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Tag: pregnant people

  • Winter Illness This Year Is a Different Kind of Ugly

    Winter Illness This Year Is a Different Kind of Ugly

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    Earlier this month, Taison Bell walked into the intensive-care unit at UVA Health and discovered that half of the patients under his care could no longer breathe on their own. All of them had been put on ventilators or high-flow oxygen. “It was early 2022 the last time I saw that,” Bell, an infectious-disease and critical-care physician at the hospital, told me—right around the time that the original Omicron variant was ripping through the region and shattering COVID-case records. This time, though, the coronavirus, flu, and RSV were coming together to fill UVA’s wards—“all at the same time,” Bell said.

    Since COVID’s arrival, experts have been fearfully predicting a winter worst: three respiratory-virus epidemics washing over the U.S. at once. Last year, those fears didn’t really play out, Sam Scarpino, an infectious-disease modeler at Northeastern University, told me. But this year, “we’re set up for that to happen,” as RSV, flu, and COVID threaten to crest in near synchrony. The situation is looking grim enough that the CDC released an urgent call last Thursday for more vaccination for all three pathogens—the first time it has struck such a note on seasonal immunizations since the pandemic began.

    Nationwide, health-care systems aren’t yet in crisis mode. Barring an unexpected twist in viral evolution, a repeat of that first terrible Omicron winter seems highly unlikely. Nor is the U.S. necessarily fated for an encore of last year’s horrors, when enormous, early waves of RSV, then flu, slammed the country, filling pediatric emergency departments and ICUs past capacity, to the point where some hospitals began to pitch temporary tents outside to accommodate overflow. On the contrary, more so than any other year since SARS-CoV-2 appeared, our usual respiratory viruses “seem to be kind of getting back to their old patterns” with regard to timing and magnitude, Kathryn Edwards, a vaccine and infectious-disease expert at Vanderbilt University, told me.

    Read: The worst pediatric-care crisis in decades

    But even so-so seasons of RSV, flu, and SARS-CoV-2 could create catastrophe if piled on top of one another. “It really doesn’t take much for any of these three viruses to tip the scale and strain hospitals,” Debra Houry, the CDC’s chief medical officer, told me. It also—in theory—shouldn’t take much to waylay the potential health-care crisis ahead. For the first time in history, the U.S. is offering vaccines against flu, COVID, and RSV: “We have three opportunities to prevent three different viral infections,” Grace Lee, a pediatrician at Stanford, told me. And yet, Americans have all but ignored the shots being offered to them.

    So far, flu-shot uptake is undershooting last year’s rate. According to recent polls, as many as half of surveyed Americans probably or definitely aren’t planning to get this year’s updated COVID-19 vaccine. RSV shots, approved for older adults in May and for pregnant people in August, have been struggling to get a foothold at all. Distributed to everyone eligible to receive them, this trifecta of shots could keep as many as hundreds of thousands of Americans out of emergency departments and ICUs this year. But that won’t happen if people continue to shirk protection. The specific tragedy of this coming winter will be that any suffering was that much more avoidable.

    Much of the agony of last year’s respiratory season can be chalked up to a terrible combination of timing and intensity. A wave of RSV hit the nation early and hard, peaking in November and leaving hospitals no time to recover before flu—also ahead of schedule—soared toward a December maximum. Children bore the brunt of these onslaughts, after spending years protected from respiratory infections by pandemic mitigations. “When masks came down, infections went up,” Lee told me. Babies and toddlers were falling seriously sick with their first respiratory illnesses—but so were plenty of older kids who had skipped the typical infections of infancy. With the health-care workforce still burnt out and substantially pared down from a pandemic exodus, hospitals ended up overwhelmed. “We just did not have enough capacity to take care of the kids we wanted to be able to take care of,” Lee said. Providers triaged cases over the phone; parents spent hours cradling their sick kids in packed waiting rooms.

    And yet, one of the biggest fears about last year’s season didn’t unfold: waves of RSV, flu, and COVID cresting all at once. COVID’s winter peak didn’t come until January, after RSV and flu had substantially died down. Now, though, RSV is hovering around the high it has maintained for weeks, COVID hospitalizations have been on a slow but steady rise, and influenza, after simmering in near-total quietude, seems to be “really taking off,” Scarpino told me. None of the three viruses has yet approached last season’s highs. But a confluence of all of them would be more than many hospitals could take. Across the country, many emergency departments and ICUs are nearing or at capacity. “We’re treading water okay right now,” Sallie Permar, the chief pediatrician at Weill Cornell Medical Center and NewYork-Presbyterian Hospital, told me. “Add much more, and we’re thrown into a similar situation as last year.”

