Speaker 1: We want to start with a disclaimer that throughout this
Speaker 1: series we feature explanations and stories that include some heavy material,
Speaker 1: including early pregnancy, loss, still birth, and other traumatic experiences
Speaker 1: of pregnancy, childbirth, and the postpartum period.
Speaker 2: There's a lot I could say about the physical difficulty
Speaker 2: of carrying a baby, that I'm going to focus on
Speaker 2: the postpartum because that was what was most surprising and
Speaker 2: unsettling to me throughout my pregnancy. I always expected that
Speaker 2: I would start kind of falling in love with the baby,
Speaker 2: like I always heard people saying, I'm already so in
Speaker 2: love with you, all those you know, social media posts
Speaker 2: and what people are talking about, and I never really
Speaker 2: felt an attachment. But I was especially promised that when
Speaker 2: you give birth, it's the happiest day of your life.
Speaker 2: You look down at the baby and you love them
Speaker 2: instantly more than it's a different love than you've ever
Speaker 2: experienced before. And so after, you know, three days of
Speaker 2: pre labor and then fifteen hours of labor, I gave
Speaker 2: birth and the baby was put on my chest and
Speaker 2: I just felt this kind of heartbreaking missed step feeling
Speaker 2: because it felt the same as it always had. There
Speaker 2: was no immediate love. There was a baby on my
Speaker 2: chest and that was it. And then in the hospital
Speaker 2: I kind of was feeling like I had no idea
Speaker 2: how to take care of this baby. There was kind
Speaker 2: of this helplessness. I couldn't feed it, he wasn't latching.
Speaker 2: I could hardly stand myself, like I needed help getting
Speaker 2: to the bathroom. I couldn't sit up, I didn't change
Speaker 2: into clothes. I just felt like very sick. And when
Speaker 2: the nurse came with the wheelchair and was going to
Speaker 2: wheel us out, I was like, how the heck am
Speaker 2: I going to go home and take care of this baby.
Speaker 2: I have no idea and I don't even love it.
Speaker 2: Does anyone know around me that I don't love this
Speaker 2: baby and that I don't know how to take care
Speaker 2: of it? And my husband drove us home and I
Speaker 2: walked into the house and it was even Actually, when
Speaker 2: we pulled into the garage, there was this immediate sense
Speaker 2: of everything around me looks different than it did, nothing
Speaker 2: looks familiar. It's like we drove into this kind of
Speaker 2: parallel universe that I'd never lived in before, and it
Speaker 2: was very unsettling. And my parents were there and everyone
Speaker 2: was so happy, and I was like, something feels so
Speaker 2: off to me. And then my husband went to take
Speaker 2: the dog for a walk because we'd been gone for
Speaker 2: three days, and I felt a panic inside me, and
Speaker 2: I left the baby with my parents and I went
Speaker 2: into my bedroom and I cried because I didn't want
Speaker 2: to be without my husband. He was the only person
Speaker 2: who knew what I'd been through the last three days.
Speaker 2: So then I had this kind of like vague feeling
Speaker 2: of desolation for a long time, and I would cry
Speaker 2: for hours at a time at night, and I just
Speaker 2: kind of I'd never really felt happy. I was always
Speaker 2: just kind of leaning towards depression, I guess, and I'd
Speaker 2: never experienced depression before, so I didn't recognize it. It
Speaker 2: just felt like homesickness, like this nagging sense of homesickness
Speaker 2: that intensified or dulled but never went away. And the
Speaker 2: scariest part was when my in laws visited and my
Speaker 2: parents also visited, and they were taking turns carrying the
Speaker 2: babe all day and when they finally when they gave
Speaker 2: him back to me after maybe an hour, I looked
Speaker 2: down and I didn't recognize my baby, and it could
Speaker 2: have been any baby I had. I had had him
Speaker 2: for two weeks. He was two weeks old, and I
Speaker 2: didn't know who he was. It could have been they
Speaker 2: could have swapped him out and I would have had
Speaker 2: no idea, and I started sobbing. I told my husband
Speaker 2: right away, and he googled mother can't recognize baby. And
Speaker 2: I watched him google that, and it was so heartbreaking.
Speaker 2: And I came up with this kind of soothing exercise
Speaker 2: where because my son's face didn't look familiar to me,
Speaker 2: I kind of broke it down into pieces and I
Speaker 2: would say, like, there's his mouth, there's his eyes, there's
Speaker 2: his nose, there's his ears, and I would memorize them
Speaker 2: in pieces, and from then on, whenever I held him,
Speaker 2: I would go over and recognize each of those small
Speaker 2: pieces until they looked familiar to me. To this day,
Speaker 2: I don't know if it was like mild psychosis or depression.
Speaker 2: By the time I went to the doctor six weeks later,
Speaker 2: it had I mean, I was still sad and should
Speaker 2: have been treated with depression, but it wasn't so startling
Speaker 2: that the doctors picked up on it. And I didn't
Speaker 2: know how to report it myself because I didn't know
Speaker 2: what to recognize. I wish that I had seen a
Speaker 2: doctor a way earlier. It wasn't required and I didn't
Speaker 2: know to ask for it, and I wish that I
Speaker 2: had been treated because that dull sadness probably stuck around
Speaker 2: for six months, and if there had been earlier intervention,
Speaker 2: I think I would have had a much more enjoyable
Speaker 2: early motherhood experience. I also told my husband that I
Speaker 2: didn't love the baby as much as I loved him,
Speaker 2: and that that seemed wrong to me, and he assured
Speaker 2: me that I'd known my husband for ten years, so
Speaker 2: it kind of made sense that I would love him
Speaker 2: more than somebody that i'd only known for two weeks.
Speaker 2: It probably took a year for me until I had
Speaker 2: the solid bond that I was expecting to have right away,
Speaker 2: and I wish that other women knew that sometimes it's
Speaker 2: just a bond that has to build as you get
Speaker 2: to know people. And now my son is six, and
Speaker 2: I couldn't possibly love him more.
Speaker 1: It has been so incredible to hear everyone's stories, and
Speaker 1: we really can't thank everyone enough for sharing your stories
Speaker 1: with us. We read hundreds of first hand accounts and
Speaker 1: it truly is such an honor and it feels so
Speaker 1: I can't. It feels surreal. Yeah, it's amazing. So thank
Speaker 1: you to each and every one of you who wrote
Speaker 1: in and who shared your stories.
Speaker 3: Yeah.
Speaker 4: We tried so hard to include as many different stories
Speaker 4: from as many different perspectives and experiences of pregnancy and
Speaker 4: childbirth and the postpartum period as we could, and we
Speaker 4: know that as many as we included, there's so many
Speaker 4: that we didn't and we just want to thank you
Speaker 4: all again from the bottom of our hearts.
Speaker 5: We really really appreciate it.
Speaker 4: It means it means the world to us, and this
Speaker 4: podcast would not be the same without all of you.
Speaker 1: Absolutely not. Yeah, it has really been. It's such an
Speaker 1: integral part. It's it's amazing.
Speaker 6: It is.
Speaker 3: Yeah.
Speaker 1: Hi, I'm Aaron Welsh.
Speaker 3: And I'm Erin Allman.
Speaker 1: Update and this is this podcast will kill you.
Speaker 4: We are coming to you with the fourth and final
Speaker 4: for now episode in our series Pregnancy Now.
Speaker 1: I mean to be continued to continue.
Speaker 5: But this is our season finale.
Speaker 1: That was lovely. Thank you.
Speaker 4: I did a drum even though it was more like
Speaker 4: a trumpet.
Speaker 1: Yeah, No, I liked it. I think it's it was.
Speaker 1: It was a really nice touch.
Speaker 4: It's also our last episode recording in the exactly right studios.
Speaker 4: So thank you guys for having us here. Yes, we're
Speaker 4: having too much fun. We are having too much fun,
Speaker 4: too much fun, No such thing. We're just relaxing. That's
Speaker 4: been the joke all morning. If you listen to the
Speaker 4: first couple episodes, you get it.
Speaker 1: Oh my god. Okay, okay, we still have an intro
Speaker 1: to get there. We do, we do. We have some.
Speaker 4: Things to discuss. If you've listened to the other episodes,
Speaker 4: you've heard these.
Speaker 1: Before, heard this before. Yeah, we want to just sort
Speaker 1: of briefly go through again what we've already covered in
Speaker 1: the first three episodes, what we're going to be covering
Speaker 1: in this episode, talk about some of the language that
Speaker 1: we'll be using, and our goals overall with creating the series.
Speaker 1: And so we decided, like we have said early on,
Speaker 1: to dedicate four episodes to pregnancy for each trimester. Clearly
Speaker 1: not enough to actually cover this huge experience that is pregnancy, childbirth,
Speaker 1: and the postpartum period. Yeah, and so if you are like, hey,
Speaker 1: I really want to hear more about this, I want
Speaker 1: to learn about this aspect, what about this? Send in
Speaker 1: your questions, Send in your topic ideas. We are happy
Speaker 1: to have them. This will not be the last episode
Speaker 1: on anything related to pregnancy now, So, yeah, we've got
Speaker 1: more to go, so much more.
Speaker 4: We know that we haven't answered all of your questions.
Speaker 4: We still have this episode to try, but we definitely
Speaker 4: have not covered every possible experience that a person could
Speaker 4: have during pregnancy, childbirth, and beyond, because pregnancy is such
Speaker 4: an individual experience. So each episode that we have done
Speaker 4: thus far has covered roughly a trimester of pregnancy. So
Speaker 4: in our very first episode we talked about how you
Speaker 4: even know whether or not you're pregnant and what happens
Speaker 4: during early development.
Speaker 1: The second episode, we talked a lot about the placenta,
Speaker 1: what an incredible organ that is, and we also talked
Speaker 1: about the physiological changes and antempal changes that someone experiences
Speaker 1: throughout pregnancy, and we touched on some of the complications
Speaker 1: that can arise.
Speaker 4: Last episode last week, we talked all about the process
Speaker 4: of childbirth itself, Yeah, all the different ways that you
Speaker 4: can do it. Yeah, a little bit about labor and
Speaker 4: modes of delivery, and then the history of the cesareans
Speaker 4: actually about C section, wasn't Julius Caesar y'all no yeah.
Speaker 1: Tune into episode three to find out more. And finally, today,
Speaker 1: our fourth episode, our final episode of the Pregnancy Series
Speaker 1: and our final episode of season seven, will be about
Speaker 1: the concept of the fourth trimester, talking about what changes
Speaker 1: are going on in your body after pregnancy, and we're
Speaker 1: also going to be talking about this big picture of
Speaker 1: how the medicalization of pregnancy and childbirth changed that experience
Speaker 1: and how we moved from home to hospital and some
Speaker 1: of the consequences of that.
Speaker 3: Yes, I'm excited for this episode arin me too.
Speaker 4: We have intended for this Pregnancy Series, as with all
Speaker 4: of our episodes, honestly, to be inclusive of all families,
Speaker 4: and we recognize that not everybody who experiences pregnancy identifies
Speaker 4: as a woman, so we try wherever we can to
Speaker 4: use gender neutral language and discuss pregnant people. At the
Speaker 4: same time, we know that a lot of what we discuss,
Speaker 4: especially when it comes to medical bias during pregnancy and childbirth,
Speaker 4: historically and today, is a result of gender discrimination and racism,
Speaker 4: and so in those context we use the term woman
Speaker 4: or women, and throughout these episodes we also use the
Speaker 4: term mother or maternal and paternal since these are the
Speaker 4: terms that are often used in the scientific and medical literature.
Speaker 1: Yes, and we also want to just you know, recognize
Speaker 1: that there is no such thing as a normal pregnancy.
Speaker 1: There's no This is what is going to happen, and
Speaker 1: this is normal, and that's.
Speaker 5: The only way that it can be, the only way
Speaker 5: there's Differently, you.
Speaker 3: Go gone over that a lot in these episodes.
Speaker 1: But it is really important in discussing, you know, a
Speaker 1: baseline of what is expected to happen, so that we
Speaker 1: can understand what happens when things happen outside of those
Speaker 1: expectations and some of the complications that can happen as
Speaker 1: a result, even defining what a complication is.
Speaker 4: Exactly exactly, And we're going to do that today for
Speaker 4: the postpartum period.
Speaker 1: We are.
Speaker 2: We are.
Speaker 1: But first, if I remembered it, this time, it's quarantine time, Aaron,
Speaker 1: what are we drinking again this week?
Speaker 5: We're drinking yet again, Great expectations.
Speaker 1: Great expectation.
Speaker 5: Which is a plasy burrita that is a non alcoholic bev.
Speaker 1: It's really good. It's got ginger ale, it's got muddled
Speaker 1: blackberries and mint, it's got lemon juice.
Speaker 5: Is shockingly delicious, very refreshing.
Speaker 1: Yeah, super refreshing. I love it. I'm thinking of it
Speaker 1: right now.
Speaker 3: Too, which I actually had one, but alas.
Speaker 1: Later today.
Speaker 4: Yes, if you want to see us make it. We
Speaker 4: made a really fun quarantine video that you can find
Speaker 4: on the YouTube tube tube. We also were very honored
Speaker 4: to be joined by Georgia Hartstark who made us a
Speaker 4: quarantin ye and alcoholic version to go along with these episodes.
Speaker 4: She called it the on teeny.
Speaker 1: The Tenius and it's delicious.
Speaker 5: Yes, and you can find that video on YouTube as well.
Speaker 1: YouTube you can also find I don't know if we
Speaker 1: have said this enough, but you can find these episodes
Speaker 1: on YouTube, these pregnancy episodes, pregnancy episodes with video with
Speaker 1: video and props.
Speaker 5: Well props.
Speaker 1: We're doing great today. And if you would like the
Speaker 1: recipes for these quarantine and place rita for this series,
Speaker 1: check out also our social media make sure you're following
Speaker 1: us or now in Blue Sky. I don't know if
Speaker 1: we've said that sure, And also our website Yes podcast
Speaker 1: will kill You dot com which features do you want
Speaker 1: me to this listen?
Speaker 5: Let's skip it today?
Speaker 1: Okay? Check out our website transcer rips. I just have
Speaker 1: to throw that in Okay, I think more business.
Speaker 4: Rate review and subscribe. We love you, thanks for listening.
Speaker 1: We'll be back soon with a new season. Yeah, and
Speaker 1: we have so like send us your ideas along the way.
Speaker 1: We are so excited to dig more into the world
Speaker 1: of health, medicine, disease biology, evolution, ecology.
Speaker 5: Literally like after we start misology, we.
Speaker 4: Already have a list of things that were like, Okay,
Speaker 4: so next season booo so like.
Speaker 1: Air quality index, yes, thank you, yeah, thank you Kenton. Okay,
Speaker 1: let's begin.
Speaker 5: Let us after a break.
Speaker 7: I found out I was pregnant on New Year's Day
Speaker 7: twenty twenty four. I was thirty three, and this would
Speaker 7: be my second baby. My pregnancy was relatively uneventful and
Speaker 7: actually a little easier than my first, but both were
Speaker 7: low risk. I went into labor naturally at thirty nine
Speaker 7: weeks and went to the hospital to help things along.
Speaker 7: My midwife broke my water manually. I felt a huge
Speaker 7: gush and things really intensified from there. At this point,
Speaker 7: my memory is a little blurry, but I do remember
Speaker 7: feeling more big gushes when I had contractions. I pushed
Speaker 7: her about an hour and then my daughter was born.
