

1:23:22

hormones and then the increase of prolactin. But even

1:23:25

as that process, before that process is really

1:23:27

kind of kicked in, in those first couple of days,

1:23:30

your body is producing this substance called

1:23:32

colostrum, and that's that kind of

1:23:34

yellowy like it's a different texture,

1:23:36

it looks different substance. We

1:23:39

actually start making that most people

1:23:41

during about the second trimester. Some people might

1:23:43

notice it, some people might not and

1:23:46

then it takes usually two

1:23:49

or three days on average for your breast milk to

1:23:51

come in okay. In

1:23:53

people who aren't going to be breastfeeding, there

1:23:56

are a lot of situations that can

1:23:58

cause challenges to that, whether it's

1:24:00

delayed milk production. One

1:24:02

of the risk factors for delayed milk production might

1:24:05

be a sea section. The mechanism

1:24:07

there not fully known right, we don't

1:24:09

know, but it is the case that sea

1:24:11

section is associated with an increased risk of

1:24:13

delayed milk production. Also early delivery,

1:24:16

whether that's early term which would be before

1:24:18

thirty seven weeks, or

1:24:20

like late pre term it's like thirty four to

1:24:23

thirty six weeks or so in there, or

1:24:25

even just that like early term thirty seven thirty

1:24:27

eight weeks. Sometimes people have a little bit of a delay

1:24:29

or have like a little bit of a

1:24:31

delayed start in their breast milk production. And then there

1:24:33

is so many individual factors as

1:24:35

well that play in have you ever breastfed before?

1:24:38

Like so many different things. There's

1:24:40

also infant factors that can really

1:24:42

contribute to the successful breastfeeding

1:24:45

relationship. Babies who are born early,

1:24:47

either that early term or preterm, might have

1:24:49

difficulty latching. They might not

1:24:51

have really good muscle tone yet because they

1:24:53

weren't fully developed in utero, and so they

1:24:56

don't have a great suck.

1:24:57

Like.

1:24:57

There's literally so many things, And

1:25:00

I feel very strongly about

1:25:03

the rhetoric around breastfeeding

1:25:05

today. Yeah, I do feel that

1:25:07

it deserves its whole own episode.

1:25:09

We will do one, absolutely, because

1:25:12

there is a lot to unpack there. Yeah,

1:25:15

And the short answer is, in my

1:25:17

opinion and per medical establishment,

1:25:19

regardless of whether they admit it.

1:25:20

Or not, fed is best.

1:25:21

Okay, long story short, two

1:25:24

to three days for breast milk production postpartum.

1:25:26

Usually.

1:25:27

Now, during all of these

1:25:29

physiologic changes that we've gone through, whether

1:25:32

you notice them or not, Like you might not notice your blood

1:25:34

volume changing, but you might notice that you're peeing

1:25:36

a.

1:25:36

Lot sort of a thing.

1:25:37

You also have just given birth,

1:25:40

either vaginally or through a C section, so

1:25:43

you might have stitches either

1:25:45

in your abdomen or in your paraneum

1:25:47

or maybe not. In either case,

1:25:50

you're probably going to be sore. There's

1:25:52

going to be pain that is there

1:25:55

because of the whole process that literally just happened.

1:25:58

And then on top of that, you

1:26:00

have an infant or multiple

1:26:03

who needs literal constant.

1:26:06

Care, constant around the clock,

1:26:09

cannot be.

1:26:10

Left alone for like a minute. Who

1:26:13

sucks at sleeping? They

1:26:15

suck at it?

1:26:16

Why are they so bad at sleeping?

1:26:17

Why are they so bad at sleeping? They

1:26:20

suck at pooping. They're not even good at there.

1:26:22

They suck at eating.

1:26:24

They cannot figure it out, and you

1:26:27

are now entirely responsible for them.

1:26:30

This is a very difficult time

1:26:32

period. Even if you are

1:26:34

good at it, or you've done it before or something like

1:26:36

that, it's very hard. And

1:26:38

we talked in these last

1:26:40

few episodes a lot about the risky parts

1:26:42

of pregnancy, the postpart

1:26:44

and period. Really often, especially

1:26:47

in the US, gets dismissed. Oh

1:26:49

right, Yeah, but all of these physiologic

1:26:51

changes that we've gone through, they don't

1:26:54

reverse themselves automatically, and

1:26:57

they are still kind of change

1:27:00

and finding a brand new baseline in

1:27:02

this postpartum period, which means that we are

1:27:04

still at increased risk of things

1:27:06

like postpartum pre acclampsia yeah

1:27:09

okay, of delayed postpartum hemorrhage

1:27:11

like I talked about. There's also the risk

1:27:13

of infections like endometritis, which

1:27:16

can happen post delivery. So there

1:27:18

is a lot of different

1:27:20

topics that I could go into, but what I'm going

1:27:22

to now shift to focusing on is

1:27:25

one of the biggest contributors to

1:27:27

postpartum morbidity, and that

1:27:29

is postpartum depression and postpartum

1:27:31

anxiety and other postpartum mood disorders.

