Healthcare systems have scrambled to create safe solutions for COVID-19. With no time for long-term studies, they’re creating standards of care for pregnant women and new mothers in real time. Policies vary among healthcare facilities, but in too many cases, women have suffered — forced to give birth without adequate support, separated from their babies, prevented from breastfeeding (the CDC now says women who test positive for COVID-19 can still breastfeed). Healthcare’s priority is to prevent transmission, and rightly so, but as often happens in maternal health settings, the question of what’s best for mothers is an afterthought.
Research studies have the power to turn maternal health on its head, yet very few focus on motherhood. Instead, most studies that examine maternal health focus on babies. This has been true during the pandemic. On January 24, The Lancet published its first paper on the clinical presentation of COVID-19; on February 12, it published the first paper investigating the possibility of vertical transmission from mother to baby in utero, a topic that was the subject of many more papers. When research does give mothers the spotlight, it almost always take a pathological “what’s wrong with her?” perspective. Considering how poor maternal health outcomes are in the United States (which has the highest maternal mortality rate of all developed countries), and how often they result from medical over-intervention, maybe it’s time to reframe how we study mothers.
We don’t study the wide range of what’s normal during this huge life event we title 'motherhood.'
Aurelie Athan, Ph.D. is a psychologist in the Department of Clinical Psychology at Teachers College, Columbia University and a founding member of the Sexuality, Women, & Gender Project. She focuses on women’s development across the lifespan, including matrescence, the transition of motherhood. Early in her career, Athan noted that whenever mothers were studied and discussed, from long before pregnancy to well into their child’s adulthood, it was almost exclusively about how her choices, health, wellbeing and life impacted her child’s experience, not hers.
“We rarely reflect on mothers’ subjective experiences,” says Athan. “We don’t ask how she’s experiencing motherhood. Studies might observe or measure her behavior, like how folic acid improves her child’s health, but not how it benefits her. When we do research her experience, say, for example, by studying postpartum depression, we look almost exclusively through the pathology lens, when something’s wrong. We don’t study the wide range of what’s normal during this huge life event we title 'motherhood.'”
How many studies focus on mothers? Very, very few. Athan’s laboratory on Maternal Psychology conducted a systematic review of 116,000 academic articles from 1992 to 2018 across medical and social science professions that were most likely to be interested in maternal wellbeing. These included clinical, developmental and social psychologies, social work, midwifery, obstetric medicine, and women’s studies. Her team’s preliminary findings discovered that only 9.76% of articles were mother-focused and only 0.05% actually studied the maternal subjective experience. Many of the rest covered related subjects, such as the mother’s impact on her child. “Journals and fields with the highest impact and strongest, most powerful voices, like psychiatry, for instance, were the quietest on mothers,” says Athan.
She says that this is because historically, people only paid attention to women’s experiences at their most distressing. “Even though mothers form the cornerstone of many fundamental psychological theories, policies and research, studies only focus on how well or not well they perform as expressed via the child. Mothers’ experiences are largely invisible because we haven’t asked, ‘What is this like for you?’”
Only 9.76% of articles were mother-focused and only 0.05% actually studied the maternal subjective experience.
In general, the best research practice is to understand what’s normative and what the challenges, expectations and setbacks are for a given subject. Then, researchers try to understand the risk factors for when things go off course. “We can’t understand why things go wrong for some mothers if we don’t understand the whole passage and not just the limited time frame from conception to childbearing. Women tell us, ‘I went from the obstetrician’s hands to the pediatrician’s hands. There wasn’t much care for me after birth.’”
Pandemic 2020 is not “normal times” and maternal healthcare, like healthcare as a whole, is being created on the fly (The Lancet editor Richard Horton recently told the New Yorker that he is receiving four to five times the usual volume of journal submissions).