    That forecast isn’t certain. RSV, which has been dancing around a national peak, could start quickly declining; flu could take its time to reach an apex. COVID, too, remains a wild card: It has not yet settled into a predictable pattern of ebb and flow, and won’t necessarily maintain or exceed its current pace. This season may still be calmer than last, and impacts of these diseases similarly, or even more, spaced out.

    But several experts told me that they think substantial overlap in the coming weeks is a likely scenario. Timing is ripe for spread, with the holiday season in full swing and people rushing through travel hubs on the way to family gatherings. Masking and testing rates remain low, and many people are back to shrugging off symptoms, heading to work or school or social events while potentially still infectious. Nor do the viruses themselves seem to be cutting us a break. Last year’s flu season, for instance, was mostly dominated by a single strain, H3N2. This year, multiple flu strains of different types appear to be on a concomitant rise, making it that much more likely that people will catch some version of the virus, or even multiple versions in quick succession. The health-care workforce is, in many ways, in better shape this year. Staffing shortages aren’t quite as dire, Permar told me, and many experts are better prepared to deal with multiple viruses at once, especially in pediatric care. Kids are also more experienced with these bugs than they were this time last year. But masking is no longer as consistent a fixture in health-care settings as it was even at the start of 2023. And should RSV, flu, and COVID flood communities simultaneously, new issues—including co-infections, which remain poorly understood—could arise. (Other respiratory illnesses are still circulating too.) There’s a lot experts just can’t anticipate: We simply haven’t yet had a year when these three viruses have truly inundated us at once.

    Read: The big COVID question for hospitals this fall

    Vaccines, of course, would temper some of the trouble—which is part of the reason the CDC issued its clarion call, Houry told me. But Americans don’t seem terribly interested in getting the shots they’re eligible for. Flu-shot uptake is down across all age groups compared with last year—even among older adults and pregnant people, who are at especially high risk. And although COVID vaccination is bumping along at a comparable pace to 2022, the rates remain “atrocious,” Bell told me, especially among children. RSV vaccines have reached just 17 percent of the population over the age of 60. Among pregnant people, the other group eligible for the vaccines, uptake has been stymied by delays and confusion over whether they qualify. Some of Permar’s pregnant physician colleagues have been turned away from pharmacies, she told me, or been told their shots might not be covered by insurance. “And then some of those same parents have babies who end up in the hospital with RSV,” she said. Infants were also supposed to be able to get a passive form of immunity from monoclonal antibodies. But those drugs have been scarce nationwide, forcing providers to restrict their use to babies at highest risk—yet another way in which actual protection against respiratory disease has fallen short of potential. “There was a lot of excitement and hope that the monoclonal was going to be the answer and that everybody could get it,” Edwards told me. “But then it became very apparent that this just functionally wasn’t going to be able to happen.”

    Last year, at least some of the respiratory-virus misery had become inevitable: After the U.S. dropped pandemic mitigations, pathogens were fated to come roaring back. The early arrivals of RSV and flu (especially on the heels of an intense summer surge of enterovirus and rhinovirus) also left little time for people to prepare. And of course, RSV vaccines weren’t yet around. This year, though, timing has been kinder, immunity stronger, and our arsenal of tools better supplied. High uptake of shots would undoubtedly lower rates of severe disease and curb community spread; it would preserve hospital capacity, and make schools and workplaces and travel hubs safer to move through. Waves of illness would peak lower and contract faster. Some might never unfold at all.

    Read: The pandemic broke the flu … again

    But so far, we’re collectively squandering our chance to shore up our defense. “It’s like we’re rushing into battle without armor,” Bell told me, even though local officials have been begging people to ready themselves for months. Which all makes this year feel terrible in a different kind of way. Whatever happens in the coming weeks and months will be a worse version of what it could have been—a season of opportunities missed.

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    Katherine J. Wu

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  • Pregnancy Can Change Your Shoe Size Forever

    Pregnancy Can Change Your Shoe Size Forever

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    One night in July, a few weeks after my son was born, I lay awake, desperately scrolling through photos of injured feet. The mounting pain from an ingrown toenail in my right foot had become excruciating, and the internet promised to help. I could no longer deny the fact that the exorbitantly expensive Hoka sneakers I’d bought just months before—to prevent pregnancy-related foot pain—had become too small. To my horror, my feet had grown half a size. Permanently.

    Pregnancy books had informed me about the less rosy aspects of new motherhood, such as shedding hair (the baby’s and mine) and uncontrollable crying (the baby’s and mine). I was even prepared for my feet to temporarily swell through the trimesters. But no one told me they might stay that way. Unlike the rest of my body, my feet did not revert to their original size 9.5 after birth. Five months later, I am now the disgruntled guardian of a large infant—and even larger feet.

