What it's like to have a baby during a pandemic
Thoughts on obstetrics, telemedicine & the future of women's health
I’m writing this newsletter to you about a month postpartum before the amnesia sets in. There are droopy bags under my eyes, but I’m more than a little obsessed with our tiny human. Writing this has been cathartic, so I’ve been jotting my thoughts down between feeds and naps.
Having a baby during a pandemic was a lonely experience. While pregnant, I did most of my visits to the doctor solo, including the ultrasounds. After the delivery, my husband wasn’t allowed to leave the hospital room except for a quick trip to the vending machine. We had no visitors. My month-old probably thinks that there are two humans in the world. In so many ways, I’m not surprised about the reports of a falling national birth rate.
But there was one huge benefit: Remote work. I’m not ashamed to say that I needed the occasional mid-afternoon nap, especially in the first trimester. And if I felt nauseous, I didn’t have to make an excuse to run out of a meeting to commune with an office bathroom. And I didn’t have to stand up in a crowded subway or the bus to work.
With the rise of fully virtual or hybrid offices, I sincerely hope that pregnant women will get a break. Because let’s get real, growing a human is no joke. Several studies have found that there was a decline in babies born premature during the pandemic. The U.K.’s Royal College of Midwives have theorized that more work from home could have increased “rest and partner support for some women,” resulting in fewer complications. Flexibility matters so much, but was rarely available to pregnant women pre-pandemic.
That’s far from the only way that we let down women and families, especially in the United States. The topic of fertility springs to mind. It’s tragic that 1 in 8 couples today are struggling to get pregnant, and yet the treatment is out of reach for most Americans - and even more so for BIPOC women. But let’s put a pin in that conversation for now. We’ll return to it at a later date.
Those that follow me know that I’ve spent a lot of time in my reporting and investing career looking into women’s health. But I’ll be the first to acknowledge that getting pregnant and giving birth gave me a whole new perspective. For this post, I also interviewed my own doctors as well as other experts in my network. Here’s what I learned:
The field of obstetrics is lagging behind other specialties when it comes to telemedicine and virtual tools. And prenatal care itself hasn’t had a redesign since it was blueprinted in the 1930s. The exception to the rule is the growing crop of start-ups in the space, including Maven, Tia Clinic and Cleo. For those interested, I’ll be doing a market map of the women’s health space for the second part of this post.
Where I see these start-ups offering the most value to patients is to provide a “care team.” That army of providers might include doulas, lactation consultants, midwives and nutritionists. My own obstetrician - California Pacific Medical Center’s Dr. Laurie Green - often talks about the benefit of giving patients a convenient way to get advice on what she calls the “sushi questions.” That might include: “Can I take Advil?” “Can I have a glass of wine?” “ Is it safe for me to eat sushi?” If a care team is responsible for this information, it theoretically frees up obstetricians to manage more complex problems. Many patients also rely on this team to think through birth plans; to guide them in communicating with work about pregnancies; and to be their advocate in the delivery room.
The field of obstetrics today still involves a whole lot of in-person visits - and that’s for good reason. Most pregnant patients in the U.S. see their obstetrician about 10 to 15 times. In the last month of the pregnancy, these visits tend to ramp up to spot potential complications that could impact the birth. Some of the appointments are quite short, no more than 10 minutes, while others are more involved.
In my case, my pregnancy was uncomplicated and by the book. That is, until we learned about the breech presentation in the final weeks. So in theory, a lot of these visits could have been done from home, which may have reduced my exposure during a pandemic. But we only ended up making 2 of the visits virtual. Why is that?
The pros and cons of bringing telemedicine to obstetrics
I called Dr. Green and asked her that very question. As the founder of MAVEN Project, a telehealth nonprofit serving vulnerable populations, she’s no stranger to technology. It’s Dr. Green’s view that her specialty is still figuring out the ideal mix between care at home, in person, via phone, video or SMS. Virtual care offers opportunities to reach underserved patients who can’t take the time off from work and lack access to childcare. But there are also risks to not seeing the patient up close. “We are in uncharted waters,” Dr. Green told me.
