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3 days ago
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There is an inherent tension between two basic facts about childbirth. On the one hand, it has happened billions and billions of times in the course of human history and it has been successful in a wide range of settings, from neolithic caves to state-of-the-art hospitals. On the other, it is objectively dangerous in many cases.
This tension can be felt in much of the modern popular discourse on birth. On my Instagram feed, there are depictions of unmedicated home births in a bathtub surrounded by flowers and a caption about how birth has got too medicalised. Some commenters are quick to note that, in their case, having that medical help was life-saving. To put it most starkly: yes, people have been giving birth at home for millions of years, but a lot of them died.
I wrestle with this tension in my writing on pregnancy. I’m an economist and have written two books designed to help women navigate their pregnancy experience by giving them a better understanding of what the data says. In the first, Expecting Better, I cover largely uncomplicated pregnancy. I talk about the decisions that arise when all is going well – whether to eat sushi, for example, and how to write a birth plan for an uncomplicated delivery. In the second, The Unexpected, I cover complicated pregnancy. With my co-author, Dr Nathan Fox, we talk about miscarriage, pre-eclampsia, stillbirth, gestational diabetes, postpartum depression, and other tough things.
These are issues I care passionately about largely because I think we do not discuss complicated pregnancy enough. Perhaps 50% of pregnancies are affected by at least one of the complications covered in the book – that’s half of pregnancies, but more than half of people who have been pregnant. In many cases, until this complication happens to someone they have no idea that it could. They feel alone, sometimes dismissed, scared.
A core problem with lack of discussion is it leads to lack of treatment or preventive activities. The lead pregnancy organisation in the US, the American College of Obstetricians and Gynecologists, has put out a recent push for more discussion of pre-eclampsia, a serious complication that affects 5 to 8% of pregnancies. The risk of pre-eclampsia can be brought down about 20% with the use of baby aspirin beginning in the second trimester of pregnancy. This treatment has virtually no risks, so it’s increasingly clear that pregnant women with any risk factors – older age, higher weight, hypertension and many others – should be treated. If people are unaware of this risk, they are less likely to seek treatment. Even if offered treatment, if they do not understand the condition, they may be reluctant to take it up.
A lack of attention given to these complications leads to a lack of information, and without a basic understanding of what happened to them (or is happening to them) in their pregnancy, patients are not able to engage as much as they should with their condition. In doing interviews when this book came out, one mother told me: “I had a postpartum haemorrhage with my second child, but until I read your book I didn’t really understand what that was, let alone how to treat or prevent it.”
I want to shout this information from the rooftops. I want to tell everyone I know that, yes, your uterus can fall into (or even come partially out of) your vagina, and that if that happens there is help. And yet: I can see the danger of focusing too much on these complications. If 50% of pregnancies are affected, then 50% are not. Where should we draw the line between making sure pregnant women are well-informed without scaring them to death? After all, a lot of times, everything does go smoothly. Giving birth in a tub at home can be a good option for some people. And I would hate more than anything for someone to decide not to have a wanted family because they are worried about pregnancy and birth.
We need to find a balance between giving women the information they need, telling them the truth about risks, and not creating unnecessary panic. I wish I could say I knew for sure what this balance looks like. What I do believe strongly is that keeping information hidden, and doling it out only after it is needed – or never – is not the right answer. We need to strike a balance between giving people information and allowing them to put the risks in context. So they can take solace in the hope – and likelihood – that all will be well, but prepared if it is not.