Speaker 7: When the midwives went to place around my chest. They
Speaker 7: discovered that the cord was very short. They could only
Speaker 7: set her on my belly under my belly button. I
Speaker 7: asked them to go ahead and cut the cord so
Speaker 7: that I could hold her on my chest instead. I
Speaker 7: got to hold her for maybe a minute and take
Speaker 7: some pictures before things started to go downhill. I was
Speaker 7: trying to nurse her, and then I started to feel
Speaker 7: very weak. I yelled out for someone to take the
Speaker 7: baby because I thought I would drop her. I had
Speaker 7: been distracted, but then I realized I still hadn't delivered
Speaker 7: the placenta. My midwives sprang to action and told me
Speaker 7: we needed to deliver it immediately. As soon as I
Speaker 7: pushed it out, I felt a huge gush. My first
Speaker 7: thought was that it was amniotic fluid, because it felt
Speaker 7: like when my water was broken. But then I realized
Speaker 7: all that fluid had already been do livered with baby,
Speaker 7: and I said, was that blood. I looked at the
Speaker 7: midwife who had been standing between my legs, and she
Speaker 7: was splattered with blood head to toe, like she'd been
Speaker 7: sprayed with a hose. From there, everything was chaos. All
Speaker 7: of a sudden, there were a lot of people in
Speaker 7: the room. The midwives were vigorously massaging my belly, but
Speaker 7: my uterus wasn't contracting and I was bleeding out. I
Speaker 7: was given multiple drugs via different routes at the same time.
Speaker 7: One of these was cide attack, also known as misiposal.
Speaker 7: This drug is talked about a lot as it is
Speaker 7: the second step in a medication abortion, but it is
Speaker 7: also used to help stop postpartum hemorrhage in labor and delivery.
Speaker 7: The hospital ob and my midwives were working frantically on
Speaker 7: me for about an hour to try to stop the bleeding.
Speaker 7: Oh my husband was doing skinned to skin with the baby.
Speaker 7: I remember thinking that my great grandmother had died from
Speaker 7: a postpartum hemorrhage. I asked one of the nurses if
Speaker 7: I was going to be okay, and all she said was,
Speaker 7: we are doing everything we can. They tried using an
Speaker 7: intrauterine balloon device to apply pressure from within. Unfortunately it
Speaker 7: got clogged with clots and didn't work for me. Staff
Speaker 7: was scooping up blood and clots off of the bed
Speaker 7: and and weighing it to see how much I lost. Ultimately,
Speaker 7: they said I lost about two to three leaders and
Speaker 7: I was given two leaders via transfusion. Eventually, my uterists
Speaker 7: did contract and they were able to stitch me up.
Speaker 7: The other day, I was looking back at those photos
Speaker 7: when I was holding my baby, and I can see
Speaker 7: that my face has a weird gray cast to it.
Speaker 7: I'm so glad that I delivered in a hospital that
Speaker 7: had all of the best medications and resources available to
Speaker 7: stop the hemorrhage. If I hadn't, the outcome could have
Speaker 7: been very different.
Speaker 6: My name is Dawn and I live in Texas. In
Speaker 6: my mid thirties, I became pregnant with my second child.
Speaker 6: My then husband and I were thrilled after having such
Speaker 6: joy from our first one. At my first prenatal appointment,
Speaker 6: everything seemed fine, my bottles were good, and we were
Speaker 6: able to detect a heartbeat. Since my first pregnancy was uneventful,
Speaker 6: I assumed this one would be similar. One thing that
Speaker 6: was very different about this pregnancy was a nausea. Although
Speaker 6: I had had nausea with my first pregnancy, this one
Speaker 6: was much more intense. I felt awful most of the
Speaker 6: time and struggle to do normal things. Nothing seemed to help.
Speaker 6: At my second prenatal appointment, the midwife was unable to
Speaker 6: detect a heartbeat. She did an in office ultrasound and
Speaker 6: confirmed the fetus was no longer alive. I don't believe
Speaker 6: any other information was gleaned from the ultrasound. My midwife
Speaker 6: suggested that I have a DNC soon. We were, of
Speaker 6: course devastated to have lost a baby. Shortly after the DNC,
Speaker 6: the midwife contacted me and asked me to come back
Speaker 6: into the office. In the appointment, she told me that
Speaker 6: pathology done on the placenta or fetal tissue had come
Speaker 6: back with some concerning results, which was that I had
Speaker 6: had a molar pregnancy. I had never heard of this diagnosis.
Speaker 6: She told me that I would need to come in
Speaker 6: for regular blood testing to be sure pregnancy hormone levels
Speaker 6: in my blood were steadily decreasing. After the appointment, I
Speaker 6: talked to my aunt, who was an OBGI in nurse.
Speaker 6: She gave me the highlights of a molar pregnancy, and
Speaker 6: of course I googled on my own. After time talking
Speaker 6: to my aunt, my basic understanding was that amolar pregnancy
Speaker 6: is an unusual, non viable pregnancy that can sometimes develop
Speaker 6: into cancer if all the abnormal cells are not removed.
Speaker 6: Years afterwards, my aunt told me she was very concerned
Speaker 6: for me. While the intense nausea remained for a few weeks.
Speaker 6: After the DNC, my pregnancy hormone levels did steadily decline,
Speaker 6: and after some time I was fortunate to have a
Speaker 6: third pregnancy that resulted in a healthy baby boy. Since
Speaker 6: I live in Texas, I do want to mention that
Speaker 6: I'm not sure if the DNC my midwife recommended would
Speaker 6: be possible now with the unprecedented removal of women's reproductive rights.
Speaker 1: Last week, I took us through the history of cesarean sections,
Speaker 1: a procedure that has been used in some capacity since
Speaker 1: at least ancient times, but one that physicians weren't able
Speaker 1: to widely utilize until the twentieth century, when antibiotics, antisepsis, transfusions,
Speaker 1: and surgical technique transformed it from an almost certain death
Speaker 1: sentence to a life saving tool, and we discussed how
Speaker 1: the high rates of sea sections have led people to
Speaker 1: question whether the surgery, life saving though it may be,
Speaker 1: is overused and what possible consequences might arise as a results. So,
Speaker 1: for many, high rates of sea sections represent sort of
Speaker 1: this dark side of the medicalization of pregnancy. And childbirth
Speaker 1: where medical intervention is seen as always necessary and women
Speaker 1: aren't trusted to give birth. This, of course, is no
Speaker 1: the complete picture, because ultimately, as childbirth moved from the
Speaker 1: home to hospitals, rates of maternal and perinatal mortality declined
Speaker 1: as medicine developed methods to manage the complications that in
Speaker 1: previous centuries may have resulted in tragedy. But this rosy
Speaker 1: picture of modern medicine marching onwards with doctors saving the
Speaker 1: day that really fails to capture the inevitable and often
Speaker 1: overlooked cost of progress. What did we leave behind when
Speaker 1: we moved from the home to the hospital. So today
Speaker 1: I want to take this big picture view of how
Speaker 1: childbirth has changed over the centuries, exploring some of the
Speaker 1: factors that have underlaid those changes, and ultimately I want
Speaker 1: to kind of just think about this question of how
Speaker 1: can we use the past to ensure a better future.
Speaker 1: Before I dig in, I want to shout out a
Speaker 1: few of the major sources that I used to put
Speaker 1: this together. There was a book called Brought to Bed
Speaker 1: by Judith Walser Levitt about childbirth in America from seventeen
Speaker 1: fifty to nineteen fifty. The title sounds somewhat dry. It
Speaker 1: is one of the most fascinating books I have ever read,
Speaker 1: very enlightening. The book A Midwife's Tale by Laurel Thatcher Ulrich,
Speaker 1: which is so good. Oh my gosh, this is the
Speaker 1: excellent history book about the life of midwife Martha Ballard snippets.
Speaker 1: It's such I love this book. I could talk about
Speaker 1: this forever. But the way that it approaches history is
Speaker 1: fascinating because it takes like, here's a segment, here's a
Speaker 1: month in her life. Now let's think about marriage laws
Speaker 1: in Massachusetts or not in Massachusetts, in Maine the late
Speaker 1: seventeen hundred, so like all the.
Speaker 5: Context of what was happenings.
Speaker 3: Oh, how interesting.
Speaker 1: It's so good not to mention like the aspects of
Speaker 1: midwiffery and childbirth and so on. Okay, another book is
Speaker 1: I use snippets of a book called The Midwife Said
Speaker 1: fear Not just about the history of midwiffery in the
Speaker 1: US up through today. That one is by Helen Varney
Speaker 1: and Joyce bb Thompson. And then finally there's a book
Speaker 1: Blue by Rachel Moran. Not our not our friend friend
Speaker 1: Rachel Moriann, but a different Rachel Moran about the history
Speaker 1: of postpartum depression in the US. So you can probably
Speaker 1: tell based on these titles that this history section is
Speaker 1: mostly going to be primarily focused on the US.
Speaker 8: It.
Speaker 1: Yeah, there is no origin story for midwives. Their existence
Speaker 1: probably predates written history, and assistance during childbirth may even
Speaker 1: be a key part of human evolution. As we kind
Speaker 1: of talked about, the word midwife means with women, and
Speaker 1: over the centuries and across the globe, midwives have taken
Speaker 1: on various roles that have held different meanings wise women
Speaker 1: all around, healer, which to the haters, and so on,
Speaker 1: but there have been a few constants that have persisted.
Speaker 1: Midwife care often focuses specifically on women, that training often
Speaker 1: involves models of apprenticeship, that scientific knowledge is incorporated into practice,
Speaker 1: and that pregnancy and birth are considered normal life events.
Speaker 1: This is not a history of midwives. I won't be
Speaker 1: talking about like the profession today, but it is a
Speaker 1: history of childbirth, and the two are of course inextricably linked.
Speaker 1: In the early years of the US, childbirth was at home,
Speaker 1: most commonly attended by midwives, then by midwives with occasional
Speaker 1: visits from physicians, then by physicians with a woman's friends
Speaker 1: and family in attendance, and then in hospitals with no
Speaker 1: familiar faces. Husbands weren't even allowed in the hospital room
Speaker 1: until the nineteen sixties like the late nineteen sixties and
Speaker 1: non spouses way later.
Speaker 3: Wow. Very interesting.
Speaker 1: Yeah, the transition from home to hospital and from midwife
Speaker 1: to physician was not uniform across the US. Immigrants, the
Speaker 1: less wealthy, non white women, and those living in rural
Speaker 1: areas gave birth at home for much longer than wealthier individuals.
Speaker 1: And so, to give you some idea of this timeline,
Speaker 1: in nineteen ten, about fifty percent of all babies were
Speaker 1: delivered by midwivesteen ten nineteen ten. By nineteen thirty that
Speaker 1: number had gone down to fifteen percent.
Speaker 3: Wow.
Speaker 1: And by nineteen seventy three about one percent of births
Speaker 1: were attended by a midwife. Wow. And compare that to
Speaker 1: twenty twenty one, which is the most recent one that
Speaker 1: I found. I'm sure there are more recent ones out there.
Speaker 1: Twelve percent. Okay, we're attended.
Speaker 4: By So we went all the way down and then
Speaker 4: a little bit back and back up. I will say
Speaker 4: that I know this is US centric but that is
Speaker 4: very different than the data today for most other high
Speaker 4: income countries even.
Speaker 1: Yes, yes, and that is part that is wrapped up
Speaker 1: in the history of how the US treated midwives, specifically laws. Yeah, yeah,
Speaker 1: the transition from home to hospital. This did not happen overnight,
Speaker 1: nor was it simply a hostel takeover by physicians, as
Speaker 1: Levitt puts it in brought to bed. The process by
Speaker 1: which this occurred reflected the needs women felt to upgrade
Speaker 1: and to control their birthing experiences, as well as the
Speaker 1: increasing medical management of birth. What I really really appreciate
Speaker 1: about this quote is what I feel like so many
Speaker 1: histories of childbirth leave out that birthing women were and
Speaker 1: are agents of change. They were not just passive bystanders
Speaker 1: of the medical and legal attacks on midwifery. They held
Speaker 1: the power to say what they wanted their childbirth to
Speaker 1: be like. Until hospitals became the default place to give birth,
Speaker 1: women often chose who would be there to help, to support,
Speaker 1: to make decisions when she could not, and the people
Speaker 1: she chose were often midwives and her female friends and family.
Speaker 1: It was like a birthing network rather than just like
Speaker 1: here's the hospital staff and as obstetrics became a more
Speaker 1: common part of medical training. Many women opted to bring
Speaker 1: a physician into that network, believing that his professionalism, his tools,
Speaker 1: and his expertise would ensure the safety of mother and baby.
Speaker 1: And I say his because that was almost universally the case. Yep, yep.
Speaker 1: In nineteen hundred, only six of doctors in the US
Speaker 1: were women.
Speaker 3: I'm actually surprised it was that high.
Speaker 1: I know, I know. I mean. The other thing, the
Speaker 1: other caveat to that is that, yes, there were six percent,
Speaker 1: but they had very few patients because most people didn't
Speaker 1: want to see them, but they were elected like a
Speaker 1: lot of women who were giving birth wanted a female doctor.
Speaker 3: Okay, interesting then back then.
Speaker 1: Yeah, And of course most medical schools banned women and
Speaker 1: non white men from applying. What led to women choosing
Speaker 1: physicians and hospitals for childbirth is wrapped up in the
Speaker 1: professionalization of medicine and active campaigns against midwiffery. Midwives were
Speaker 1: portrayed as lacking the training in medical expertise to safely
Speaker 1: deliver babies, while also being explicitly forbidden to seek that
Speaker 1: training and medical expertise.
Speaker 3: Wow, yeah, okay, and.
Speaker 1: Women wanting to make the safest decision for themselves and
Speaker 1: their baby broaden male physicians believing that they would provide
Speaker 1: protection from the dangers of childbirth, which there were many. Yeah,
Speaker 1: all right, so now that we've got the big picture
Speaker 1: of view, let's dig a bit deeper to see how
Speaker 1: this all went down. We as a society have a
Speaker 1: tendency to romanticize certain aspects of the past, like how
Speaker 1: much better food must have tasted it didn't.
Speaker 3: I feel like I've never thought of that.
Speaker 1: Oh yeah, absolutely. And they also though see our book
Speaker 1: Club episode on the poison Squad, like there is a
Speaker 1: reason that pasteurization is hailed as one of the most
Speaker 1: life saving inventions. Yes, and I think that this romanticization
Speaker 1: happens to a certain degree also with pregnancy and childbirth.
Speaker 1: A call for less medical intervention is understandable, especially when
Speaker 1: you consider how early medical interventions during childbirth often caused
Speaker 1: more harm than good. But it also fails to acknowledge
Speaker 1: that childbirth can be dangerous. And no, it is not
Speaker 1: a disease, and it's not an unnatural state of being,
Speaker 1: as early twentieth century physicians believed, but it is a
Speaker 1: physically demanding experience with potential impact on both mother and
Speaker 1: babies life and health. Although I really I did find
Speaker 1: it interesting that in that Diary of a Midwife Life,
Speaker 1: the Martha Ballard, she called like when a woman was
Speaker 1: starting labor, she called it her illness is beginning, which
Speaker 1: I think is very fascinating.
Speaker 4: It was like the pregnancy was not the illness, but
Speaker 4: the delivery.
Speaker 1: The laborers you're at, which maybe just shows how she
Speaker 1: saw it as like this is a potential where like
Speaker 1: there is a lot of attention thats needed here, right right? Yeah.
Speaker 1: Imagining the women of the seventeen hundreds giving birth with
Speaker 1: no fear, as relaxed as could be, is erasing the
Speaker 1: experience of so many who approached their labors with dread
Speaker 1: and apprehension. In the early eighteen hundreds, women in the
Speaker 1: US had an average of seven children. That the number
Speaker 1: of pregnancies was probably higher, yes, because that doesn't include miscarriage, stir.
Speaker 1: Many women spent the majority of their adult lives pregnant, breastfading,
Speaker 1: recovering from childbirth, and taking care of small children. A
Speaker 1: baby every two or three years was kind of expected,
Speaker 1: a routine part of life, but that didn't mean that
Speaker 1: women necessarily looked towards childbirth without anxiety. It wasn't just
Speaker 1: the loss of a child, the potential loss of a
Speaker 1: child that weighed on them. It was the physical act
Speaker 1: of childbirth that carried with it the threat of death.