“I know of cases where the patient developed pre-eclampsia (a pregnancy complication characterized by high blood pressure and signs of damage to another organ system) that wasn’t picked up because of a virtual visit,” she said. “If they had been seen in person, the provider could have seen their leg or taken a more accurate blood pressure reading.” Home blood pressure monitors could theoretically help solve this problem, but quality is highly variable.
Dr. Green views the telemedicine trend as similar to the introduction of the earliest mobile devices to medicine. Patients with phones would call her all the time, including during dinner with her family. It took time to develop etiquette with patients. But Dr. Green recalls realizing early on that there were some unique benefits to voice, particularly in cases where she really knew the patient. Once, during an outbreak of Norovirus - a contagious virus that causes vomiting and diarrhea - a slew of her patients called in to the office to get more information about the potential risks to their pregnancies. One of these patients sounded different than the others. Dr. Green asked her to come in immediately because she could sense something was off. It turned out to be severe HELLP syndrome, a potentially life threatening pregnancy complication that was diagnosed in the nick of time.
Given my relatively smooth pregnancy, I asked Dr. Green if she would have been comfortable sending me home with a wireless weight scale, a blood pressure cuff and some at-home urine tests. That’s in line with some of the programs that are starting to pop up at health systems across the country to reduce the number of in-person visits (and a few start-ups too). For a first baby, she indicated that she would be comfortable transitioning a few of the visits to be virtual - but not in the last month. By physically touching my belly, for instance, Dr. Green was able to determine that my baby was breech. It also felt important to sit face-to-face to talk through the birth, given that I had hopes for a vaginal delivery.
I also spoke to other obstetricians, including Dr. Jane van Dis, an OB hospitalist and medical director at Maven. She would be comfortable with up to 4 virtual visits (at 16 weeks, 22 weeks and 32 weeks potentially) and 7 in person for her pregnant patients. So each provider might be different in their approach, but most will continue to do the majority of the visits at their clinic.
Still, the Norovirus example shared by Dr. Green spoke to me for a few reasons. It’s a perfect illustration that there needs to be a baseline relationship between the doctor and patient before we can flip to telemedicine, and that’s true across many specialties. Once that has been established, it may very well be possible to pickup potential problems from home. But as Dr. Green points out, there’s also a lot of potential liability here. Missing something would be a disaster.
Taking a step back, the United States already has a shockingly high maternal mortality rate compared to most other countries in the developing world - and most of these deaths are preventable. As it stands today, the U.S. - which spends more on health care than any other country in the world - is on par with Romania, Latvia and Oman when it comes to outcomes. A lot of these problems are not going to be solved by simply getting patients a virtual consult, although some care may be better than no care at all.
So what would make a difference?
Well, increasing access to care would be a good start. Other countries have a lot more maternity care providers relative to the number of births. The U.S. is particularly lacking when it comes to midwives and primary care.
(Source: Commonwealth Fund).
This country is also unique in failing to offer at-home visits to check up on new mothers, as well as guaranteed paid leave. Many women will only see their obstetrician six weeks after the birth, though the American College of ObGyn now recommends a visit or phone call within 3 weeks - sooner if blood pressure or other complications of pregnancy were present - and then a comprehensive exam no later than 12 weeks.
Postpartum, when visits to the obstetrician dwindle and then effectively stop, there’s an urgent need for support around breastfeeding, recovery, and emotional health and wellbeing. There’s a lack of content to inform patients about their recovery, particularly compared to birth and pregnancy.
“A lot of women feel like they’re dropped off at the curb when it comes to postpartum and there are so many issues from lack of sleep to bleeding to problems with stitches after a surgery,” Dr. Van Dis said.
Pediatricians tell me it often falls on them to screen mothers for postpartum depression. In my case, I filled out a paper-based questionnaire after the baby was born asking if I felt despair or suicidal thoughts, and that was basically it. This is particularly problematic as it can take months for symptoms to show up, and women are often left on their own. It’s also more important than ever than we do take steps to support mental health, given that studies are showing elevated rates of anxiety and depression in the postpartum period.
Importantly, Dr. Van Dis notes, Congress just passed sweeping legislation expanding Medicaid coverage (48% of all births in the U.S are covered by Medicaid) for postpartum care from 6 weeks, up to a year after birth. This is an important start.