    Mom Feet is not a niche condition. Studies have found that anywhere from 44 to 61 percent of new moms experience lasting foot growth, and many seem to be surprised when it happens, just as I was. “Why does no one talk about the PERMANENT foot size changes after pregnancy?” one Reddit user lamented. My thoughts exactly.

    Temporary swelling in the feet (and hands) is a normal part of pregnancy, particularly in the third trimester. Extra fluid in the body tends to pool in “gravity-dependent areas,” causing ankles and toes to become noticeably puffy, Silvana Ribaudo, an ob-gyn at Columbia University Irving Medical Center, told me. This is not the same thing as Mom Feet, which I learned the hard way by wearing my Hokas long after they’d started to pinch.

    Foot swelling subsides after a person gives birth, but structural changes in the foot do not. Permanent foot growth, like most other disconcerting bodily changes that happen during pregnancy, can be attributed to hormones—in this case, one aptly named relaxin. It relaxes body tissue so that a growing baby can unfurl, then squiggle out. These changes are especially welcome in the pelvic region. In the feet, not so much.

    If a pre-pregnancy foot is like an ice-cream sandwich straight out of the freezer—sturdy, structured—one relaxed by relaxin is a sandwich left out in the sun. The hormone causes the ligaments and tendons in the foot and ankle to lose their rigidity and strength, so the foot tends to spread out, Alexandra Black, a podiatrist at Foot and Ankle Specialists of Central Ohio who co-authored a recent review of pregnancy-related foot changes, told me. Throwing pregnancy weight on them only compounds the problems. “It leads to more of a flatter foot, a wider foot, and a longer foot,” Black said. According to the few small studies on the topic, pregnant feet, on average, go up by roughly half a shoe size and lengthen by 0.4 inches. It is a small consolation that this effect is most pronounced during first pregnancies, meaning that feet won’t grow indefinitely along with one’s brood.

    It would have been nice to learn this before I bought my Hokas, of course. Had I known better, I probably wouldn’t have purchased so many Nike Air Maxes in recent years, or suggested to my husband that we buy matching white Jordans at an outlet mall during our honeymoon. Now those beloved shoes, along with the Hokas, have been banished to storage, while I’ve had to pay up for new winter boots, high heels, and sandals.

    Having to buy new shoes is expensive but admittedly kind of fun. Other consequences of Mom Feet are not. Footwear is annoying, because even a small shift in foot size can lead to shoes that don’t fit. And the collapse of the arch in your feet can be especially painful. Mine used to be graceful, like the arc of a leaping gazelle. Now the gazelle has face-planted. That’s because a tendon on the inside of the ankle, which normally acts like a bungee cable stabilizing the arch, goes slack during pregnancy. Lengthening and flattening this tendon can cause “a flat-foot deformity,” Black said, “and it’s kind of hard to reverse that.” Flat feet can cause the knee and tibia to over-rotate, throwing the bones and muscles involved in walking and standing into disarray—a “major contributor to pain” in pregnancy, one review noted. Conditions such as painful heels caused by plantar fasciitis, leg cramps, bunions, and nail issues are all linked to Mom Feet.

    Had I known about Mom Feet, I might have been better prepared for it. Some pregnant people and new moms find it helpful to use compression stockings to reduce swelling and get orthotics for extra arch support, Black said. Unfortunately, none of my doctors (who I should note were very good) warned me about it. Ditto for any pregnancy book I read, such as What to Expect When You’re Expecting, which said only that swelling of the feet was “normal” and “temporary.” I am far from the only person who has been caught off guard by newly big feet. Mystified mothers abound on pregnancy forums; colleagues told me they were “not warned” and “had no idea this was A Thing.”

    Perhaps the reason it is commonly overlooked is that, in the grand scheme of things that mothers-to-be have to deal with, such as gestational diabetes and life-threatening spikes in blood pressure, foot pain is relatively inconsequential. Because foot-size changes “are not concerning for the well-being of mom or baby,” they might not be deemed worthy of discussion, Leena Nathan, an ob-gyn at UCLA Health–Westlake Village, told me.

    But perhaps Mom Feet isn’t talked about because many things about it are still unknown. Not everyone experiences pain, and although permanent changes are well documented, feet might still possibly revert to their original size eventually. “It can take several years,” Ribaudo said, but “sometimes it never goes back.”According to Nathan, it isn’t well understood why some people experience changes in foot size and others don’t. Even the true prevalence of this condition isn’t known for certain, because the few studies that have examined it were small. One thing is clear, however: There is a dearth of research on foot changes during pregnancy, because pregnant women, in general, are understudied. People are “hesitant to do research on pregnant women, because it’s a sensitive population,” Black said.