Speaker 1: Diary entries and letters written in the eighteen hundreds give
Speaker 1: us a glimpse into these worries, as women wrote wills
Speaker 1: or gave instructions on who should care for the baby
Speaker 1: if she died.
Speaker 3: This hurts my heart.
Speaker 1: I know, I know, I'm sorry, but I feel like
Speaker 1: it's such a part that we don't think that much about,
Speaker 1: or at least I don't. Maybe that's just putting my
Speaker 1: own No, I.
Speaker 4: Do think, especially because I think a lot of what
Speaker 4: you're talking about already is like we see and we
Speaker 4: see this in a lot of aspects of medicine. We
Speaker 4: see these pendulum swings, yes, right, and we see things
Speaker 4: going from like absolutely no intervention, too far, too m
Speaker 4: or like. And it's not just in obstetrics, right, It's
Speaker 4: in so many aspects of medicine. And so I think
Speaker 4: that that we see that playing out a lot of
Speaker 4: especially in like social media right now, where it's like
Speaker 4: there's all the intervention or there's natural childbirth, which we
Speaker 4: talked about last episode of like that that mean that
Speaker 4: word does not have meaning, right, And yeah, I just
Speaker 4: I think that that is such an important part that
Speaker 4: isn't ever discussed when we're talking about like a low
Speaker 4: intervention birth or something like that.
Speaker 3: Yeah that like it.
Speaker 5: Wasn't all roses back in the day.
Speaker 1: Yeah, yeah, So I want to I've pulled a lot
Speaker 1: of these quotes from Brought to Bed because I think
Speaker 1: that there they just illustrate this, like this idea that
Speaker 1: it's not There are many there's a lot of nuance
Speaker 1: to how people felt about their impending you know, pregnancy,
Speaker 1: childbirth and so on. So Lizzie Cabot wrote to her
Speaker 1: sister in the mid eighteen hundreds, I have made my
Speaker 1: will and divided off all my little things and don't
Speaker 1: mean to leave undone what I ought to do if
Speaker 1: I can help it. Sarah Ripley Sterns wrote in her
Speaker 1: diary late in her pregnancy, perhaps this is the last
Speaker 1: time I shall be permitted to join with my earthly friends.
Speaker 1: A woman described her third birth in eighteen eighty five
Speaker 1: between oceans of pain, their stretch, continence of fear, fear,
Speaker 1: of death and dread of suffering beyond bearing. Those who
Speaker 1: attended births, midwives and physicians felt similar apprehension. Like there
Speaker 1: was a physician writing in eighteen seventy who described his
Speaker 1: feelings of alarm and gloomy forebodings after seeing a patient
Speaker 1: die unexpectedly during childbirth. He goes on to write about
Speaker 1: how those feelings stayed with him, making it impossible quote
Speaker 1: while attending a case of confinement to banish the feeling
Speaker 1: of uncertainty and dread as to the results of cases
Speaker 1: which seemingly are terminating unfavorably. Sometimes the dread wasn't isolated
Speaker 1: to the act of childbirth itself, but extended to the
Speaker 1: long period of recovery. Like Agnes Read's letter about her
Speaker 1: second pregnancy, I confess I had dreaded it with a
Speaker 1: dread that every mother must feel in repeating the experience
Speaker 1: of child bearing. I could only think that another birth
Speaker 1: would mean another pitiful struggle of days duration followed by
Speaker 1: months of weakness as it had been before. Yeah. Yeah,
Speaker 1: And when comparing historical and modern experiences of childbirth, we
Speaker 1: use data, right, Like we're talking about what about the data?
Speaker 1: And our data are limited to things like maternal mortality
Speaker 1: or complicated births. They're not that great anyway, and we
Speaker 1: can look at I think it's interesting to look at
Speaker 1: Martha Ballard's eight hundred and fourteen deliveries from seventeen eighty
Speaker 1: five to eighteen twelve, so five maternal deaths, none during delivery,
Speaker 1: all during two weeks after birth. And that's today compared
Speaker 1: to zero point two two per every one thousand, so
Speaker 1: five per one thousand, two point two two. Okay, yeah,
Speaker 1: Martha recorded twenty neonatal deaths. That's two point five for
Speaker 1: every one hundred live births, compared today two point five
Speaker 1: to six.
Speaker 4: So that I think also is very often left out
Speaker 4: of the discussion, even when we're talking about interventions that
Speaker 4: have reduced maternal mortality. I think that it's easy to
Speaker 4: gloss over how much we have improved infant survival and
Speaker 4: reduced still birth and neonatal mortality like drastically, not even
Speaker 4: to mention like vaccines and saving life's postpartum and all that.
Speaker 1: Right, right, but during childbirth experience itself, yes exactly, yeah, yeah,
Speaker 1: you still birth she recorded fourteen. That's one point eight
Speaker 1: for every one hundred today, that's point six every one hundred,
Speaker 1: So yeah, there's a lot of I mean, we can
Speaker 1: use those data to a certain degree, but I think
Speaker 1: also like hearing those experiences from the women who you
Speaker 1: know went through this is a really fascinating part of it.
Speaker 1: And these data also don't show us what women dealt
Speaker 1: with in other outcomes of pregnancy, Like we talked about
Speaker 1: prolapsed uterus ficials, extensive tearing, perinatal mortality, and the emotional
Speaker 1: experience of that late pregnancy loss, the range of emotions
Speaker 1: that could accompany having limited control over your reproduction. Mary
Speaker 1: Foote described it in the eighteen hundreds as a sort
Speaker 1: of pendulum between joy and dread. For Hannah Whittall Smith,
Speaker 1: writing in eighteen fifty two, that pendulum swung more towards dread.
Speaker 1: I am very unhappy now that trial of my womanhood,
Speaker 1: which to me is so very bitter, has come upon
Speaker 1: me again. When my little Ellie is two years old,
Speaker 1: she will have a little brother or sister. And this
Speaker 1: is the end of all my hopes, my pleasing anticipations,
Speaker 1: my returning youthful joyousness. Well, it is a woman's lot,
Speaker 1: and I must try to become resigned and bear it.
Speaker 1: In patience and silence and not make my home unhappy
Speaker 1: because I am so but oh how hard it is.
Speaker 4: Wow, that's a really heartbreaking are Yeah, it's it's.
Speaker 1: Yeah, yeah, we have gained so much and then now
Speaker 1: we're losing so much again.
Speaker 4: But yeah, I know, yeah, to not because like like
Speaker 4: she said, to not have any control over do not
Speaker 4: have any control, any control over it?
Speaker 1: Right, And it's just like here, it is, it is
Speaker 1: my it is not added life. Yeah. So yeah. Even
Speaker 1: though pregnancy and childbirth were much more common historically, that
Speaker 1: didn't necessarily make them more welcome or more looked forward to.
Speaker 1: Just as with today, women's experiences were incredibly varied and complex,
Speaker 1: and they created ways to manage their fears, whether that
Speaker 1: was surrounding themselves with familiar faces or seeking the latest
Speaker 1: medical advancements or both. The choices available to women depended
Speaker 1: on when she lived, where she lived, and how much
Speaker 1: money she had. Early in US history, most births were
Speaker 1: attended by midwives, who played a largely non interventionist, supportive role.
Speaker 1: According to Levitt, as much as possible, they let nature
Speaker 1: take its course. They examined the cervix or encouraged women
Speaker 1: to walk around they lubricated the perenial tissues to aid stretching.
Speaker 1: They delivered the child and tied the umbilical cord, and
Speaker 1: sometimes they manually expressed the placenta. Historically, at least from
Speaker 1: my understanding, there wasn't a ton of post natal care
Speaker 1: for like mom and baby. She would be there for
Speaker 1: a bit and maybe make another visit, but usually the
Speaker 1: woman had other friends who would come and help with
Speaker 1: like other women in her life and that it's exactly yeah,
Speaker 1: And the midwife was typically not alone in the like
Speaker 1: in attendance. Often they were like friends and family right
Speaker 1: as well, usually formal friends and family. But as the
Speaker 1: practice of medicine became a formal profession, meaning like you
Speaker 1: had to have a certificate, you had to go to
Speaker 1: show your training here at.
Speaker 4: School yep, then they developed residency. That's the whole episode
Speaker 4: something episode yep.
Speaker 1: So this active professionalization started in the late seventeen hundred
Speaker 1: early eighteen hundreds, maybe even a little bit earlier in
Speaker 1: the seventeen hundreds. Towns. That meant that towns and cities
Speaker 1: had more physicians that could be called in during birth,
Speaker 1: and sometimes that call came from the midwife who wanted
Speaker 1: a bit of extra assistance during a particularly difficult berth.
Speaker 3: It's been a long time since I've watched Call the Midwife.
Speaker 1: I know, I love love that show. I really love that.
Speaker 1: There are probably seasons I haven't seen it, definitely, so yeah, yeah,
Speaker 1: I should watch it. And physicians and midwives weren't always
Speaker 1: in direct opposition during this time, and many physicians saw
Speaker 1: the potential for partnership, with midwives primarily being the ones
Speaker 1: attending the births and only calling in doctors in cases
Speaker 1: of emergency, and these occasions could also lead to tension,
Speaker 1: though if the midwife and doctor disagreed, some physicians might
Speaker 1: defer to a midwife with hundreds of berths under her belt,
Speaker 1: but gender and class dynamics ultimately put the authority in
Speaker 1: the hands of the doctor, no matter how little experience
Speaker 1: he had. So I want to read you a quote
Speaker 1: from Martha Ballard's diary. She records a few of these clashes,
Speaker 1: and here's one of them. They meaning the parents, They
Speaker 1: were intimidated and called doctor Page, who gave my patient
Speaker 1: twenty drops of laudanum, which put her into such a
Speaker 1: stupor that her pains, which were regular and promising in
Speaker 1: a matter stopped till near night when she puked, and
Speaker 1: they returned and she delivered at seven hour evening of
Speaker 1: a son, her firstborn.
Speaker 4: Okay, Aaron, so I told you that I read that
Speaker 4: like fictional Okay, that that story is in there, but
Speaker 4: in like way more detail because it's obviously like fictionalized
Speaker 4: version of history.
Speaker 5: It is fascinating to hear.
Speaker 1: The actual like diary entry.
Speaker 4: Yes, and then like the like the description because this
Speaker 4: story it's called frozen for the book, and it's like
Speaker 4: they go she goes so much into like what she
Speaker 4: assumes that Martha Ballard was thinking during the time and
Speaker 4: stuff like that, which is just so like fun and fascinating.
Speaker 1: Yeah.
Speaker 3: Yeah, but that story isn't in there, so I knew
Speaker 3: that one.
Speaker 1: I want to read that book. I'm very curious because
Speaker 1: like there is her diary entries are so so sparse
Speaker 1: in terms of like rightail, that's what she said, very
Speaker 1: few emotions. There have been like a couple times well
Speaker 1: she'll say like poor poor mother because she lost a
Speaker 1: baby or kind of thing. But but yeah, this and
Speaker 1: then I think there's another time she calls out doctor
Speaker 1: Page and she's like, what an unfortunate man or something
Speaker 1: like that. But it's hard to know if she's like
Speaker 1: and who knows is she irritated at him or does
Speaker 1: she actually feel bad because he is chosen a profession
Speaker 1: that clearly is not to his skill set.
Speaker 3: Yeah, yeah, so interesting.
Speaker 5: Yeah, check out this those books to check out those books.
Speaker 1: As doctors became a more regular presence during childbirth, so
Speaker 1: did the doctor's toolkit, which probably helped bolster appearance of expertise.
Speaker 9: Right.
Speaker 1: If midwives took a largely non interventionist approach, nineteenth century
Speaker 1: doctors did the opposite. There was laudanum or opium, as
Speaker 1: Martha mentioned, blood letting even in the case of hemorrhage.
Speaker 4: Oh, I still can't get I'm sorry. Yeah, but yes,
Speaker 4: we haven't talked about he are blood letting these all
Speaker 4: these episodes, So.
Speaker 1: I know the humors I didn't. That's the only thing
Speaker 1: that I haven't mentioned is the humors. At some point,
Speaker 1: there was something called tobacco infusions I don't know, doesn't
Speaker 1: sound great, surgical separation of pelvic bones, which was often
Speaker 1: led to like permanent disability yea, And of course forceps.
Speaker 1: By the mid nineteenth century, forceps came in all shapes
Speaker 1: and sizes, and were restricted by law to medical professionals,
Speaker 1: like you could not own a pair of forceps unless
Speaker 1: you could prove you were a doctor.
Speaker 3: Wow. Okay.
Speaker 1: One doctor bragged in jama in the mid eighteen eighties
Speaker 1: that I hate this quote. Okay quote. I take pride
Speaker 1: in stating that, as far as my recollection goes, in
Speaker 1: no case of my own was a woman ever allowed
Speaker 1: to lie in suffering and danger till the cervix was
Speaker 1: completely dilated. Oh no, I'm sorry. Oh no, yeah, yeah,
Speaker 1: they would like prophylactically use forceps.
Speaker 5: But like before the survices all the way dilated.
Speaker 1: Yes, no, like before the baby had even fully entered
Speaker 1: the berth, that they had the long long forceps.
Speaker 3: No, nope, nope, nope, nope, nope, nope, nope.
Speaker 1: Yeah, nope, nope, nope, nope, nope.
Speaker 4: Okay, that's not how forceps are used today. I just
Speaker 4: want to put that out there.
Speaker 1: No, no, no, put that over there. We have corrected,
Speaker 1: of course.
Speaker 5: Yeah, are not used in that way today. No, Wow,
Speaker 5: they used to be used.
Speaker 1: Yeah okay. So, unsurprisingly, the site of forceps was not
Speaker 1: always a welcome one, and so the doctor would just
Speaker 1: be instructed to like he instructed his students to hide them.
Speaker 1: Just wear big gowns so that you can hide your tools,
Speaker 1: because it'll, you know, make make the woman nervous. If
Speaker 1: a medical school included training specifically on obstetrics, and few
Speaker 1: actually did and the late eighteen hundreds, it mostly centered
Speaker 1: on how to use these tools and rarely included hands
Speaker 1: on supervised experience. Awesome, Okay, there, So there's one example
Speaker 1: that I want to share with you.
Speaker 3: I don't want to hear it.
Speaker 1: I hope it's an urban led, but I don't know.
Speaker 1: I would actually believe that it's not necessarily that. Okay.
Speaker 1: Tells the story of a newly graduated doctor, official doctor
Speaker 1: in the late eighteen hundreds, who examined his first laboring patient,
Speaker 1: only to be horrified at what he thought was a
Speaker 1: tumor blocking the birth canal. He figured, Okay, no, she's
Speaker 1: a goner. I just have to wait for her to pass,
Speaker 1: only to realize a few minutes later after she gave
Speaker 1: birth that what he thought was a tumor was the
Speaker 1: baby's head.
Speaker 4: Okay, I thought it was going to go a different way,
Speaker 4: and I was getting very nervous.
Speaker 1: Oh no, what did you think I was. I'm not
Speaker 1: going to say, okay, we can we can discuss off camera.
Speaker 3: Okay.
Speaker 1: Yeah. So someone who is a medical doctor and didn't
Speaker 1: know how babies were born.
Speaker 5: Well, I mean, I'm that doesn't surprise me.
Speaker 1: No, I know. Back in the day, yeah, yeah, but sorry,
Speaker 1: wouldn't you have at least seen a diagram somewhere?
Speaker 5: I don't know, I wasn't in med school in the age.
Speaker 1: They did have like theaters where someone the students could
Speaker 1: watch someone. Can you just imagine the horror of that?