The current provider shortages and gaps in care primarily impact women of color. Covid-19 laid bare how the problems of our healthcare system - if you can call it that - disproportionately affects low-income populations. Obstetricians know this better than anyone. Black, American Indian, and Alaska Native women are two to three times more likely to die from pregnancy-related causes than white women – and this disparity increases with age, according to research from the Centers for Disease Control and Prevention.
So I’m all for telehealth - assuming it’s used appropriately - but I also urge more conversation about how we can support women to also get seen in person before and after birth.
Dr. Green notes that it would make a big difference to provide patients with free childcare, so their kids can be taken care of while they’re at the doctor’s office. During Covid-19, it was not possible for patients to bring anyone else into their appointments, which only exacerbated this problem. We also desperately need paid time off from work, care-matching, language translators, programs to address rural maternity care gaps, better broadband access, and reliable transportation. The industry refers to this - the spectrum of things that impact health outcomes outside of medical care - as the “social determinants of health.”
Beyond that, we also need to build up trust between these populations and their medical providers. That’s been broken, for so many reasons. Several of the obstetricians I spoke to said that a lot of what needs to change here is the way we communicate with patients. More openness and shared decision-making wherever possible, versus paternalism, would go a long way. And in recognizing the power of patients’ intuition - and educating parents on what to look for. So many of my mom friends have relied on their gut instinct when something doesn’t feel right with their pregnancy - and it can often meant the difference between life and death.
How we guilt and shame new parents
So I’m going to get super real with you all here. I felt a lot of guilt in the period after my baby was born. I had a C section and not a vaginal delivery (the term “natural birth” contributed to that, as it implies that my baby came into the world in an “unnatural” way). My newborn had low birth sugars so he was given formula in the first few days when I couldn’t feed him. I was exhausted after my surgery and felt relieved when the very nice nurses took the baby to the nursery, so I could get some sleep. I felt guilty about that relief too. My milk didn’t come in for five days. After my first attempt at pumping, I experienced debilitating pain from my uterus contracting and asked for stronger pain medication. I feared that he wouldn’t want to breastfeed in favor of the bottle, or that I somehow had contributed to “nipple confusion.”
All of these things felt like I was failing somehow. In needing a break from my child, I was somehow a less involved mother. Looking back at it now with hindsight, I feel somewhat differently. I did something hard and amazing! A C-section is a major surgery, so taking care of myself was essential in those early days. Once we took him home, I was up every three or four hours. My milk came in just fine. And no one asked me how exactly the baby came into the world.
On the pain front, I talked to the anesthesiologist who administered my spinal block - CPMC’s Dr. Jeffrey Swisher - after returning home. He expressed that he wished I had contacted him directly, as he would have reassured me. “Women’s pain is not taken as seriously as men’s pain, and it’s a bias in medicine,” he said (indeed, multiple studies bear this out). “I often see women internalize this sense of failing and that they’re supposed to tough it out, but someone is literally cutting you open and taking a baby out.”
This can also extend to epidurals. Dr. Swisher told me that with his own kids, his wife got pressure during a birthing class to not take one. He ended up writing a personal essay on that experience, sharing that he totally lost it at the instructor.
Much of this is rooted in societal expectations of women. A friend of mine told me recently that she experienced back labor for hours at home, but didn’t go into the hospital until it was too late for an epidural. She was so concerned about seeking medical care too soon and being sent home that she didn’t trust her own pain. She later told me that she didn’t know how to contextualize how she felt at the time, because all that she had been told is that labor is excruciating. So she felt like she was gaslighting herself by coping with the pain, and then undermining it by thinking “well there’s nothing to see here.”
I’m far from the only one who experiences this guilt and shame. Dr. Pooja Lakshim, a perinatal psychiatrist specializing in women’s health, has seen it so much that she started an online program called “how to overcome mom guilt.” So there are resources and tools out there.
On that note, I will also say that there’s judgement placed on women who choose to work in this period. I’ve felt pressured to enjoy my newborn, nap, take a break from social media, not write, not respond to emails, and so on. But it makes me feel like a person to do those things. I’m deeply enjoying my son, but similarly craving some intellectual stimulation. I recently called a dear friend Leslie Schrock about this, as she wrote a book about pregnancy while pregnant with her first child. Her manuscript was due six weeks postpartum. She told me she felt a lot of guilt about not spending every waking moment with her son after he was born. But she later realized that she could learn to be a mother and be happy taking space to work.