1:27:35

So postpartum depression,

1:27:37

which is the one that gets probably the most pressed

1:27:39

these days and is the most well defined

1:27:41

because it does exist kind of in the DSM

1:27:44

five. It is generally recognized

1:27:47

as more than two weeks, and sometimes

1:27:49

it's like has to be developed in the first

1:27:51

four weeks of a depressed mood

1:27:56

in the postpartum period, and we use

1:27:58

a number of different screening tools

1:28:00

that are very well validated, like this

1:28:03

questionnaire which is called the Edinburgh

1:28:05

Depression Scale or Edinburgh Postpartum Depression

1:28:07

Scale to decide if

1:28:09

somebody meets criteria or needs

1:28:11

additional evaluation for postpartum depression.

1:28:14

So it's a series of questions and there are

1:28:16

things like how like

1:28:19

in the last two weeks, how

1:28:21

often have you felt like I'm not

1:28:23

looking forward to enjoyment with things,

1:28:26

or how often Some of the ones that I

1:28:28

really hate are like do you feel

1:28:31

like you are worried for no good reason.

1:28:34

This is when I told you I feel like I lie on

1:28:36

these because I'm like, sorry, I am very worried for.

1:28:38

A very good reason.

1:28:41

I am been anxious for no good reason

1:28:43

at all. Right, I've been crying for no reason.

1:28:45

Right to ask someone to say, are

1:28:48

your anxieties justified? Are your worries

1:28:50

justified? Like that's not.

1:28:51

Yeah, but that's just my personal feelings. These are very

1:28:53

well validated tools

1:28:55

for screening, and

1:28:58

so this is the kind of first thing that's recommend that

1:29:00

everybody during pregnancy and postpartum

1:29:02

is supposed to be offered questionnaires like

1:29:05

this to try and identify people who

1:29:07

are perhaps experiencing postpartum

1:29:09

mood disorders or who are at risk of developing

1:29:12

postpartum mood disorders. Globally,

1:29:15

postpartum depression has an estimated

1:29:17

prevalence of seventeen percent.

1:29:20

That is so much higher than any of

1:29:22

the other complications that we have talked about, like,

1:29:25

so much higher. That global

1:29:27

number, though is not you can't

1:29:29

just leave it there, okay, because the variation

1:29:32

geographically is huge.

1:29:34

Okay.

1:29:35

Now, low and middle income countries

1:29:37

prevalence is significantly higher,

1:29:40

significantly higher than in high income countries.

1:29:42

The average if you just lump

1:29:44

all low in middle income countries, which is not a fair thing

1:29:47

to do, but if you do that, then the prevalence

1:29:49

is estimated at around twenty percent. High

1:29:52

income countries, the average is like

1:29:54

fifteen and a half percent. But

1:29:57

as you can see, there's a graph that's in a

1:29:59

paper that I cite that

1:30:01

shows this huge range in

1:30:04

distribution. Some countries are as high

1:30:06

as thirty in the thirty percentile. So

1:30:09

yeah, so the range is really really huge, and a

1:30:12

lot of high income countries the

1:30:14

prevalence of postpartum depression is in the

1:30:16

single digits, like eight nine percent.

1:30:19

The US and the UK are a little bit

1:30:21

of outliers in the high income country

1:30:23

bracket, where the prevalence

1:30:26

is estimated at eighteen and twenty percent

1:30:28

respectively. Okay,

1:30:30

okay, now pause for a

1:30:32

second because we're gonna err and math this a

1:30:34

little bit. Because that

1:30:37

is, in the US, we have an estimated

1:30:39

around three and a half million live berths

1:30:41

every year if eighteen

1:30:43

percent of those, and postpartum depression

1:30:46

is not limited to live births. This also encompasses

1:30:49

depression post miscarriage and still

1:30:51

birth, which those rates are even higher.

1:30:54

But even if we just look at those numbers,

1:30:57

three and a half million live berths, eighteen

1:30:59

percent of those people having

1:31:01

postpartum depression is over six hundred

1:31:04

and thirty thousand people in just the

1:31:06

US every year. That's not a small number

1:31:08

of individuals or families

1:31:11

that are being affected. So

1:31:15

that's postpartum depression, which is

1:31:17

just one of the postpartum mood disorders

1:31:21

post part of anxiety.