Speaker 3: No.
Speaker 1: Yeah, But aside from forceps, the other major tool that
Speaker 1: was employed by nineteenth century physicians was anesthesia. First ether
Speaker 1: and then chloroform were introduced in the mid eighteen hundreds,
Speaker 1: and pretty quickly they exploded in popularity. And it wasn't
Speaker 1: just like popular with doctors. Everyone wanted them, especially after
Speaker 1: Queen Victoria had one of her kids with I don't
Speaker 1: know if it was ether or chloroform, but it was
Speaker 1: like made the news. You know who administered it, John
Speaker 1: Snow as John John Snow of Color Effe color not
Speaker 1: disgraced Game of Thrones. Yeah yeah, wow yeah, And so
Speaker 1: that that really I think allowed people to go, oh,
Speaker 1: I want that, And she was like, this was great.
Speaker 5: Yeah, it again, I would highly recommend.
Speaker 1: Yes, okay, yeah, and it's I think it's pretty easy
Speaker 1: to see the appeal if you if you look at
Speaker 1: some of them, I mean, even not based on today,
Speaker 1: but like and like people you know you have experienced
Speaker 1: child grouth, but the at the time, you know, in
Speaker 1: these diary entries. In these letters, women described their labor
Speaker 1: pains as travail suffering, screams of agony, anguish tortures, pains
Speaker 1: from hell, and from the doctor's perspective, popular there too, right.
Speaker 1: It made for a much more compliant patient whose arms
Speaker 1: and legs would usually be strapped down to the bed.
Speaker 1: And yeah, this is when the bed often became the
Speaker 1: place instead of like a birthing stool, instead of leaning
Speaker 1: on somebody else, instead of doing what feels like you
Speaker 1: want to do, you were physically, in some cases strapped
Speaker 1: down to a bed. I'm not going to get into
Speaker 1: twilight sleep here, because I had a long section that
Speaker 1: I was like, this deserves its own thing when we
Speaker 1: talk about, you know, anthesia, but twilight birth was this
Speaker 1: thing where you would be given like scopolamine and something
Speaker 1: else and often the effect was not or the goal
Speaker 1: was not necessarily to believe pain, but it was to
Speaker 1: make you forget and it could induce a lot of
Speaker 1: anxiety and delusions, and so they would be physically strapped down.
Speaker 1: And then this idea was that you would wake up
Speaker 1: with a baby in your arms.
Speaker 3: Alah Madmen Allah.
Speaker 1: Madmen and Betty Yeah yep. By nineteen hundred, ether or
Speaker 1: chloroform was used in fifty percent of births attended by
Speaker 1: a physician. Wow, ether or chloroform. And we got better
Speaker 1: lead around in terms of like the safety because a
Speaker 1: lot of doctors did have concerns about the safety of
Speaker 1: like general anesthesia and these in particular, and the demand
Speaker 1: for anesthesia during childbirth actually helped to speed up the
Speaker 1: move from home birth to hospital because the equipment necessary
Speaker 1: to administer these drugs would be hard to haul around
Speaker 1: from like house to house. The introduction of both anesthesia
Speaker 1: and other medical tools changed expectations for childbirth in the
Speaker 1: late nineteenth century. It can be done quickly, safely.
Speaker 3: And with no pain.
Speaker 1: That was what childbirth had become, right like, this is
Speaker 1: what medicine promised. This is an option, and of course
Speaker 1: that was not always the reality, Nor was it the
Speaker 1: reality for those who couldn't afford to pay for a physician,
Speaker 1: or who felt it was taboo to have a man
Speaker 1: present during labor and delivery. Doctors charged more for midwives, so,
Speaker 1: for instance, Martha Ballard charged two dollars for her assistance
Speaker 1: during labor and delivery and her contemporary doctor Page charged
Speaker 1: six dollars. Yeah, this could be a lucrative job for physicians,
Speaker 1: and as more doctors incorporated childbirth into their practice, they
Speaker 1: increasingly saw midwives as competition for patients rather than collaborators.
Speaker 1: And instead of this high price discouraging people from hiring doctors,
Speaker 1: it played into the psychological phenomenon familiar to many of us.
Speaker 1: All of us were higher price is equated with higher quality. Yeah, yeah,
Speaker 1: and that is completely understandable, right. Who wouldn't pay whatever
Speaker 1: they could if it meant the best care possible for
Speaker 1: mom and baby? The issue was whether it was actually
Speaker 1: the best care. In the last few decades of the
Speaker 1: eighteen hundreds, childbirth became increasingly medicalized. Physicians now attended nearly
Speaker 1: half of all births and tried their hands at various interventions,
Speaker 1: none of which had been adequately examined. For safety or efficacy,
Speaker 1: and while women still held the power in home childbirth,
Speaker 1: doctors were growing more resentful of that conversation should be prohibited.
Speaker 1: Nothing is more common than for the patient's friends to
Speaker 1: object to blood letting urging as a reason that she
Speaker 1: has lost blood enough of this, They are in no
Speaker 1: respect suitable judges. Oh gosh right, Her friends are probably
Speaker 1: like she is, like, she has been drained, stoppedop. And
Speaker 1: he's like, oh, come on, you don't know anything.
Speaker 3: Yeah, you didn't go to Harvard.
Speaker 1: Medical schools were also blamed for high rates of pupil
Speaker 1: fever and sepsis, despite adence that it was in fact
Speaker 1: doctors who were more much more responsible for the infections
Speaker 1: due to their proclivity to just go from cadaver dissection
Speaker 1: to the labor and delivery room in hospitals. Listened to
Speaker 1: our pupil fever episode. There's so much more on that,
Speaker 1: And in fact, maternal mortality in the US was on
Speaker 1: the decline by the end of the nineteenth century, but
Speaker 1: it plateaued for a while until the late nineteen thirties,
Speaker 1: which was after most births were happening in hospitals. Interesting, okay,
Speaker 1: and that's probably because of all of the adjustment we'll
Speaker 1: call charitably call it adjustment for transition to the hospital
Speaker 1: where people were still trying to figure things out.
Speaker 4: Well and still studying and learning things because they hadn't
Speaker 4: done that, right.
Speaker 1: Yep, it's all yeah, yeah, the field of gynecology being
Speaker 1: built on the backs of people who probably did not
Speaker 1: consent in a way that was meaningful. Oh yeah, yeah,
Speaker 1: Medical Bondage. For more on that, Medical Bondage. Yes, yeah,
Speaker 1: that's such a great book. The US seemed an especially
Speaker 1: deadly place to have a baby. In nineteen ten, one
Speaker 1: mother died for every one hundred and fifty four live births.
Speaker 3: Wow.
Speaker 1: Compare that to Sweden at the same time, where the
Speaker 1: number was one in every four hundred and thirty.
Speaker 3: Okay, yeah wow.
Speaker 1: In the early nineteen hundreds, US states introduced laws banning midwiffery,
Speaker 1: and all midwiffrey became illegal in nineteen fifty nine under
Speaker 1: a law that redefined midwiffery as the practice of medicine.
Speaker 4: Interesting, eron, I did not know that.
Speaker 1: Yeah, And I'm not saying that we should have like
Speaker 1: there's like, I'm not advocating for a blanket defense of midwiffery.
Speaker 1: At the time, because undoubtedly they were unnecessary injuries or
Speaker 1: infections and deaths at the hands of midwives, just as
Speaker 1: there were for doctors. But those early bands did not
Speaker 1: provide any pathways for training or certification for midwives, and
Speaker 1: so then that disproportionately impacted poor women who couldn't afford
Speaker 1: a doctor or who were then forced to go to
Speaker 1: a hospital, which were deadly at the time.
Speaker 4: And this is like at the time when becoming a physician,
Speaker 4: and like the process of that is becoming very well regulated.
Speaker 4: Oh even before then, yes, and then there's no pathway
Speaker 4: to become a like certified licensed midwife the way that
Speaker 4: we have today with like a registered nurse midwife kind
Speaker 4: of thing.
Speaker 1: And so other countries did have that pathway for midwise
Speaker 1: in the US we did not get it, okay, And
Speaker 1: so then this eliminated an entire career path that women had.
Speaker 1: So then what what do you do?
Speaker 3: Interesting?
Speaker 1: Okay, this process devalued the contribution of midwives and the
Speaker 1: importance of human presence as an essential part of care,
Speaker 1: like familiar human presence, not just like a nurse or
Speaker 1: a doctor popping in every hour thirty minutes something like that.
Speaker 1: This also furthered the notion of pregnancy and childbirth as pathologies.
Speaker 1: The father of modern obstetrics, Joseph D. Lee. Does his
Speaker 1: name sound familiar to at all? I don't think I've
Speaker 1: ever talked about him, Yeah, okay, I didn't know if
Speaker 1: like in med school or something. Okay, he wrote in
Speaker 1: nineteen twenty. So frequent are these bad effects that I
Speaker 1: often wonder whether nature did not deliberately intend women to
Speaker 1: be used up in the process of reproduction in a
Speaker 1: manner analogous to that of salmon, which dies after spawning.
Speaker 1: Oh my god, we're just fish. That's also also male
Speaker 1: salmon die too. Come on.
Speaker 4: But also that's like doesn't make evolution, Like clearly you
Speaker 4: don't understand evolution for that to make so, because salmon
Speaker 4: spawned like bajillions of fish. Listen, and we're reproducing one
Speaker 4: offspring at a time, who's going to require intensive care thereafter?
Speaker 8: Like?
Speaker 3: Come on.
Speaker 1: He's the father of modern obstetric case and not the
Speaker 1: modern synthesis and evolutionary Okay, I'm for his part because
Speaker 1: there's nuance to every most people. He was aware of
Speaker 1: the dangers that hospitals posed in terms of infections, and
Speaker 1: he was a big advocate for home birth or like
Speaker 1: birthing centers and keeping and like creating new different types
Speaker 1: of maternity wards where it would be separate from the
Speaker 1: rest of the hospital and you had different kind of care. Interesting, Okay, okay, right, still,
Speaker 1: thanks for Salmon. But pathologizing childbirth was a way to
Speaker 1: send home the message that midwives were not qualified. Right,
Speaker 1: this is a dangerous state, and you need someone who
Speaker 1: is has been trained in this way and has this
Speaker 1: you know, diploma from this university, right, yea. And the
Speaker 1: way that society saw women during this time, especially middle
Speaker 1: and upper class white women, as fragile and over civilized
Speaker 1: in need of protection this birth exactly, exactly, And so
Speaker 1: all of these factors drove childbirth from the home to
Speaker 1: the hospital. Midwiffrey discredited and banned the pathologization of childbirth,
Speaker 1: the growth of hospitals, women themselves choosing hospitals and physicians.
Speaker 1: As Levitt writes, women who opted for hospital childbirth quote
Speaker 1: gave up some kinds of control for others because, on balance,
Speaker 1: the new benefits seemed more important. Okay, yeah, yeah, that's
Speaker 1: completely understandable.
Speaker 3: Yeah.
Speaker 1: One woman wrote to her mother in nineteen eighteen, I
Speaker 1: have placed myself in the hands of a specialist in obstetrics.
Speaker 1: I have every confidence in him, and it is a
Speaker 1: great relief. Another described her hospital stay as a quote
Speaker 1: unquote lovely vacation, but some women felt the loss of
Speaker 1: familiar faces keenly quote. The cruelest part of hospital childbirth
Speaker 1: is being alone among strangers. Another called it a nightmare
Speaker 1: of impersonality. Another quote months later, I would scream out
Speaker 1: loud and wake up remembering that lonely labor room and
Speaker 1: just feeling no one cared what happened to me. No
Speaker 1: one kind reassuring word was spoken by nurse or doctor.
Speaker 1: I was treated as if I was an inanimate object.
Speaker 3: Oh my god, Yeah, awful.
Speaker 1: Awful, truly like dehumanizing. You are just a machine to
Speaker 1: make babies, so no one cares about your mental well being.
Speaker 1: We know best. This period from the nineteen thirties to
Speaker 1: the nineteen sixties is marked by tremendous gains and our
Speaker 1: understanding of the physiology of childbirth, which is clear from
Speaker 1: the drastic drop in maternal and neonatal mortality during this time.
Speaker 1: But along with those gains came losses, the loss of
Speaker 1: control and choice that women had in previous centuries, the
Speaker 1: loss of friends and family in the birthing room and
Speaker 1: the loss of a voice. This was just how it was.
Speaker 1: Deal with it. This is what you get. And it
Speaker 1: took women years to reckon with those losses and to
Speaker 1: put words to them. And of course not everyone felt
Speaker 1: those losses to the same degree. Right, Some women didn't
Speaker 1: think twice about their hospital experience. It was a lovely vacation.
Speaker 1: Others maybe didn't love it, but didn't mind it overall,
Speaker 1: and it was like, yeah, okay, that was.
Speaker 3: Sure, was what it was, and now it's done right exactly.
Speaker 1: And then some were completely traumatized and everything in between. Yeah,
Speaker 1: as we've said a million times, there is no universal childbirth, pregnancy,
Speaker 1: postpartum experience. In the nineteen sixties and the nineteen seventies,
Speaker 1: those who did feel the losses began to fight against them.
Speaker 1: To reclaim a voice in the birthing room. They demanded
Speaker 1: that their partners be allowed in that they could breastfeed
Speaker 1: on their own schedule rather than the hospital mandated one.
Speaker 1: Oh that is really really interesting. Yeah, and they would
Speaker 1: be like, oh no, not here two hours.
Speaker 4: And they also that was at the time when it
Speaker 4: was like nurseries, and so your baby was taken away
Speaker 4: and put in a nursery, which is like the opposite
Speaker 4: of what we do now, which also people have opinions
Speaker 4: about because then it means a mother doesn't get any rest.
Speaker 3: Oh my god, there's so much I don't.
Speaker 1: Know, right, I mean, we have this is like jumping
Speaker 1: ahead a little bit. But the history of this, this
Speaker 1: whole series, yeah, just shows us that, like we don't
Speaker 1: have everything figured out. And that's I mean, that's okay.
Speaker 1: It is things are really overall good, yeah, and which
Speaker 1: people are talking about them, are researching them, are writing
Speaker 1: about them, are sharing their experiences. I think it just
Speaker 1: gives such hope that things will continue to improve. But
Speaker 1: it is really also that is not to erase the
Speaker 1: experience of people who are like I did not have
Speaker 1: a good.
Speaker 4: Time, right, yeah, right, And I think I think it
Speaker 4: is just so interesting to do what you're doing right now, Aaron,
Speaker 4: which is like look back at like how did it
Speaker 4: used to be, How did people feel about that at
Speaker 4: the time, How did we get from there to here?
Speaker 4: Why did the pendulum swing this way? Where are we
Speaker 4: in this pendulum arc right now? It's so interesting to
Speaker 4: go back and try and kind of piece it together
Speaker 4: on like, because it gives you so much context that
Speaker 4: sometimes might make something that feels horrible today make more
Speaker 4: sense and then make it more like you you can, Okay,
Speaker 4: I understand why this thing happened, right, I think that's
Speaker 4: so important.
Speaker 1: Why why are we here today?
Speaker 3: Why are we here today?
Speaker 1: Yeah? Did not mean to get that existential, although I'm surprised,
Speaker 1: given that this is a series on pregnancy that we
Speaker 1: haven't gotten that existential for that. Yeah, putting it all
Speaker 1: on the table, all on the table. But yeah, all
Speaker 1: of these, all of these new choices or choices that
Speaker 1: previously had not been available, things like having your your
Speaker 1: partner in the room, right, breastfeeding whenever you want, do
Speaker 1: I want an epidural or not? And so many other
Speaker 1: choices that simply probably were not available. Right, And we
Speaker 1: are now, I think, coming to terms with some of these,
Speaker 1: like the voices and the range of choices. And I
Speaker 1: will say too that that is a double edged sword.