Through our conversation, it really hit home for me that it didn’t make me less of a parent for wanting some time to myself.
‘The medical industrial complex’
Women’s experiences of pregnancy and postpartum will vary depending on where they live, the philosophies of their care team and the type of birth experience they have. But many will be burdened by the so-called “medical industrial complex.” I spoke about this in depth with Dr. Chitra Akileswaran, co-founder of the women’s health start-up Cleo and an obstetrician based in the Bay Area. Despite being an expert in this area, Dr. Akileswaran experienced it first hand when her own child was born several years ago.
One of the problems, in her view, is the pressure on health systems to hit certain metrics, oftentimes from insurers. In parts of the country, including San Francisco, where I gave birth, that can mean reducing C-section rates (these surgeries are a lot more expensive for insurers than vaginal deliveries) and more breastfeeding. That can be positive or negative depending on the culture of the health system, adds Dr. Van Dis, who told me that most patients don’t have “any idea” this is happening behind-the-scenes. It’s complicated, because there are certainly cases where C-sections have been performed that aren’t necessary - but there’s also lots of grey area here.
We’ve also seen the rise in baby friendly hospitals, which some patients are flocking to but others find stressful. A growing number of these hospitals are eliminating the nursery that kept me sane in those early days in favor of so-called “rooming in,” meaning keeping the infant with the mother 24/7.
Dr. Akileswaran said some of her patients have felt exhausted and in pain after labor and they might not be ready to nurse immediately. This can set off alarm bells, particularly when there are objectives related to breastfeeding. Patients may end up feeling pushed by their providers, rather than reassured and supported. “Moms will do anything for their babies, so it’s a time when the feelings of guilt and shame are so heightened,” she said.
“When things are scrutinized and measured,” Dr. Akileswaran continued, “that means there’s less ability to do what’s right for individual patients.” So what’s best for one patient might not be for another. It’s so unfortunate when patients feel overloaded with expectations from their care teams without understanding why.
Going forward, a lot of these choices need to be made on a case-by-case basis, Dr. Akileswaran stresses. Not every mother can or wants to breastfeed; sometimes C sections are necessary and advisable; and effective pain relief can make all the difference when it comes to labor and recovery.
About that care team...
When I left the hospital after my surgery, I realized I had neglected to ask many questions of my nurses about my followup care. I had learned so much about my newborn from the paediatricians and nurses that visited us in the hospital room, but I was relying on information from mommy blogs and websites like “What to Expect.com” on my own recovery. As a result, I was surprised when I started sweating profusely at night and bled continuously for weeks.
Every day, I feel fortunate to be able to afford help. I’ve had multiple sessions with a lactation consultant because breastfeeding has been a challenge. Seriously it’s so hard. My husband’s company has a generous leave policy so he’s taken some time off from work. I also have a network of amazing and understanding mom friends to turn to. And I’ve been able to afford some really great tools, including Oath Care, where I’ve had access to a virtual community of other parents and get access to paediatricians, mental health experts and other providers (for transparency, I liked Oath so much as a user that I made a personal investment).
Not everyone has these resources - and that’s a travesty. When I polled doctors on social media who are also parents, most said they got more sleep during residency than they did while caring for their babies. Many parents live in a different state, or even country, from their own family. So they’re left on their own during an extremely challenging time. And all of this was exacerbated by the pandemic.
We still need a village to raise children. And we need more than just our doctors around us. Dr. Akileswaran acknowledged that she was trained to be a successful surgeon and to manage complications, but she told me that wasn’t initiated in how to help her patients be successful parents.
Where I hope the next generation of new businesses will play a role is to step in and help during pregnancy and postpartum. And I hope to see more state and federal policies that support families, too. All of this is so needed - and I’ll dive into it deeper in my next newsletter.
In the meantime, I’ll leave you with a final thought...
Parents: You are freaking heroes.
In my role at OMERS, I’ll be looking to invest in women’s health start-ups once I’m back from maternity leave. If you’re working in this space, I’d love to hear from you. As always, you can reach me @chrissyfarr on Twitter.