    During my pregnancy, I was often shocked at how little was known about concerns both minor and monumental: whether eating pineapple would induce contractions, for example, or when the baby would actually be born. Walking, climbing stairs, and having sex are commonly recommended to help induce labor, but “it’s difficult to establish whether they actually worked—or whether labor, coincidentally, started on its own at the same time,” notes What to Expect When You’re Expecting. Pregnancy literature is rife with these sorts of equivocations. Many times over the trimesters, I wondered why so much of pregnancy still felt so medieval, full of guessing, folklore, and hearsay. It’s 2023: Why are new moms still surprised when their feet grow? To this, I have found few satisfactory answers. But at the very least, I have found an ingrown-toenail treatment that works.

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    Yasmin Tayag

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  • Why So Many Accidental Pregnancies Happen in Your 40s

    Why So Many Accidental Pregnancies Happen in Your 40s

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    After she turned 42, Teesha Karr thought she was done having kids. Six, in her mind, was perfect. And besides, she was pretty sure she had started menopause. For the past six months she’d had all the same signs as her friends: hot flashes, mood swings, tender breasts. She and her husband decided they could probably safely do away with contraception. But less than a month later, Karr felt a familiar twinge of pain in her ovary—the same twinge she’d felt every time she’d been pregnant before.

    Karr felt embarrassed. “Teenagers accidentally get pregnant. Forty-two-year-old women don’t usually accidentally get pregnant,” she told me. But, really, 42-year-old women accidentally getting pregnant is surprisingly common. Nearly 4 percent of all new babies are born to women 40 and older, according to the latest data from the National Center for Health Statistics. As many as 75 percent of pregnancies in this age range are unplanned. It’s a frequent enough occurrence that the plots of Downton Abbey, Sex Education, And Just Like That, Grey’s Anatomy, and Black-ish have depended on it.

    Many women still believe that by their 40s, unintended pregnancy just isn’t something they have to worry about. After all, many of us are told our whole lives that our biological clock is ticking, that our fertility plummets after 35, and that if we wait too long we’ll likely need some form of reproductive technology to get pregnant—if we can get pregnant at all. If conceiving at this age is so hard, surely you wouldn’t get pregnant by accident, right?

    To understand why pregnancy can, and does, happen at this age, it helps to consider the wacky in-between land that is perimenopause. This stage, which can last anywhere from a few months to about eight years, is typically assumed to be a smooth transition into menopause. In reality, it’s more like the hormonal chaos of puberty, when the ovaries first sputter to life, wreaking all sorts of bodily havoc as they try to figure out their new groove.

    In perimenopause, the ovaries are once again trying to adapt to a new normal. Only now they’re in overdrive, sending out scattered spurts of estrogen to recruit a much scarcer pool of eggs to release during ovulation. During this time, you might ovulate twice in one cycle, miss a cycle altogether, or experience unpredictable flash periods. “Those ovaries are kind of going nuts,” Robin Noble, a gynecologist and menopause specialist in Maine, told me. That can have all sorts of weird consequences. For one, extreme hormone spikes can stimulate the ovary to release extra eggs, which is one reason why fraternal twins are more common in older pregnancies.

    If your ovaries are still ovulating, however sporadically, then you can still get pregnant. The likelihood of getting pregnant does decline with age, particularly toward the tail end of your 30s. By 40, according to the American Society for Reproductive Medicine, the chance of getting pregnant during a single menstrual cycle is less than 5 percent. The problem starts when these low odds lead women to use less reliable contraception, such as the rhythm method or withdrawal. Thanks to hormone spikes and the menstrual cycle becoming less predictable, those methods become even riskier during perimenopause, and the odds can stack up.

    Read: The secret power of menopause

    “I hear it every day,” Rachel Pope, an OB/GYN and the head of female sexual health at University Hospitals, in Ohio, told me. “Many women really think that their reproductive potential doesn’t exist anymore, which is not true.” In reality, you can’t be sure you’re in menopause—and therefore really done worrying about pregnancy—until you haven’t had a period for at least a year. For this reason, the Menopause Society recommends keeping a hormonal IUD in or continuing hormonal birth-control pills for a year after your last period, just in case.