Speaker 9: Right.
Speaker 1: Since the nineteen seventies, women, along with researchers, doctors, nurses, midwives, dulas, partners, parents,
Speaker 1: have examined the childbirth experience from every angle, asking what
Speaker 1: do I want what's best for me, what's safest for baby?
Speaker 1: How do we balance everyone's needs? And today there are
Speaker 1: so many choices, there are so many options, and there
Speaker 1: are so much information out there that it can feel overwhelming.
Speaker 1: How do you make the right choice, especially when the
Speaker 1: internet has very strong opinions about everything. What happens when
Speaker 1: you are not able to choose or if the choice
Speaker 1: is made for you. Navigating pregnancy, childbirth, and the fourth
Speaker 1: trimester is a huge challenge, which is the understatement of
Speaker 1: this series.
Speaker 5: I'm getting like so many flashbacks right now.
Speaker 1: It's a lot from you.
Speaker 5: Yeah, yeah, yeah, yeah, yeah, keep going home?
Speaker 1: Is this the right strugg the right choice?
Speaker 3: Is that the right choice?
Speaker 5: If I don't make a choice, what does that mean?
Speaker 5: And when if this happens?
Speaker 1: Yes? And what if there's a choice that like, did
Speaker 1: I have a choice? I'm not sure? Yeah that yeah?
Speaker 1: And there are a million voices telling you yes, no,
Speaker 1: maybe in conflict, maybe not in conflict? Do this do
Speaker 1: that that we have more choices and more knowledge today
Speaker 1: than we did sixty or one hundred years ago is
Speaker 1: a powerful testament to the work of countless women and
Speaker 1: modern medicine striving to make this a safer and better experience,
Speaker 1: and of course there's still room for improvement. There will
Speaker 1: always be room for improvement. But understanding our past, understanding
Speaker 1: what we lost during the medicalization of pregnancy, as well
Speaker 1: as just how much we've gained, is crucial for creating
Speaker 1: a better future. Recognizing those gains is especially important because
Speaker 1: I think sometimes we take them for granted, yes, or
Speaker 1: we lose sight of them. Next to the negative impacts
Speaker 1: of medicalization, that is what stands out the most to us.
Speaker 3: Yeah.
Speaker 1: For instance, take postpartum depression and other postpartum perinatal mood
Speaker 1: disorders from pupil insanity in the late nineteenth century, which
Speaker 1: is what it was called, well, which is what it
Speaker 1: was a diagnosis, so it's not necessarily there's more. There's
Speaker 1: more nuance to pupil insanity, yes, yea, to what was
Speaker 1: called baby blues post World War two, to postpartum depression
Speaker 1: finally making it into the DSM four in nineteen ninety four.
Speaker 1: Nineteen ninety four, I told my mom that she was like,
Speaker 1: really wait, oh, and it's not even I know. And
Speaker 1: then in there there's like a whole journey about how
Speaker 1: it got in there, and it was it actually put
Speaker 1: place in there in an appropriate way.
Speaker 3: And what we don't have in there today.
Speaker 1: They don't have in there today. And then also like
Speaker 1: there's the book Blue is really fascinating too because it
Speaker 1: talks about how postpartum depression became like aiined more awareness
Speaker 1: and it was through the work of a lot of
Speaker 1: people advocates who worked really strongly to make people more
Speaker 1: aware of this potential outcome. But the way that popular
Speaker 1: media often seized on postpartum depression was through the most
Speaker 1: sensationalist news stories possible. And so then that was like
Speaker 1: I think in some ways had this effect of oh,
Speaker 1: well I didn't I don't think I had postprime depression
Speaker 1: because it was you know, exactly, wasn't that bad? So
Speaker 1: the extreme scenarios right, right, And I think that we
Speaker 1: have now like there's been such incredible representation in the media,
Speaker 1: and it's still again room for improvement. But yeah, I mean,
Speaker 1: I think it's safe to say that since the late
Speaker 1: eighteen hundred's postpartum depression post part of mental health has
Speaker 1: really been on a journey and ultimately creating a clinical
Speaker 1: definition for PPD imperfect, though it may be, it opened
Speaker 1: up research areas for treatment. It raised awareness and established
Speaker 1: ways to treat people or reach people who might need help,
Speaker 1: and it removed some of the blame that had been
Speaker 1: so central to postparti mental health for decades. Oh, she's
Speaker 1: depressed because she hasn't accepted her role as a mother,
Speaker 1: thanks Freud. She's got PPD because she had a C section.
Speaker 1: Working moms bring on PPD themselves because they're just not equipped. Yeah. Yeah,
Speaker 1: blame certainly remains. It is not gone by any means.
Speaker 1: But turning this into a more having a more biological
Speaker 1: framework for understanding this has helped to remove some of
Speaker 1: that to some degree. And there is, of course downside
Speaker 1: to this medicalization, right it has discouraged to some degree
Speaker 1: consideration of systemic and societal drivers that might underlie PPD
Speaker 1: that I know you're going to talk about, sure, am By,
Speaker 1: because if you're treating it just as a hormonal or
Speaker 1: chemical imbalance, and it's like so, but it's not happening
Speaker 1: in a vacuum.
Speaker 4: Oh my god, Aaron, I literally can't believe how well
Speaker 4: this is like segueing in.
Speaker 5: To what I'm going to talk about, Like we do this,
Speaker 5: it's like it's our job.
Speaker 1: But yes, yes, And it creates boundaries around what is normal, right,
Speaker 1: And those boundaries might be different for different people, But
Speaker 1: it's really hard to incorporate that into a medical definition, right.
Speaker 1: And I will say also those boundaries are a necessary
Speaker 1: part of any medical definition. But having that lack of
Speaker 1: nuance in understanding the individual can also be really have
Speaker 1: consequences associated with it. Yeah, personalization of care is a
Speaker 1: crucial aspect, not just for PPD, but also for childbirth
Speaker 1: and pregnancy more broadly. And I want to end with
Speaker 1: yet another quote by Judith Walser Levitt. I really loved
Speaker 1: this book. As you can tell quote, throughout American history,
Speaker 1: women have wanted and have worked to achieve their own
Speaker 1: deals of childbirth, ideals that have developed and been nurtured
Speaker 1: within their own communities in conjunction with the rest of
Speaker 1: their life experiences. Childbirth remains as it has always been
Speaker 1: a cultural event as much as a biological one. Problems
Speaker 1: emerged during the middle of the twentieth century because the
Speaker 1: hospital acted to homogenize the birth experience and make it
Speaker 1: similar for all women. But childbirth cannot successfully be reduced
Speaker 1: to one kind of experience, and at the same time,
Speaker 1: satisfy the wide range of expectations women bring to it.
Speaker 1: The diversity that women seek will continue to reflect the
Speaker 1: differences of the women themselves. End quote and chills and
Speaker 1: with that, err and oh turn it over me right there.
Speaker 1: Tell me about the fourth trimester.
Speaker 5: Okay, you might need a little breather after that.
Speaker 1: Okay, we can do that.
Speaker 5: I'll take a break and then get into it.
Speaker 1: Sho, let's do it.
Speaker 9: At thirty two years old, I got pregnant for the
Speaker 9: first time. I had what you'd call a textbook pregnancy,
Speaker 9: healthy baby, low risk, and a noticeabook low.
Speaker 3: But there was a lot of.
Speaker 9: Things that I wasn't warned about, and things that just
Speaker 9: weren't talked about unless I brought them up harmy and
Speaker 9: I started trying for a baby in September, and luckily enough,
Speaker 9: by November, I was pregnant. My first symptom wasn't warning
Speaker 9: sickness or anything like that. In fact, it was excruciating
Speaker 9: period pain. I genuinely thought I was about to have
Speaker 9: the worst period ever, as some kind of cruel joke.
Speaker 9: Turns out, it was implantation. The next time I felt
Speaker 9: that level of pain was actually an active labor within
Speaker 9: two weeks of conception, my body already started changing. My
Speaker 9: boobs went from an age with seacup almost a night overnight,
Speaker 9: and they continued to grow throughout my pregnancy and got
Speaker 9: pretty big during breastfeeding. My stomach also grew quickly. I
Speaker 9: was mostly water because the baby boy was measuring perfect
Speaker 9: the entire time. I was very lucky when it came
Speaker 9: to nausea. I only experienced it for about a week
Speaker 9: and cardamin tea helped a lot. I only vomited twice,
Speaker 9: once from a bad meal which my husband also got
Speaker 9: sick from, and once when I accidentally ate bacon. Because
Speaker 9: pork was a major food version for me, which is
Speaker 9: kind of surprising giving my Italian Australian background. Thankfully, since
Speaker 9: my husband is Muslim, pork wasn't something I had to
Speaker 9: deal with in the house. The cravings did start really
Speaker 9: early at first, to as salt, venigo, chips, and anything sour,
Speaker 9: especially lemon ice cream. In a second trimester, I craved
Speaker 9: corn and coffee. Of course, I only ate drank decaf,
Speaker 9: but I never drank coffee before pregnancy. Funnily enough, I'm
Speaker 9: still drinking it now after giving birth. By the third trimester,
Speaker 9: my cravings had evolved to steak with an egg on top.
Speaker 9: On the flip side, I couldn't stand chicken or pork.
Speaker 9: Even the smell of chicken maybe nauseous, to the point
Speaker 9: that if my husband ate it, he had to brush
Speaker 9: his teeth before coming miming. Pregnancy also came with a
Speaker 9: long list of symptoms. I just wasn't prepared for. Blood noses,
Speaker 9: gray hairs, loose ligaments, ligament pain triggered by sneezing, dry skin,
Speaker 9: exhaustion that left me sleeping for ten hours at night
Speaker 9: and then still napping for four hours during the day,
Speaker 9: acid reflux, and reoccurring thrush, which I had never experienced
Speaker 9: before pregnancy. The physical strain was pretty intense. At times,
Speaker 9: it felt like I'd done a hardcore leg day at
Speaker 9: the gym, or I'd been riding a horse bearback for hours.
Speaker 9: I had to give up weightlifting and running because I
Speaker 9: was just too exhausted. But I did manage to do
Speaker 9: a little bit of yoga a couple of times a week,
Speaker 9: and maybe that's why I could still time my own
Speaker 9: shoes at nine months pregnant.
Speaker 3: Who knows.
Speaker 9: In my third trimester, I needed an iron infusion. My
Speaker 9: iron levels were actually fine, but my hemoglobins were slightly load,
Speaker 9: so it was recommended that I do it. Around this time,
Speaker 9: baby boy started moving into position and I could feel
Speaker 9: every shift. There was a moment when I genuinely thought
Speaker 9: that he might just fall out because of how low
Speaker 9: he moved. Despite all the unexpected symptoms, I got the
Speaker 9: birth experience that I wanted. I had a pain relief
Speaker 9: water berth, and in the final moments, I reached down
Speaker 9: and pulled my baby at myself. It was an intense
Speaker 9: and transformative experience and one that I'm really grateful for.
Speaker 9: Looking back, I know I was lucky to have such
Speaker 9: a smooth pregnancy, but that doesn't mean it was easy.
Speaker 9: There were a lot of challenges, surprises, and lots of
Speaker 9: moments of discomfort. Through it all, my body did exactly
Speaker 9: what I needed to do, and I'm so grateful for
Speaker 9: my body for doing that and for giving me my beautiful,
Speaker 9: healthy baby boy.
Speaker 10: Hi, Aaron's. My name is Miranda, and I want to
Speaker 10: thank you for allowing me to share my pregnancy and
Speaker 10: birth journey. I have to say that overall, my pregnancy
Speaker 10: journey was relatively uneventful and I'm very thankful for that
Speaker 10: for the health of myself and of my baby boy,
Speaker 10: who is now eighteen months old. I will say the
Speaker 10: most annoying and most prominent pregnancy symptom I had was
Speaker 10: actually carpal tunnel syndrome, which going into pregnancy I had
Speaker 10: no idea that that was a common symptom. I spent
Speaker 10: probably the second half of my pregnancy with my hands
Speaker 10: being numb or tingling, or painful, almost twenty four to seven,
Speaker 10: so that was definitely frustrating. Other than that, towards the
Speaker 10: end of my pregnancy, I started to have some gestational hypertension,
Speaker 10: so we did a few non stress tests in biophysical
Speaker 10: profiles to make sure that I was safe and that
Speaker 10: my little guy was safe. On the fourth of July,
Speaker 10: maybe I had a little too much fun on the
Speaker 10: lake and enjoyed some salty snacks, but my blood pressure
Speaker 10: did go pretty high, so they ended up deciding to
Speaker 10: induce me when I was due in mid July, so
Speaker 10: it was not too early. I really didn't need much
Speaker 10: of a kickstart for labor. Thankfully, I started labor pretty
Speaker 10: darn quickly without even having any potocin. Unfortunately, I did
Speaker 10: not progress in labor as we'd hoped. I was in
Speaker 10: labor for eighteen hours and I was dilated to nine
Speaker 10: and a half centimeters and I was stalled out. So
Speaker 10: after about six hours stalled out, my son's heart rate
Speaker 10: started dropping, and my doctor advised us that we could
Speaker 10: wait a little bit longer and potentially have to have
Speaker 10: an emergency sea section, or we could just do a
Speaker 10: sea section now, And after eighteen hours of labor, I
Speaker 10: was on board with that. We had a beautiful and
Speaker 10: wonderful sea section experience, and I'm so thankful for all
Speaker 10: of the staff and my husband and my mom for
Speaker 10: being there to support me. I was very surprised by
Speaker 10: the swelling after the sea section. I couldn't wear shoes
Speaker 10: for two to three days, But other than that, my
Speaker 10: little guy was happy and healthy and I had an
Speaker 10: overall great experience. Thank you.
Speaker 4: So last week, at the end of episode three, I
Speaker 4: ended where most conversations regarding pregnancy end, and that is once.
Speaker 1: The baby's delivered, right, everything's over. Yeah, But that's not
Speaker 1: where pregnancy ends.
Speaker 3: At all.
Speaker 4: So Aarin, you just walked us through a lot of
Speaker 4: the kind of social and institutional, high level factors that
Speaker 4: have caused this shift in where delivery happens, and how
Speaker 4: these things have kind of contributed to a lot of
Speaker 4: the big picture postpartum outcomes. Those big picture things are
Speaker 4: like maternal mortality rates, even like postpartum depression rates, which
Speaker 4: we'll get into. And so that is where I'm I'm
Speaker 4: kind of picking up your threads right there, perfect, but
Speaker 4: then I'm gonna unravel them a little bit more to
Speaker 4: also remind us of what is going on biologically in
Speaker 4: this so called fourth trimester, why it might be rocky
Speaker 4: for some of us. And my favorite, what do we
Speaker 4: know about evidence based ways to improve outcomes?
Speaker 1: Evidence based? What a beautiful phrase. Oh, I just love it.
Speaker 3: You want a spoiler alert on what it is we
Speaker 3: don't know public health?
Speaker 1: Oh, okay, don't worry. We know we don't know.
Speaker 5: No, we do know health.
Speaker 1: But then, yeah, do we invest in public health?
Speaker 5: Maybe we will.
Speaker 4: Someone will listen to this episode and be like, aha,
Speaker 4: I didn't want to read the Lancet Global Health article,
Speaker 4: but I listened to this podcast will kill you, and.
Speaker 3: Now I have all the answers.
Speaker 4: Okay, I do also want to quickly acknowledge what I
Speaker 4: Am not going to talk about in this episode, even
Speaker 4: though it's so cool, And that is the physiology of
Speaker 4: the newborn. Just like I kind of breezed through early
Speaker 4: embryonic development and I didn't talk at all about the
Speaker 4: rest of fetal development. I am not going to talk
Speaker 4: about the physiology of the newborn, but it is really
Speaker 4: cool and fascinating.