Leah, who asked to be identified by her first name, checked into the hospital in May in active labor. She received a rapid COVID test and was told that if she tested positive, she’d have to labor alone while her husband waited at home. A negative result came back within minutes and her husband, who was not tested, supported her in the delivery room. Five weeks later, with body aches and a raging fever, she drove herself to urgent care. She received another COVID test, a prescription for antibiotics and guidelines to stay away from her baby, except for feedings, until her test results were back. For the next four days, until she was finally emailed a negative result, she was afraid for her life, afraid to touch her children and not sure how to take care of herself. She was lucky and the antibiotics worked, but she received almost no follow-up care and Leah says, “Most of my medical support was directed at the baby. Obviously I was worried about him, but I was very sick and I felt like nobody was all that interested in me.”
How does this lack of interest in normal motherhood translate as women become mothers? That largely depends on their healthcare providers’ perspectives and training. Perinatal care from a midwife revolves around pregnancy as a normal, healthy experience. An obstetrician’s perspective is usually more focused on potential complications — that’s their specialty and how they’re trained, but this frequently puts normal women under the pathology microscope instead of showing the whole picture.
Routine prenatal care focuses on potential pathologies through an expanding list of tests and exams (blood pressures, urine samples, blood tests, genetic tests, ultrasounds, fetal heart monitoring and more). These tests rule out complications that are dangerous and scary, but that generally impact only a small number of pregnancies. When it comes to advice for normal mothers, pamphlets and instructions cover foods to avoid, fitness and hospital care, based on studies and guidelines for what’s best for the baby. The message is clear: baby’s experience is the most important outcome in maternal child health.
Take for example the radical shift obstetric care made in the late '90s to ban vaginal births after cesarean (VBACs). C-section rates were at an all-time low early in the 1990s. Then, almost overnight, hospital C-section rates shot up based on a study that linked VBACs with uterine rupture and fetal death. Women who’d had a previous C-section were told during prenatal care that they’d definitely need surgery for all subsequent births. They usually didn’t get much say in the matter, even when later studies indicated that most mothers could absolutely VBAC safely and that too many C-sections were causing maternal death rates to spike. Regardless, VBAC bans persist today all over the country and most mothers take it for granted that “once a C-section, always a C-section” is the safest policy if they want a healthy baby.
It’s part of my life's work to get both mothers and researchers to see women’s intrinsic value as people, not just as birth vessels.
Amanda Williams, M.D., OB-GYN and Chief of Obstetrics at the Kaiser Oakland Medical Center is working to change the trend of baby-dominated care by refocusing maternal healthcare on women. Williams says, “This is more than a pet peeve of mine. It’s part of my life's work to get both mothers and researchers to see women’s intrinsic value as people, not just as birth vessels. In recent years, we've looked more closely at maternal morbidity and mortality in this country, which is going up, not down, and contrasts with the entire rest of the developed world. In the last 25 years, we’ve almost exclusively studied newborn outcomes first and then studied the mother relative to her child, but almost exclusively in secondary analyses.”
Why aren’t mothers the primary reason studies are conducted? In large part, Williams explains, because of funding. “The NICHD (the National Institute of Child Health and Human Development) is one of the biggest research funding sources and intentionally structured around funding child health. So… follow the money.” Williams and other maternal health stakeholders are making it a priority to influence research funding back to the maternal part of maternal-child health. They know that when mothers are well cared for, and their needs are met, their babies are usually healthy too.
"We need to see women more wholly and honor the normalcy of the birth experience," says Williams. "People have been having babies since the beginning of time. Our work should preserve and optimize that birth experience." In terms of medical practice, Williams' facility is shifting that dynamic for medical residents by giving them a solid foundation in what’s normal during pregnancy, labor and birth by training them with midwives before they specialize in complications.
Given time, this simple shift of focus in research and healthcare from babies back to mothers may finally help improve maternal healthcare for both.
Amanda Williams, M.D., OB-GYN and Chief of Obstetrics at the Kaiser Oakland Medical Center
Huang, C., Wang, Y., Li, X., Ren, L., Zhao, J., Hu, Y., et al. (2020) Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. The Lancet, https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30183-5/fulltext
Chen, H., Guo, J., Wang, C., Luo, F., Yu, X., Zhang, W., et al. (2020) Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. The Lancet, https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30360-3/fulltext