1:31:22

I have a question. Okay, sorry, I

1:31:24

know you're like, I just want to I know, I

1:31:27

know, I know. Okay, this

1:31:29

map that shows the rate of

1:31:32

postpartum depression or the prevalence, prevalence

1:31:34

or prevalence. Okay,

1:31:36

what is postpartum depression? Is this all

1:31:39

being defined?

1:31:40

It's all being defined as DSM five definitions.

1:31:42

Yes, depressions.

1:31:45

Post Partum anxiety another one of the post partum

1:31:47

mood disorders, estimated to effect eight

1:31:49

to twelve percent of people postpartum.

1:31:51

Here's the big problem here, Okay,

1:31:55

we don't have diagnostic criteria. There is no

1:31:57

such disorder. There

1:32:00

is no disorder that is called postpartum

1:32:02

anxiety. We also do not

1:32:05

have a screening test. In

1:32:07

theory, the EDS should be capturing

1:32:09

people who are at risk for postpartum anxiety

1:32:12

type mood disorders, yeah, and depressive

1:32:15

disorders, but it doesn't

1:32:17

like there's no screening test for anxiety

1:32:20

that is universally administered in the postpartum

1:32:22

period, and there is also not a specific

1:32:25

like disorder that is recognized

1:32:27

as a post part of anxiety disorder. So then people

1:32:30

have to like to get a diagnosis

1:32:32

quote unquote whether that's important or not is a different

1:32:34

discussion. But it would then be a

1:32:36

different type of anxiety disorder, like a generalized

1:32:39

anxiety disorder, obsessive compulsive disorder,

1:32:41

right, like all these other type of anxiety

1:32:43

disorders, because anxiety is

1:32:45

a symptom and not a diagnosis.

1:32:48

Okay, good questions here,

1:32:51

So a person could have postpartum

1:32:53

depression and postpartum anxiety absolutely, Okay.

1:32:56

Secondly, then do postprium

1:32:59

depression post partum ascis because I know that

1:33:01

in reading about the history the postpartum

1:33:04

like there was a huge fight

1:33:06

or struggle to get postpartum

1:33:08

to be a specific thing, and part of that was

1:33:10

related to insurance and stuff, so

1:33:13

that it's like, oh, if this was pre existing, we're

1:33:15

not going to cover it.

1:33:15

Correct.

1:33:16

But but and so then that

1:33:18

postpartum period was shown as

1:33:20

a risk factor, and that

1:33:23

is how we got postpartum depression as

1:33:25

a diagnosis.

1:33:25

But then what

1:33:28

was so I think it's usually

1:33:31

it has to last longer than two weeks,

1:33:33

okay, because the first two weeks

1:33:36

postpartum people can have a depressed

1:33:38

mood that is still called the baby blues.

1:33:40

Yeah, the postpartum blues.

1:33:42

Which is people have described

1:33:44

it as infantilizing, but.

1:33:47

I'd agree with that. Yeah.

1:33:49

In the sixties, do you want to know what, like I

1:33:51

think it was doctor Spock or something, you know, like

1:33:53

the Benjamin S. Bacao was like, this is how to care

1:33:55

for people.

1:33:55

I only know this Spock with like the livelong and

1:33:58

prosper.

1:33:58

This is relative Okay, yeah,

1:34:01

not really. Oh no,

1:34:09

it was recommended that to pick

1:34:11

to like, oh, if you have baby blues, pick yourself

1:34:13

up by getting yourself a new hat or treat yourself

1:34:15

to a new dress, Go get

1:34:18

your hair done.

1:34:18

Get your hair DoD.

1:34:19

That was literally okay, yeah,

1:34:21

I love that anyway.

1:34:23

Yeah, so lasting more than two weeks.

1:34:25

And then in terms of the onset of development,

1:34:28

it's like usually the first year postpartum

1:34:31

is all still considered within the postpartum period.

1:34:33

Okay, that's what that was My terribly

1:34:36

worded question was trying.

1:34:37

To get the like overall time frame.

1:34:39

Yeah, yeah, yeah, yeah yeah.

1:34:42

And then of course, there is also the

1:34:44

most severe spectrum

1:34:46

of maternal like postpartum mental

1:34:49

health disorders, and that is postpartum psychosis,

1:34:51

which is not called postpartum psychosis. It's

1:34:54

brief psychotic disorder with postpartum onset

1:34:56

is the DSM five title.

1:34:59

But this is the set.