Speaker 1: We'll do it someday. Second fourth trimester exactly.
Speaker 4: Yeah, yeah, but this is pregnancy, and so this is
Speaker 4: the fourth trimester of pregnancy. Yeah, pregnant person, Yes, Okay. Physiologically,
Speaker 4: there is still a lot of changes to take place
Speaker 4: after the baby and placenta have been delivered. Now, the placenta,
Speaker 4: our favorite, is the primary organ that was making all
Speaker 4: of the hormones that kept the pregnancy going. So once
Speaker 4: that placenta has been delivered, you have a rapid withdrawal
Speaker 4: of placental hormones, and that results in significant decreases because
Speaker 4: the placental hormones are like there's a whole bunch of
Speaker 4: different things, and a lot of them. It's not necessarily
Speaker 4: just like estrogen and progesterone alone, but it's like hormones
Speaker 4: that are telling us to make more estrogen and progesterone
Speaker 4: and stuff.
Speaker 1: It's it's like both a radio tower. It's not just
Speaker 1: like a trans Okay, here's what I was thinking. Love
Speaker 1: is blind. It's not just the window between the two, right,
Speaker 1: It's like if the window we're also saying now go
Speaker 1: get flat. Also the producers, Yes, the producers. Analogy does
Speaker 1: not need to exist, but I like it. Love a
Speaker 1: bad analogy. Yes, Okay, it's that. Okay, it is the producer,
Speaker 1: the director, whatever.
Speaker 5: But so once this.
Speaker 4: Placenta is gone, you have a significant and pretty rapid,
Speaker 4: like in a number of days weeks decline in estrogen
Speaker 4: and progesterone especially, And this cascade is what results in
Speaker 4: a lot of the physiologic changes that we see. So
Speaker 4: I'm going to kind of walk through again a little
Speaker 4: bit system by system about what some of these changes are.
Speaker 4: Most of these changes kind of get you back to
Speaker 4: and I hate to say back to because it's.
Speaker 3: Really a new normal.
Speaker 4: Okay, But in terms of your physiology, a lot of
Speaker 4: it is closer to pre pregnancy levels of the stuff
Speaker 4: that we're going to talk about by about six weeks.
Speaker 4: Some of it takes about twelve weeks.
Speaker 1: So can I ask a question about, like, what how
Speaker 1: different are those changes? Like is there just a way,
Speaker 1: so I can in my head quantify what that looks like.
Speaker 1: And I guess it's hard to know, like how much
Speaker 1: estrogen is actually.
Speaker 4: Yeah, those numbers, Yeah, I don't know. I think one
Speaker 4: of the graphs that I had in last episode showed
Speaker 4: like hormone concentrations and stuff like that, But there's also
Speaker 4: such ranges. And especially like anyone who is menstruating, your
Speaker 4: levels fluctuate so much with your menstrual cycle. I will
Speaker 4: say that after like in postpardum, you have a withdrawal
Speaker 4: of these hormones, so they go down to very low levels,
Speaker 4: and if you are breastfeeding, they remain suppressed because of prolactin.
Speaker 4: That's being so like the withdrawal of progesterone, skipping around
Speaker 4: to my notes, the withdrawal of progesterone causes an increase
Speaker 4: in prolactin, which is the hormone that stimulates milk production.
Speaker 4: So if you are then breastfeeding, you continue to have
Speaker 4: high levels of prolactin, and that suppresses the release of
Speaker 4: LH which is lutinizing hormone, and FSH which is follicle
Speaker 4: stimulating hormone, and those are what would induce a normal
Speaker 4: ovulatory and menstrual cycle, and that is why you see
Speaker 4: suppression of mensis during breastfeeding, and why that is for
Speaker 4: a lot of people a good form of contraception.
Speaker 1: But doesn't always it doesn't.
Speaker 5: But okay, in no way. But I mean it is
Speaker 5: like it's more effective than condoms.
Speaker 1: Okay, that's interesting.
Speaker 4: It does not get I had a whole paragraph on
Speaker 4: this somewhere, but I can't even find it, so I'm
Speaker 4: gonna just talk to you from my brain. Yeah, it is,
Speaker 4: I forget the exact number, but it is actually quite effective.
Speaker 4: But it's only for the first six months postpartum that
Speaker 4: we have good data on it, and it's only when
Speaker 4: people are exclusively breastfeeding, which does not include pumping, because
Speaker 4: it is also breastfeeding on demand, which means that you
Speaker 4: are breastfeeding based on your newborn's cues and not necessarily
Speaker 4: on an hourly schedule, which is what you end up
Speaker 4: having to do if you're exclusively pumping. Not everybody is
Speaker 4: going to remain a menner reec which means they're not
Speaker 4: having mensis. But it is it as actually, as per
Speaker 4: the World Health Organization guidelines, it is an effective and
Speaker 4: recommended form of birth control for a lot of people.
Speaker 1: Oh my god, Okay, I didn't know that there's more
Speaker 1: nuance because I know a number of people who have
Speaker 1: gotten pregnant. Absolutely absolutely, and.
Speaker 4: So there's more nuance too because if you are sort
Speaker 4: of supplementing with formula, or if you're having to be
Speaker 4: away and then you're pumping and things like that, then
Speaker 4: absolutely your mensies can come back earlier than that six months.
Speaker 4: They can come back in a matter of weeks. Again,
Speaker 4: it's going to be different person to person. That's why
Speaker 4: it's not one hundred percent effective what it means, but yeah,
Speaker 4: it is.
Speaker 3: This is really interesting. Yeah, how about that tangent for
Speaker 3: us there?
Speaker 1: I love a tangent me too.
Speaker 4: So, yes, we see this big hormonal change, and then
Speaker 4: a lot of those physiologic changes that happened to sustain
Speaker 4: the pregnancy are going to kind of unravel themselves.
Speaker 5: So your blood volume, which.
Speaker 4: Again had increased by about fifty percent during pregnancy, is
Speaker 4: going to return to pre pregnancy baseline within a matter
Speaker 4: of weeks. And what that means is that you immediately
Speaker 4: after birth have way more fluid on your body than
Speaker 4: your body thinks that it needs. Now that there's no
Speaker 4: placenta there secreting hormones to say, keep up this blood volume,
Speaker 4: so your kidneys have to take over the work of
Speaker 4: excreting all that extra fluid, and so your kidneys have
Speaker 4: to further increase their diuresis, and so you have this
Speaker 4: physiologic diuresis. So a lot of times you'll you'll be
Speaker 4: very kind of puffy immediately postpartum, and that's because of
Speaker 4: all this excess fluid that your kidneys are now just
Speaker 4: trying to like shunt out, and then you're peeing all
Speaker 4: the time because of that.
Speaker 1: And how long does that last?
Speaker 4: A few days usually for like the physiologic diuresis, I
Speaker 4: think it. I don't remember the exact days that it peaks,
Speaker 4: but it's like a few days and then you kind
Speaker 4: of go back to your pre pregnancy baseline. Ish your
Speaker 4: GI tract, which remembers slowed down a lot during pregnancy
Speaker 4: because of progesterone, It actually slows down even further during labor,
Speaker 4: and it will start to return to a pre pregnancy
Speaker 4: type of functioning, like mobility will come back within a
Speaker 4: few days. But in those first few days immediately postpartum,
Speaker 4: you can have that continue like it's a little bit
Speaker 4: more slow, and that can result in constipation. This is
Speaker 4: exacerbated by c sections because those are again abdominal surgeries
Speaker 4: where it can cause the bowels to kind of like
Speaker 4: go to sleep a little bit, and so that can
Speaker 4: mean that you can end up a little bit constipated. Plus,
Speaker 4: opioids are often used, and so those slow down the
Speaker 4: bowels even more. So that can make people either very
Speaker 4: nervous about their first bowel movement postpartum because if whether
Speaker 4: you had a vaginal delivery or a C section, you
Speaker 4: might be worried about a hard stool that might be
Speaker 4: harder to pass. So, yes, that's the thing that can happens.
Speaker 4: Constipation postpartum usually gets better within a few days unless
Speaker 4: you're on opioids continuously. Okay, Yeah, Your uterus, which of
Speaker 4: course had to grow so large that it displaced all
Speaker 4: of the rest of your organs, like we talked about
Speaker 4: last episode, has to shrink back down, and it does
Speaker 4: this very quickly, except that it doesn't go all the
Speaker 4: way back to pre pregnancy baseline until a number of
Speaker 4: weeks later, closer to like six weeks later, because it
Speaker 4: just has to like continue to shrink. Part of that
Speaker 4: process also means a couple things are happening to encourage
Speaker 4: that process. One is that the release of oxytocin, which
Speaker 4: is triggered by breastfeeding. So for people who are breastfeeding,
Speaker 4: they're going to have an increase in the release of oxytocin.
Speaker 4: That oxytocin is the hormone that stimulates uterine contraction, so
Speaker 4: that's going to cause further uterine shrinkage back down to
Speaker 4: like the size of a fist, which is what it
Speaker 4: is pre pregnancy.
Speaker 1: And is that pumping or.
Speaker 4: Pumping or breastfeeding either one. And then even if you
Speaker 4: are not breastfeeding, it's still going to shrink on its own.
Speaker 4: It just might maybe take a little bit longer or
Speaker 4: things like that. But yeah, so that it's going to
Speaker 4: take a few weeks before it really goes back down.
Speaker 4: It's not like a automatic It clamps way down, but
Speaker 4: it doesn't like go back takes time.
Speaker 1: Yeahs sense.
Speaker 4: And as part of all of this, as this uterus
Speaker 4: is continuing to shrink and contract, it also means that
Speaker 4: you are going to be shedding all of the remnants
Speaker 4: of your endometrium. Regardless of your mode of delivery, you
Speaker 4: are going to be shedding this lining of your uterus,
Speaker 4: and your uterus is remodeling its whole inner lining. So
Speaker 4: you have a lot of vaginal bleeding. This is called lokia.
Speaker 4: That's like just what we call the postpartum heating l
Speaker 4: o chia.
Speaker 1: Huh lokia. And how how long does that last? How
Speaker 1: much blood?
Speaker 4: Like, yeah, so how much blood can vary? Of course,
Speaker 4: it usually can last anywhere from like a couple of
Speaker 4: weeks to a month or more, totally person dependent, okay, Yeah, and.
Speaker 1: The amount of like relative to a regular like if
Speaker 1: you have more regular periods.
Speaker 5: What is a regular period.
Speaker 1: For an individual that doesn't even that?
Speaker 5: No, yeah, it totally varies.
Speaker 4: What I will say is what we Okay, we talked
Speaker 4: a lot about postpartum hemorrhage last episode. Yeah, delayed postpartum
Speaker 4: hemorrhage is also a thing where you can have a
Speaker 4: hemorrhage that occurs later on after delivery, in the days
Speaker 4: or weeks.
Speaker 1: Posts or weeks okay.
Speaker 4: And so what I will say is like the general
Speaker 4: advice in terms of how much is too much bleeding?
Speaker 4: I don't actually like to give medical advice on this podcast.
Speaker 4: This is not medical advice. We are not your doctors.
Speaker 4: We can hould your doctor. But usually if somebody is
Speaker 4: bleeding so much they're that they're like completely saturating pads
Speaker 4: for like hours in a row, or they're passing very
Speaker 4: large blood clots, that is usually considered too much bleeding. Okay,
Speaker 4: so it's kind of it should be like a moderate amount,
Speaker 4: but not like heavy heavy bleeding, right, But again can
Speaker 4: farely vary. Some people have very little bleeding, okay. Yeah,
Speaker 4: And then we of course have milk production, which we
Speaker 4: kind of already talked about, so I can skip it
Speaker 4: unless you have any other questions about that.
Speaker 1: When does it really like, of course I have questions
Speaker 1: about that? Kidding me.
Speaker 4: So the first milk quote unquote that you produce. All
Speaker 4: of this is stimulated by again this withdrawal of hormones
Speaker 4: and then the increase of prolactin. But even as that process,
Speaker 4: before that process is really kind of kicked in, in
Speaker 4: those first couple of days, your body is producing this
Speaker 4: substance called colostrum, and that's that kind of yellowy like
Speaker 4: it's a different texture, it looks different substance. We actually
Speaker 4: start making that most people during about the second trimester.
Speaker 4: Some people might notice it, some people might not and
Speaker 4: then it takes usually two or three days on average
Speaker 4: for your breast milk to come in okay. In people
Speaker 4: who aren't going to be breastfeeding, there are a lot
Speaker 4: of situations that can cause challenges to that, whether it's
Speaker 4: delayed milk production. One of the risk factors for delayed
Speaker 4: milk production might be a sea section. The mechanism there
Speaker 4: not fully known right, we don't know, but it is
Speaker 4: the case that sea section is associated with an increased
Speaker 4: risk of delayed milk production. Also early delivery, whether that's
Speaker 4: early term which would be before thirty seven weeks, or
Speaker 4: like late pre term it's like thirty four to thirty
Speaker 4: six weeks or so in there, or even just that
Speaker 4: like early term thirty seven thirty eight weeks. Sometimes people
Speaker 4: have a little bit of a delay or have like
Speaker 4: a little bit of a delayed start in their breast
Speaker 4: milk production. And then there is so many individual factors
Speaker 4: as well that play in have you ever breastfed before?
Speaker 4: Like so many different things. There's also infant factors that
Speaker 4: can really contribute to the successful breastfeeding relationship. Babies who
Speaker 4: are born early, either that early term or preterm, might
Speaker 4: have difficulty latching. They might not have really good muscle
Speaker 4: tone yet because they weren't fully developed in utero, and
Speaker 4: so they don't have a great suck.
Speaker 9: Like.
Speaker 4: There's literally so many things, And I feel very strongly
Speaker 4: about the rhetoric around breastfeeding today. Yeah, I do feel
Speaker 4: that it deserves its whole own episode.
Speaker 1: We will do one, absolutely, because there is a lot
Speaker 1: to unpack there. Yeah, And the short answer is, in
Speaker 1: my opinion and per medical establishment, regardless of whether they
Speaker 1: admit it.
Speaker 3: Or not, fed is best.
Speaker 4: Okay, long story short, two to three days for breast
Speaker 4: milk production postpartum.
Speaker 3: Usually.
Speaker 4: Now, during all of these physiologic changes that we've gone through,
Speaker 4: whether you notice them or not, Like you might not
Speaker 4: notice your blood volume changing, but you might notice that
Speaker 4: you're peeing a.
Speaker 3: Lot sort of a thing.
Speaker 4: You also have just given birth, either vaginally or through
Speaker 4: a C section, so you might have stitches either in
Speaker 4: your abdomen or in your paraneum or maybe not. In
Speaker 4: either case, you're probably going to be sore. There's going
Speaker 4: to be pain that is there because of the whole
Speaker 4: process that literally just happened. And then on top of that,
Speaker 4: you have an infant or multiple who needs literal constant.
Speaker 1: Care, constant around the clock, cannot be.
Speaker 4: Left alone for like a minute. Who sucks at sleeping?
Speaker 4: They suck at it?
Speaker 1: Why are they so bad at sleeping?
Speaker 4: Why are they so bad at sleeping? They suck at pooping.
Speaker 4: They're not even good at there. They suck at eating.
Speaker 4: They cannot figure it out, and you are now entirely
Speaker 4: responsible for them. This is a very difficult time period.
