The Supreme Court decision overturning Roe asserts that a zygote, the single cell that is the union of egg and sperm, enjoys more Constitutional protection than the owner of the uterus in which it implants–an interpretation that affects almost sixty percent of people of reproductive age in (at current count) fourteen states. Although this decision upends 50 years of federally protected access to abortion, it is consistent with our country’s approach to healthcare aimed at birthing people (the lionshare of whom are women), which lives on a continuum from deficient to dangerous, weighing most heavily on people of color and those with fewer resources. Numerous studies find that reducing access to abortion does not reduce abortion; it limits access to reproductive healthcare. While this care affects every facet of a woman’s life, pregnancy in particular requires expertise in managing the massive reordering of almost every body system, along with its resolution after the baby is born. Unfortunately, rather than depending on evidence based protocols, the care a mother receives after delivery depends entirely on the hospital in which they find themselves–with detrimental consequences for their short and long term health. The other participant in this process, the baby, has, since the 1950s, benefitted from an APGAR test–a scientifically assessed, universally applied, screening tool to identify the possible need for medical intervention. We need a universally applied, scientifically backed approach to closely monitor the health of the postpartum mother; we need an APGAR for women. (Note: I have used some version of “women” and “birthing people” interchangeably in the essay that follows.)
Although pregnancy can last nine months and delivery has a discrete endpoint, the effects of pregnancy don’t disappear once a person exits the delivery room. Traditionally the postpartum period lasts for six weeks, a date pegged to the time it takes for the uterus to shrink down to its pre pregnancy size. But many other physical adaptations made for pregnancy don’t adjust on this timeline. The cardiovascular system, for example, takes many months to reorient to a post-pregnancy body. Roughly four million Americans a year experience the fourth trimester, and some relatively common experiences include: bleeding for 5 weeks; between 25 and 55 percent of birthing people lose bladder control, some for weeks after delivery, some for much longer. Roughly 1 in 6 will experience peripartum depression during pregnancy and after delivery. The components in the blood that contribute to clotting don’t normalize for months after pregnancy, leaving postpartum women at a 24 fold increase in the risk for clots for weeks after delivery.
In 2005 Brooke Shields shared her struggle with postpartum depression, making her a pioneer in defending the possibility that pregnancy had consequences other than parenthood. In 2018, it was shocking to hear Serena Williams talk about almost being killed by a pulmonary embolism after delivery. In 2019 Amy Shumer brought attention to the challenges of IVF and hyperemesis. Despite how common these issues are, they haven’t garnered much attention until recently. We as a nation are only starting to acknowledge the physical, medical and emotional challenges that commonly accompany the postpartum period. The national conversation around pregnancy is largely focused on who has the right to terminate a pregnancy–a conversation that is often couched in terms of “maternal safety”, although ending a pregnancy in the first trimester is not nearly as dangerous as pregnancy and birth can be. The most dangerous time for maternal mortality is in the postpartum period–a particularly unpredictable time in a woman’s life made more hazardous by the lack of standard, empirically based approaches to the many issues that can arise.
The danger that too many birthing people face in this transition is now a regular feature in the New York Times (here, here and here, to name a few). Roughly 60,000 birthing people a year experience what Ms.Williams endured–known in the world of maternal health as a ”near miss”–a life threatening complication of pregnancy or delivery commonly diagnosed after birth. The rate of these distressing events has increased dramatically over the last 20 years in the US, while falling dramatically in the EU over this same period. Both race and insurance status are predictive of poorer maternal outcomes. A critically important fact in this story is that a material portion of severe complications may occur due to delays in examination or treatment and are later deemed preventable. We need to focus care on birthing people after delivery as if their lives depend on it– because they do.
This focus has been applied to newborns, to great effect. Since the 1950s every newborn’s health is immediately graded after birth to determine how they weathered the transition from fetus to baby with a screening tool called the APGAR. Low scores at 1 minute, 5 minutes and 10 minutes after birth provide valuable insight to focus medical resources. An APGAR for birthing people could take the form of a checklist that combines information about preexisting conditions and vital signs and would be used at regular intervals to grade their post delivery condition (like the Maternal Early Warning Trigger ); and like the APGAR for babies, anyone scoring below a certain level would be flagged for closer observation. Teams of doctors have already created separate checklists (or screens) to address the three biggest threats at delivery: postpartum hemorrhage, preeclampsia and sepsis. But these tools are not implemented as the standard of care everywhere. We’ve already run the experiment where we try to address emergencies as they arise (see all previous history). The result has been too many childbearing people are left with lifelong health problems.
The good news is some states have materially changed the way they manage pregnancy and birth to produce maternal health on par with the best countries in Europe. Many useful practices can be exported to places with poorer maternal outcomes. California, for example, improved maternal outcomes in the 2000s by creating the California Maternal Quality Care Collaborative (CMQCC), a collection of healthcare professionals that came together to design a data center–essentially a “fitbit” for hospitals vis a vis their maternal health– in conjunction with evidence based strategies to manage emergencies after delivery. Making granular data available quickly allows hospitals to identify problem areas and readily assess whether changes in protocols have the desired effect. These protocols (also known as toolkits or ‘bundles’) contain practices and procedures in preparation for the severe complications that will arise. One of the practices California implemented is the use of screening tools to suss out impending trouble. Evidence suggests that the use of screening tools, in combination with nearly ‘real-time’ data, have contributed to the state’s dramatic decline (55% from 2006 to 2013) in maternal health consequences. We can universalize these screening protocols to try to dampen the tragic trend of severe complications for mothers after delivery.
Looking at the practices of other countries, a stream of services follow a birthing person home from the hospital or birthing center: a home visit from a nurse or midwife in the days after delivery, universally available physical rehabilitation services for the pelvic floor, and time to recuperate through paid leave policies. Despite revised guidance from the American College of Gynecologists and Obstetricians in 2018 promoting increased touchpoints between a new mother and their doctor after leaving the hospital, such care is still not the norm in the US. Until postpartum care reflects this guidance, we need to ensure that birthing people and their supports are well informed and primed to act if they witness the signs of trouble at home in the fourth trimester. In the wake of the pandemic, we can make better use of telehealth and remote patient monitoring. We may not adopt every innovation that’s worked at home or abroad, but we can’t continue to do what we’ve been doing: send birthing people home after delivery with fingers firmly crossed and no follow up visit until the far shore of six weeks.
When we focus on maternal care, it’s important to remember what’s actually at stake: the short and long term health of the vast majority of birthing people (roughly 90% of birthing people in the US experience pregnancy at some point in their lives) and every baby born and all future generations. Every birth creates a new baby, and at the same time, a postpartum person; the lasting health consequences for the mother are part of the picture we tend to blur out. Let’s implement structural strategies, like the APGAR that will save and improve the lives of those who give birth. They deserve it. We all do.