1:35:00

Of hallucinations or delusions

1:35:03

and like disorganized behavior

1:35:05

and things like that that usually go along

1:35:08

with depression or depressive symptoms

1:35:10

during this postpartum period. This

1:35:13

is thought to be relatively rare, though our

1:35:15

studies are not as robust on it, but

1:35:18

estimated between zero point eight six

1:35:20

to two point six per one thousand berths.

1:35:22

So it's commonly cited as like one to

1:35:24

two per thousand based on a global

1:35:27

analysis from twenty seventeen. But

1:35:29

it is also the most acutely dangerous

1:35:31

of the maternal mental health disorders because this

1:35:33

can be it can be very severe and

1:35:36

really disturbing for the mom

1:35:38

and the family, and so often results

1:35:41

in hospitalization.

1:35:42

Yeah, I am I think I told

1:35:44

you this, Aaron, But I listened to a book

1:35:46

called a memoir called Inferno, a

1:35:48

Memoir of Motherhood and Madness by Catherine

1:35:50

Choe, and it was about this

1:35:53

person's experience with postpartum

1:35:55

psychosis. And it was a really

1:35:59

insightful and meaning full and also

1:36:01

like really, I just it feels like a really important

1:36:04

book. I really appreciated it. But

1:36:06

the other thing that I think was really interesting about

1:36:08

that was how she talked

1:36:11

about she was in the US when

1:36:13

this, when this this happened, and when

1:36:15

she was hospitalized, but she was actually

1:36:18

like traveling from

1:36:20

the UK where she lived in the

1:36:22

UK, and the treatment is

1:36:24

very different in terms of like the management okay,

1:36:27

okay, well keep mom with baby,

1:36:29

okay, UK, keep mom separate from baby

1:36:31

in the US, and just like interesting, I

1:36:33

just yeah, yeah,

1:36:35

all the different all the different choices.

1:36:37

And I will say that our understanding

1:36:40

of like the neurologic or the biologic

1:36:43

basis that underpins postpartum

1:36:45

depression anxiety psychosis,

1:36:47

like it is poor, to say the least.

1:36:50

It's like an understatement. It

1:36:52

is very often blamed, especially

1:36:54

in like popular media press, about

1:36:56

postpartum depression on quote unquote hormones.

1:37:00

Yeah, maybe

1:37:03

there is some data that that might be true for

1:37:05

this quote unquote baby blues

1:37:07

period, where I also

1:37:09

it's important to say that like forty to seventy

1:37:12

percent of people can experience this mood

1:37:14

lability during those first two weeks, and

1:37:16

that is when our hormonal shifts are the most

1:37:19

extreme. So sure, maybe that

1:37:21

is responsible for that first

1:37:23

period, but we actually do not have

1:37:25

data to suggest that there are

1:37:27

hormonal differences in

1:37:29

people who are experiencing other postpartum

1:37:32

mood disorders past that two week period

1:37:34

and people who do not, So we do not

1:37:37

understand it the same way that we don't understand

1:37:39

the biologic causes of depression

1:37:41

or anxiety or other mood disorders outside

1:37:43

of the postpartum period. However,

1:37:46

However, what is clear

1:37:49

from the epidemiological correlates

1:37:52

from the facts that, for

1:37:54

example, as we saw globally,

1:37:57

the rates are significantly higher in

1:37:59

low and middle income countries that lack

1:38:02

health infrastructure, that

1:38:04

lack access to healthcare in

1:38:06

the prenatal and post natal period, or

1:38:10

that rates of postpartum depression are significantly

1:38:13

higher in lower income households

1:38:15

in high income countries that

1:38:17

lack access to healthcare, that

1:38:20

they are higher in people who are subjected

1:38:22

to additional stressors such

1:38:25

as abusive or unsafe relationships,

1:38:27

or unintended pregnancies. What

1:38:31

is clear from these epidemiological studies

1:38:33

is that a lot of the factors

1:38:35

that contribute to an increased

1:38:38

risk of postpartum depression and other

1:38:40

mood disorders are potentially

1:38:42

modifiable and not

1:38:44

on an individual level, so important,

1:38:47

not on an individual level, and in fact,

1:38:50

the single greatest risk factor for

1:38:52

postpartum depression and postpartum anxiety

1:38:55

are untreated anxiety and depression

1:38:58

outside or during pregnant and see

1:39:00

so if we can actually recognize

1:39:03

and provide treatment of mental

1:39:05

health disorders outside of the context of pregnancy,

1:39:07

we can help reduce the burden of postpartum

1:39:10

disorders as well. So I'm

1:39:12

going to now shift this to talk about

1:39:14

what we know from data

1:39:17

about how to improve postpartum outcomes