Speaker 4: Even if you are good at it, or you've done
Speaker 4: it before or something like that, it's very hard. And
Speaker 4: we talked in these last few episodes a lot about
Speaker 4: the risky parts of pregnancy, the postpart and period. Really often,
Speaker 4: especially in the US, gets dismissed. Oh right, Yeah, but
Speaker 4: all of these physiologic changes that we've gone through, they
Speaker 4: don't reverse themselves automatically, and they are still kind of
Speaker 4: change and finding a brand new baseline in this postpartum period,
Speaker 4: which means that we are still at increased risk of
Speaker 4: things like postpartum pre acclampsia yeah okay, of delayed postpartum
Speaker 4: hemorrhage like I talked about. There's also the risk of
Speaker 4: infections like endometritis, which can happen post delivery. So there
Speaker 4: is a lot of different topics that I could go into,
Speaker 4: but what I'm going to now shift to focusing on
Speaker 4: is one of the biggest contributors to postpartum morbidity, and
Speaker 4: that is postpartum depression and postpartum anxiety and other postpartum
Speaker 4: mood disorders. So postpartum depression, which is the one that
Speaker 4: gets probably the most pressed these days and is the
Speaker 4: most well defined because it does exist kind of in
Speaker 4: the DSM five. It is generally recognized as more than
Speaker 4: two weeks, and sometimes it's like has to be developed
Speaker 4: in the first four weeks of a depressed mood in
Speaker 4: the postpartum period, and we use a number of different
Speaker 4: screening tools that are very well validated, like this questionnaire
Speaker 4: which is called the Edinburgh Depression Scale or Edinburgh Postpartum
Speaker 4: Depression Scale to decide if somebody meets criteria or needs
Speaker 4: additional evaluation for postpartum depression. So it's a series of
Speaker 4: questions and there are things like how like in the
Speaker 4: last two weeks, how often have you felt like I'm
Speaker 4: not looking forward to enjoyment with things, or how often
Speaker 4: Some of the ones that I really hate are like
Speaker 4: do you feel like you are worried for no good reason.
Speaker 4: This is when I told you I feel like I
Speaker 4: lie on these because I'm like, sorry, I am very
Speaker 4: worried for.
Speaker 1: A very good reason.
Speaker 4: I am been anxious for no good reason at all. Right,
Speaker 4: I've been crying for no reason.
Speaker 1: Right to ask someone to say, are your anxieties justified?
Speaker 1: Are your worries justified? Like that's not.
Speaker 4: Yeah, but that's just my personal feelings. These are very
Speaker 4: well validated tools for screening, and so this is the
Speaker 4: kind of first thing that's recommend that everybody during pregnancy
Speaker 4: and postpartum is supposed to be offered questionnaires like this
Speaker 4: to try and identify people who are perhaps experiencing postpartum
Speaker 4: mood disorders or who are at risk of developing postpartum
Speaker 4: mood disorders. Globally, postpartum depression has an estimated prevalence of
Speaker 4: seventeen percent. That is so much higher than any of
Speaker 4: the other complications that we have talked about, like, so
Speaker 4: much higher. That global number, though is not you can't
Speaker 4: just leave it there, okay, because the variation geographically is huge.
Speaker 1: Okay.
Speaker 4: Now, low and middle income countries prevalence is significantly higher,
Speaker 4: significantly higher than in high income countries. The average if
Speaker 4: you just lump all low in middle income countries, which
Speaker 4: is not a fair thing to do, but if you
Speaker 4: do that, then the prevalence is estimated at around twenty percent.
Speaker 4: High income countries, the average is like fifteen and a
Speaker 4: half percent. But as you can see, there's a graph
Speaker 4: that's in a paper that I cite that shows this
Speaker 4: huge range in distribution. Some countries are as high as
Speaker 4: thirty in the thirty percentile. So yeah, so the range
Speaker 4: is really really huge, and a lot of high income
Speaker 4: countries the prevalence of postpartum depression is in the single digits,
Speaker 4: like eight nine percent. The US and the UK are
Speaker 4: a little bit of outliers in the high income country bracket,
Speaker 4: where the prevalence is estimated at eighteen and twenty percent respectively. Okay, okay,
Speaker 4: now pause for a second because we're gonna err and
Speaker 4: math this a little bit. Because that is, in the US,
Speaker 4: we have an estimated around three and a half million
Speaker 4: live berths every year if eighteen percent of those, and
Speaker 4: postpartum depression is not limited to live births. This also
Speaker 4: encompasses depression post miscarriage and still birth, which those rates
Speaker 4: are even higher. But even if we just look at
Speaker 4: those numbers, three and a half million live berths, eighteen
Speaker 4: percent of those people having postpartum depression is over six
Speaker 4: hundred and thirty thousand people in just the US every year.
Speaker 4: That's not a small number of individuals or families that
Speaker 4: are being affected. So that's postpartum depression, which is just
Speaker 4: one of the postpartum mood disorders post part of anxiety.
Speaker 1: I have a question. Okay, sorry, I know you're like,
Speaker 1: I just want to I know, I know, I know. Okay,
Speaker 1: this map that shows the rate of postpartum depression or
Speaker 1: the prevalence, prevalence or prevalence. Okay, what is postpartum depression?
Speaker 1: Is this all being defined?
Speaker 4: It's all being defined as DSM five definitions.
Speaker 1: Yes, depressions.
Speaker 4: Post Partum anxiety another one of the post partum mood disorders,
Speaker 4: estimated to effect eight to twelve percent of people postpartum.
Speaker 4: Here's the big problem here, Okay, we don't have diagnostic criteria.
Speaker 4: There is no such disorder. There is no disorder that
Speaker 4: is called postpartum anxiety. We also do not have a
Speaker 4: screening test. In theory, the EDS should be capturing people
Speaker 4: who are at risk for postpartum anxiety type mood disorders, yeah,
Speaker 4: and depressive disorders, but it doesn't like there's no screening
Speaker 4: test for anxiety that is universally administered in the postpartum period,
Speaker 4: and there is also not a specific like disorder that
Speaker 4: is recognized as a post part of anxiety disorder. So
Speaker 4: then people have to like to get a diagnosis quote
Speaker 4: unquote whether that's important or not is a different discussion.
Speaker 4: But it would then be a different type of anxiety disorder,
Speaker 4: like a generalized anxiety disorder, obsessive compulsive disorder, right, like
Speaker 4: all these other type of anxiety disorders, because anxiety is
Speaker 4: a symptom and not a diagnosis.
Speaker 1: Okay, good questions here, So a person could have postpartum
Speaker 1: depression and postpartum anxiety absolutely, Okay. Secondly, then do postprium
Speaker 1: depression post partum ascis because I know that in reading
Speaker 1: about the history the postpartum like there was a huge
Speaker 1: fight or struggle to get postpartum to be a specific thing,
Speaker 1: and part of that was related to insurance and stuff,
Speaker 1: so that it's like, oh, if this was pre existing,
Speaker 1: we're not going to cover it.
Speaker 5: Correct.
Speaker 1: But but and so then that postpartum period was shown
Speaker 1: as a risk factor, and that is how we got
Speaker 1: postpartum depression as a diagnosis.
Speaker 8: But then what was so I think it's usually it
Speaker 8: has to last longer than two weeks, okay, because the
Speaker 8: first two weeks postpartum people can have a depressed mood
Speaker 8: that is still called the baby blues.
Speaker 3: Yeah, the postpartum blues.
Speaker 1: Which is people have described it as infantilizing, but.
Speaker 3: I'd agree with that. Yeah.
Speaker 1: In the sixties, do you want to know what, like
Speaker 1: I think it was doctor Spock or something, you know,
Speaker 1: like the Benjamin S. Bacao was like, this is how
Speaker 1: to care for people.
Speaker 3: I only know this Spock with like the livelong and prosper.
Speaker 1: This is relative Okay, yeah, not really. Oh no, it
Speaker 1: was recommended that to pick to like, oh, if you
Speaker 1: have baby blues, pick yourself up by getting yourself a
Speaker 1: new hat or treat yourself to a new dress, Go
Speaker 1: get your hair done.
Speaker 3: Get your hair DoD.
Speaker 1: That was literally okay, yeah, I love that anyway.
Speaker 4: Yeah, so lasting more than two weeks. And then in
Speaker 4: terms of the onset of development, it's like usually the
Speaker 4: first year postpartum is all still considered within the postpartum period.
Speaker 1: Okay, that's what that was My terribly worded question was trying.
Speaker 5: To get the like overall time frame.
Speaker 1: Yeah, yeah, yeah, yeah yeah.
Speaker 4: And then of course, there is also the most severe
Speaker 4: spectrum of maternal like postpartum mental health disorders, and that
Speaker 4: is postpartum psychosis, which is not called postpartum psychosis. It's
Speaker 4: brief psychotic disorder with postpartum onset is the DSM five title.
Speaker 5: But this is the set.
Speaker 4: Of hallucinations or delusions and like disorganized behavior and things
Speaker 4: like that that usually go along with depression or depressive
Speaker 4: symptoms during this postpartum period. This is thought to be
Speaker 4: relatively rare, though our studies are not as robust on it,
Speaker 4: but estimated between zero point eight six to two point
Speaker 4: six per one thousand berths. So it's commonly cited as
Speaker 4: like one to two per thousand based on a global
Speaker 4: analysis from twenty seventeen. But it is also the most
Speaker 4: acutely dangerous of the maternal mental health disorders because this
Speaker 4: can be it can be very severe and really disturbing
Speaker 4: for the mom and the family, and so often results
Speaker 4: in hospitalization.
Speaker 1: Yeah, I am I think I told you this, Aaron,
Speaker 1: But I listened to a book called a memoir called Inferno,
Speaker 1: a Memoir of Motherhood and Madness by Catherine Choe, and
Speaker 1: it was about this person's experience with postpartum psychosis. And
Speaker 1: it was a really insightful and meaning full and also
Speaker 1: like really, I just it feels like a really important book.
Speaker 1: I really appreciated it. But the other thing that I
Speaker 1: think was really interesting about that was how she talked
Speaker 1: about she was in the US when this, when this
Speaker 1: this happened, and when she was hospitalized, but she was
Speaker 1: actually like traveling from the UK where she lived in
Speaker 1: the UK, and the treatment is very different in terms
Speaker 1: of like the management okay, okay, well keep mom with baby, okay, UK,
Speaker 1: keep mom separate from baby in the US, and just
Speaker 1: like interesting, I just yeah, yeah, all the different all
Speaker 1: the different choices.
Speaker 4: And I will say that our understanding of like the
Speaker 4: neurologic or the biologic basis that underpins postpartum depression anxiety psychosis,
Speaker 4: like it is poor, to say the least. It's like
Speaker 4: an understatement. It is very often blamed, especially in like
Speaker 4: popular media press, about postpartum depression on quote unquote hormones. Yeah,
Speaker 4: maybe there is some data that that might be true
Speaker 4: for this quote unquote baby blues period, where I also
Speaker 4: it's important to say that like forty to seventy percent
Speaker 4: of people can experience this mood lability during those first
Speaker 4: two weeks, and that is when our hormonal shifts are
Speaker 4: the most extreme. So sure, maybe that is responsible for
Speaker 4: that first period, but we actually do not have data
Speaker 4: to suggest that there are hormonal differences in people who
Speaker 4: are experiencing other postpartum mood disorders past that two week
Speaker 4: period and people who do not, So we do not
Speaker 4: understand it the same way that we don't understand the
Speaker 4: biologic causes of depression or anxiety or other mood disorders
Speaker 4: outside of the postpartum period. However, However, what is clear
Speaker 4: from the epidemiological correlates from the facts that, for example,
Speaker 4: as we saw globally, the rates are significantly higher in
Speaker 4: low and middle income countries that lack health infrastructure, that
Speaker 4: lack access to healthcare in the prenatal and post natal period,
Speaker 4: or that rates of postpartum depression are significantly higher in
Speaker 4: lower income households in high income countries that lack access
Speaker 4: to healthcare, that they are higher in people who are
Speaker 4: subjected to additional stressors such as abusive or unsafe relationships,
Speaker 4: or unintended pregnancies. What is clear from these epidemiological studies
Speaker 4: is that a lot of the factors that contribute to
Speaker 4: an increased risk of postpartum depression and other mood disorders
Speaker 4: are potentially modifiable and not on an individual level, so important,
Speaker 4: not on an individual level, and in fact, the single
Speaker 4: greatest risk factor for postpartum depression and postpartum anxiety are
Speaker 4: untreated anxiety and depression outside or during pregnant and see
Speaker 4: so if we can actually recognize and provide treatment of
Speaker 4: mental health disorders outside of the context of pregnancy, we
Speaker 4: can help reduce the burden of postpartum disorders as well.
Speaker 4: So I'm going to now shift this to talk about
Speaker 4: what we know from data about how to improve postpartum
Speaker 4: outcomes overall at ready based. I found a quote from
Speaker 4: an article from twenty sixteen in the American Journal of
Speaker 4: Obstetrics and Kynecology.
Speaker 3: That's it end I quote.
Speaker 4: The intense focus on women's health prenatally is unbalanced by
Speaker 4: infrequent and late postpartum care.
Speaker 3: End quote yep.
Speaker 4: And that in the United States of America is an
Speaker 4: understatement because postpartum care is not just infrequent for most
Speaker 4: people in the US. It is one singular visit which
Speaker 4: forty percent of people, especially those on public insurance, do
Speaker 4: not usually attend. And it occurs at six weeks postpartum,
Speaker 4: which is when I already said that most of those
Speaker 4: changes that are happening are done.
Speaker 3: They're done.
Speaker 4: Contrast this with getting weekly visits for at least the
Speaker 4: first the four weeks prior to delivery, and then every
Speaker 4: two week visits for the several months prior to that.
Speaker 1: Like, yeah, well, okay. Also then, Aaron, and I feel
Speaker 1: like I'm jumping ahead, give it. During pregnancy, who are
Speaker 1: you seeing? And then after pregnancy, who are you seeing? Aaron?
Speaker 4: Let me tell you, as a family medicine physician what
Speaker 4: my feelings about that are. Yes, in the US, our
Speaker 4: system is very fragmented. We are generally seeing obgyn providers
Speaker 4: primarily during prenatal period, during your all your prenatal visits,
Speaker 4: and then afterwards you're seeing a pediatrician and you are
Speaker 4: seeing them pretty frequently, and they are there for baby
Speaker 4: and not for you, And then you see your obgyn one.
Speaker 3: Time at six weeks. Yeah, okay.
Speaker 4: So this concept of a fourth trimester is a recent concept,
Speaker 4: at least in US medicine, and it really is kind of.
Speaker 5: An admission of.
Speaker 4: Our failure thus far to adequately care for people who
Speaker 4: have recently given birth. In the US, an estimated twenty
Speaker 4: three percent of employed women returned to work within ten days.
Speaker 1: Postpartum, sorry ten days.
Speaker 3: Ten days postpartum.
Speaker 4: And if that is not one of the most shocking statistics,
Speaker 4: then I don't know if you've been paying attention to
Speaker 4: these episodes. Now, that is not the case everywhere. So
Speaker 4: I'm going to walk you through a paper that really
Speaker 4: was very interesting. It was a comparative analysis that compared
Speaker 4: and contrasted postpartum care, prenatal and postpartum care in the
Speaker 4: US and five other high income countries, because again, this
Speaker 4: is what we have to compare to, like kind of
Speaker 4: apples to apples, right, And this compared the US to France, Japan, Australia, England,
Speaker 4: and the Netherlands. And we know from things like the
Speaker 4: data on maternal mortality that outcomes are very different in
Speaker 4: the United States compared to all of those other high
Speaker 4: income countries. Our maternal mortality rates are three times as
Speaker 4: high as France and the UK, and nearly ten times
Speaker 4: as high as Australia. Our maternal mortality rates in the
Speaker 4: US have been on a rise faster than any other countries,
Speaker 4: though there has been a rise in the UK, but
Speaker 4: it's been at a less substantial rate compared to the US.
Speaker 4: And maternal mortality is incredibly unequal, with Black American women
Speaker 4: dying at nearly three times the rate. In twenty twenty two,
Speaker 4: maternal mortality for Black women was fifty per one hundred
Speaker 4: thousand live births, compared to nineteen per one hundred thousand
Speaker 4: for white women and sixteen per one hundred thousand for
Speaker 4: Latino women. And I will say the numbers were different
Speaker 4: in twenty twenty one, but we don't know if that
Speaker 4: was because of COVID or what. But this trend has
Speaker 4: been there for decades.
Speaker 3: Yeah, okay.
Speaker 4: And so this comparative analysis was looking at prenatal and
Speaker 4: postnatal care, not just looking at like delivery method or
Speaker 4: like one time point, but like, let's look at these
Speaker 4: overall systems of care to see if there are any
Speaker 4: big themes that come out and boy, how do you
Speaker 4: do they So as a baseline to understand where a
Speaker 4: lot of other countries maybe are getting ideas from the
Speaker 4: World Health Organization recommends immediate postpartum care, so like immediately
Speaker 4: in that postpartum period, like after delivery of placenta for
Speaker 4: the first twenty four hours, and then care in the
Speaker 4: first twenty four hours, and then additional visits at three days,
Speaker 4: seven to fourteen days, and at six weeks postpartum, and
Speaker 4: that should include both maternal and newborn care. And again,
Speaker 4: in the US, our care is divided between specialists in
Speaker 4: obstetrics and kynecology and pediatricians. So in this comparative analysis,
Speaker 4: in every other country that they analyzed aside from the US,
Speaker 4: postnatal care included home visits universal home visit that begin
Speaker 4: immediately post discharge from the hospital and are specifically intended
Speaker 4: to address both maternal and infant health. These programs are
Speaker 4: typically run erin by midwives or nurses who are trained
Speaker 4: in prenatal care and infant care.
Speaker 1: YEP.
Speaker 4: The US has absolutely no such universal system none. We
Speaker 4: have some programs in some parts of the country or
Speaker 4: maybe some specific cities, but they only ever target specific
Speaker 4: populations that are considered high risk, which also means that
Speaker 4: they usually carry with them a lot of shame and stigma.
Speaker 9: YEP.
Speaker 1: Okay, yep.
Speaker 4: Now it's also true that the US, in this comparative analysis,
Speaker 4: was the only country where the majority of our prenatal
Speaker 4: care was conducted by obgins as opposed to midwives. Okay,
Speaker 4: we also in the US, it's not just postnatal care,
Speaker 4: it's not just postpartum care. We have huge inequalities in
Speaker 4: our acts as to care early in pregnancy because of
Speaker 4: our ridiculous insurance system. Those are my editorialization that wasn't
Speaker 4: in the paper. So that like, even though in the
Speaker 4: US pregnant people are guaranteed access to Medicaid services, However, individuals,
Speaker 4: like from data, individuals that are on public insurance such
Speaker 4: as Medicaid, start prenatal care significantly later. They in many
Speaker 4: states lose their insurance at sixty days postpartum. Mm hmm,
Speaker 4: I'm sorry, yeah, what and that What that means is
Speaker 4: that in the US, more people are coming into their
Speaker 4: pregnancy without any access to healthcare to address their underlying
Speaker 4: or chronic health conditions that existed prior to pregnancy.
Speaker 5: Then they have the.
Speaker 4: Bare minimum of prenatal care, and in fact, over six
Speaker 4: percent of pregnant women in the US have no prenatal
Speaker 4: care at all. Or they don't start prenatal care until
Speaker 4: the third trimester, even though again they're supposed to be
Speaker 4: eligible for Medicaid services, and then they attend one postpartum
Speaker 4: visit if they're lucky, and then they lose their insurance. Again,
Speaker 4: it is not like this in other high income countries,
Speaker 4: period period. Now, there is data, and I think you
Speaker 4: mentioned this at one point, I don't remember in which episode,
Speaker 4: that like the prevalence of a lot of conditions that
Speaker 4: we know are associated with an increased risk of adverse
Speaker 4: pregnancy outcomes, right, things like hypertension, diabetes, older maternal aged
Speaker 4: at your first pregnancy. We know that these things are
Speaker 4: associated with riskier pregnancies, and some of these things are
Speaker 4: in fact on the rise in the US and elsewhere,
Speaker 4: and certainly that likely contributes to some of the trends
Speaker 4: that we are seeing. But I think that what ends
Speaker 4: up happening in the rhetoric about this is that politicians especially,
Speaker 4: and organizations and even individuals lay this blame on individuals themselves.
Speaker 5: It's because of your pre existing condition, it's your medic complication,
Speaker 5: is your age, Oh.
Speaker 1: You chose to have a career first, it's your choice.
Speaker 4: Yep, Yeah, and that makes it seem like it was
Speaker 4: unavoidable or it was your it was your lifestyle.
Speaker 1: Lifestyle.
Speaker 4: Yeah, that is a lie period across the globe, not
Speaker 4: just in the US. Millions of maternal deaths each decade
Speaker 4: are due to preventable factors. And this is not just
Speaker 4: coming from me. This is coming from the Lancet Global
Speaker 4: Health twenty twenty four. They said, and I quote these,
Speaker 4: these maternal deaths are quote tangible manifestations of the prevailing
Speaker 4: determinants of maternal health and persistent inequities in global health
Speaker 4: and socioeconomic development.
Speaker 1: Yep, yep. So we know.
Speaker 4: I'm getting like we can sweaty from how angry I
Speaker 4: get about this, because it's like, I feel really passionate about.
Speaker 1: This, justifiably angry.
Speaker 4: We know the things to do to prevent this. We
Speaker 4: can prevent maternal mortality, we can prevent adverse neonatal outcomes
Speaker 4: as well by doing what erin.
Speaker 3: Let me tell you.
Speaker 4: Number one, access to universal health care. Number two, specifically
Speaker 4: access to comprehensive This is again from data. This is
Speaker 4: not just me Aaron Onrman Updike saying this. Okay, I
Speaker 4: say this, but this is literally the data that we
Speaker 4: have on what prevents.
Speaker 1: Adversources we have.
Speaker 4: We need universal access to comprehensive and modern contraception so
Speaker 4: that people can plan if and when they want to
Speaker 4: get pregnant.
Speaker 1: Yep.
Speaker 4: We need universal legal, safe access to abortion services, which
Speaker 4: are life saving.
Speaker 3: Medical care, medical care.
Speaker 4: We need universal access to high quality prenatal, intrapartum and
Speaker 4: postpartum care, which includes wives and obstetrics and gynecology and
Speaker 4: family physicians and pediatricians, all.
Speaker 1: Of it, all of it working together.
Speaker 4: We're together as annical system. And this particular paper does
Speaker 4: not get into this like deep of detail, but I
Speaker 4: have other sources that show that guaranteed paid parental leave,
Speaker 4: which we also do not have in the US, is
Speaker 4: in fact associated with reductions in the risk of postpartum depression,
Speaker 4: depression later in life, lower risk of intimate partner violence,
Speaker 4: which is added is peak during pregnancy and postpartumy. Paid
Speaker 4: parental leave also increases the likelihood and duration of breastfeeding.
Speaker 4: So folks who are all making sure that everyone breastfeeds,
Speaker 4: that's a thing that can help it and it is
Speaker 4: directly associated with decreased infant mortality. Sorry, we have a playbook.
Speaker 1: The answer is here.
Speaker 5: We know the answers, we just have to implement them.
Speaker 5: I'm done.
Speaker 1: No, but it's it is. Oh, it's really hard sometimes
Speaker 1: because it's like, on the one hand, I want to
Speaker 1: find that very inspirational or like hopeful or like here, look,
Speaker 1: we know how to do this. We have answer. We
Speaker 1: have had these answers I know for so long.
Speaker 5: I know, I know it, I know it.
Speaker 1: It's true.
Speaker 3: It's true, it's tru it's true. But we have the answers.
Speaker 4: We know the answers, right, These answers just have to
Speaker 4: be enacted, and they are being done in certain places
Speaker 4: in this I mean, the state by state mortality data
Speaker 4: in the US is like shocking. If you go to
Speaker 4: the CDC website and you look at like what the
Speaker 4: rates are in like one state versus another, it's like
Speaker 4: the disparities are very severe. Systemic racism plays a huge
Speaker 4: role in all of this in the United States, in
Speaker 4: addition to like the quality of care that people get
Speaker 4: depending on what color their skin is. So there is
Speaker 4: a lot of things that are not easy to fix.
Speaker 4: I mean, they could be easy to fix because we
Speaker 4: know how to do them.
Speaker 1: We can fix parts of most everything, right, Yeah.
Speaker 3: But so we've we've done all your work for you.
Speaker 1: It required no investment. It does and that is the
Speaker 1: hardest thing to convince people.
Speaker 5: That's our constant theme and it's my favorite thing on
Speaker 5: this podcast. Will kill You.
Speaker 1: Investment and trade offs and investing now is public health,
Speaker 1: and public health is investing in saving money and it's not.
Speaker 3: Yeah, yeah, I know, so, Aaron, I.
Speaker 1: Can't believe are we done? We're done for now.
Speaker 5: While we're done with this season, we're done with this series.
Speaker 1: I have so many feelings about everything. Me too.
Speaker 4: I also, I just want to say, because I know
Speaker 4: that there was a lot of parts of this series
Speaker 4: where we got very heavy, we got very heavy, and
Speaker 4: where we focused a lot on the kind of complications
Speaker 4: or things that can go wrong.
Speaker 5: I love to.
Speaker 4: Know these things and know at the same time in
Speaker 4: my brain how often everything.
Speaker 5: Goes and goes just fine.
Speaker 1: Absolutely, and it is.
Speaker 4: Beautiful and amazing and phenomenal to like see that happen
Speaker 4: and to know that it happens so frequently. It truly
Speaker 4: is like I get. I really love prenatal care. I
Speaker 4: really love this whole process. I just love everything about
Speaker 4: this and I really loved doing this even though I
Speaker 4: know we focus a lot on the bad things.
Speaker 1: Well, I feel like there's it's it's all about contextualizing
Speaker 1: it is everything, yeah, right, Like you and I had
Speaker 1: a lot of discussions about this, like how do we
Speaker 1: balance this approach where we're not doing the what to
Speaker 1: expect while you're expecting, like you just lay back and
Speaker 1: back and have anyone else do the work. It's totally fine,
Speaker 1: and it's like knowledge is power.
Speaker 5: It is, and but we also can increase my anxiety
Speaker 5: and it.
Speaker 1: Can increase anxiety. And so I feel like this is
Speaker 1: you know, we really did try hard to balance like
Speaker 1: talking about what are the pieces that we feel are
Speaker 1: valuable to talk about, yeah, and also while not talking
Speaker 1: about everything that is valuable to talk about. Yeah. So
Speaker 1: it's yeah, but it is. It's it's true, Like I
Speaker 1: I hope we didn't make everyone be like oh God,
Speaker 1: oh God for me, never for me or our our
Speaker 1: you know, healthcare system and country is broken broken.
Speaker 4: I mean I have no interest in having any other kids.
Speaker 3: Definitely not absolutely not.
Speaker 1: I'm done.
Speaker 5: But there were moments in this where it's.
Speaker 4: Like, oh, you know, reading, like relearning these things, and yeah,
Speaker 4: it's it is.
Speaker 5: It's a little bit of magic.
Speaker 3: I feel absolutely yeah.
Speaker 1: I mean I think I have never I have never
Speaker 1: wanted to have kids. But throughout this series, I called
Speaker 1: my mom so often to be like, oh, what about this?
Speaker 1: Did she take a pregnancy test? Did you like, tell
Speaker 1: me about your ultrasound? Tell me about your delivery? What
Speaker 1: was it like? You know, she waited for one of
Speaker 1: my brothers, Er was on, and she was like a
Speaker 1: like a rabid Er fan, and she was like, I
Speaker 1: went into labor and I waited. I watched Er and
Speaker 1: then I went to the hospital because I didn't want
Speaker 1: to miss it. Yeah, and that was before DVR. But
Speaker 1: like that experience, it's like so many things that we
Speaker 1: had never talked about before about pregnancy and thinking about
Speaker 1: her experiences and it just that was It's been such
Speaker 1: an amazing process to like do all this reading and
Speaker 1: think about yeah.
Speaker 4: Think about so many different aspects of it. Ah, if
Speaker 4: you want to learn so much more, so much more,
Speaker 4: we've got source it.
Speaker 1: Oh my god, I feel like this was a one.
Speaker 1: This is Yeah. I have a lot of books for this.
Speaker 1: I know I'm gonna briefly because I've already mentioned a
Speaker 1: few of them, mentioned him again, so Brought to Bed
Speaker 1: by Judith Wollster Levitt, Tina Cassidy a book called Birth,
Speaker 1: The Surprising History of How We Are Born. Barbara Ehrenrich
Speaker 1: and Deirdre English wrote a book called Witches, Midwives and Nurses.
Speaker 1: It's like a classic feminist feminist text. Rachel Moran again
Speaker 1: blew a history of postprimum Depression in America. Joyce Thompson
Speaker 1: and Helen Varney Burst a history of midwiffrey in the
Speaker 1: United States. Laurel Thatcher Ulrich a midwives Tale, The Life
Speaker 1: of Martha Ballard based on her diary, and again that
Speaker 1: More Inferno by Catherine Show.
Speaker 4: I had a lot of papers for this one. I
Speaker 4: already shouted out a couple like that Lancet Global Health
Speaker 4: twenty twenty four paper that was a global analysis of
Speaker 4: the determinants of maternal health and transitions and maternal mortality.
Speaker 4: Such a good read. There was also the paper I mentioned.
Speaker 4: It was from the American Journal of Obstetrics and Gynecology,
Speaker 4: titled the Fourth Trimester, a Critical Transition period with Unmet
Speaker 4: maternal health needs. I think I might have said twenty sixteen,
Speaker 4: it was actually twenty seventeen. And then the paper where
Speaker 4: the map of postpartum depression trends came from was from
Speaker 4: Translational Psychiatry from twenty one that was titled Mapping Global
Speaker 4: Prevalence of Depression among Postpartum Women. But we have so
Speaker 4: many more on our website, this podcast will kill you
Speaker 4: dot com, where we list all of the sources from
Speaker 4: this episode in every one of our episodes from all
Speaker 4: seven seasons.
Speaker 1: So many sources, so many. You know, we've said thank
Speaker 1: you every single episode, and we mean it every single episode,
Speaker 1: And thank you to every single person who provided a
Speaker 1: first hand account, who sent in their firstend account, who
Speaker 1: thought about sending in a first hand account like we.
Speaker 1: We appreciate you. This is we. This series would have
Speaker 1: not been the same by any means without.
Speaker 4: You, No, it's it means the absolute world to us.
Speaker 4: Thank you, thank you, thank you, thank you, thank you.
Speaker 4: Thank you to everyone here at the exactly Right Studios.
Speaker 4: Are really sad to have to leave.
Speaker 3: Because we had so much fun doing this, I know.
Speaker 4: Thank you to today Leanna and Jessica and Brent and
Speaker 4: Craig and Tom yesterday, everyone all of you here, thank you,
Speaker 4: thank you, thank.
Speaker 1: You, ah thank you to Bloodmobile for providing the music
Speaker 1: for this episode and all of our episodes.
Speaker 4: And thank you to you listeners seven seasons in for
Speaker 4: all episodes on pregnancy.
Speaker 3: Thank you for.
Speaker 4: Sticking with us, Yes in this short break between seasons.
Speaker 4: Tell us what you want to hear more of.
Speaker 1: Always we love to hear it. And a big thank you,
Speaker 1: of course to our generous, beautiful, fantastic patrons.
Speaker 5: We appreciate your support so very much.
Speaker 3: We really do. Thank you.
Speaker 1: Until next season.
Speaker 5: Wash your hands, Sealthy Animals, M.