    To add to the confusion, some symptoms of perimenopause—missed periods, fatigue, mood shifts—resemble early signs of pregnancy. Lisa Perriera, an OB/GYN and the chief medical director of the Women’s Centers, a group of abortion clinics across several states, sees women almost every month who are shocked to find that their body is still capable of getting pregnant. “I’ve definitely cared for my share of 47-year-olds that are like, ‘I just thought it was menopause,’” she told me.

    Because women in their 40s may be expecting aging-related changes in their body but not looking out for signs of pregnancy, many don’t realize they’re pregnant until 16 or even 20 weeks along, Perriera said. That’s what happened to Anne Ruiz. In 2017, the 43-year-old mom wasn’t experiencing any signs of perimenopause but figured her window for pregnancy was closing fast. Her period had always been irregular, so she wasn’t overly concerned when it didn’t come for a month or two. By the time she started getting morning sickness and took a pregnancy test, she was almost four months pregnant.

    Read: Capitalism has plans for menopause

    Ruiz and her husband welcomed the news, but also felt overwhelmed. “It was probably maybe like 60 percent excited and 40 percent Oh my God, how are we going to start over?” she told me. She gave birth the next year and immediately got an IUD.

    Facing a pregnancy at a time when you think it is no longer a possibility can be profoundly distressing. “I do see a lot of people shaken by it,” Pope said. “Having a pregnancy that’s not planned can be just so life-altering,” especially at a time when abortions are difficult or impossible to access in many states. A common first reaction is denial. After Christina Ficicchia started experiencing irregular periods, at 42, her gynecologist told her she was in perimenopause. So when she missed a period entirely, she assumed her menstrual cycle was on its way out. Then she started “feeling” pregnant—“after you’ve been pregnant a few times, you kind of know,” she told me. Yet even after a positive pregnancy test, she asked her doctor to take an in-office test to confirm the results. After planning her first two children, Ficicchia struggled to wrap her mind around the choice that she now faced: “It was one that I realistically never thought that I had to make.”

    Many women face extra distress because they know that being pregnant over the age of 40 comes with greater risks. The chance of miscarriage above that age rises to one in three, if not much higher, according to the Mayo Clinic. Pregnant people over 40 are also at a greater risk for preeclampsia, gestational diabetes, placenta previa, preterm delivery, hypertension, pelvic-floor injuries—“basically everything that could go wrong,” Pope said. Risks for Down syndrome and other chromosomal abnormalities also rise.

    Read: Please don’t call my cervix incompetent

    After talking with her obstetrician, Ficicchia ultimately chose to continue her pregnancy. Despite her heightened anxiety, she delivered her fourth child, Emmerson, at age 43 with no complications. Karr wasn’t so lucky. After she and her husband adjusted to the news, Karr told her other children to expect a new sibling, and even told her colleagues. Then, at her eight-week ultrasound, the technician told her the fetus had no heartbeat.

    After finally having allowed herself to imagine another baby in her future, Karr was crushed. “I was pretty set with where I was in life and then this all happened and turned everything upside down,” she said. She is still trying to make sense of the loss, and dreads the weekly emails she still receives from pregnancy websites, telling her what to expect at each stage of pregnancy and advertising breastfeeding products. “If I’d known what was happening in my body, then this would have never happened,” she told me. “I was not informed.”

    Of course, bodies can be confusing even for the extremely well informed—for instance, doctors who spend their days explaining perimenopause to their patients. When Pope missed her period in July and started feeling tenderness in her breasts, she had a hunch that she knew what was going on: perimenopause. At 38, she was on the early side. Still, she thought, “this is probably it,” she said. A spontaneous pregnancy seemed unlikely, given that she and her husband had used IVF for their two children and were planning on using it again.

    “Then my husband, who’s a family doctor, was like, ‘Maybe you should check a pregnancy test,’” she said. In fact, Pope wasn’t perimenopausal. She was five weeks pregnant.

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    Rachel E. Gross

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  • An Unusual Theory Suggests That Sex Helps the Body Tolerate a Fetus

    An Unusual Theory Suggests That Sex Helps the Body Tolerate a Fetus

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    In the early 1990s, while studying preeclampsia in Guadeloupe, Pierre-Yves Robillard hit upon a realization that seemed to shake the foundations of his field. Preeclampsia, a pregnancy complication that causes some 500,000 fetal deaths and 70,000 maternal deaths around the world each year, had for decades been regarded as a condition most common among new mothers, whose bodies were mounting an inappropriate attack on a first baby. But Robillard, now a neonatologist and epidemiologist at Centre Hospitalier Universitaire de La Réunion, on Réunion Island in the Indian Ocean, kept seeing the condition crop up during second, third, or fourth pregnancies—a pattern that a few other studies had documented, but had yet to fully explain. Then, Robillard noticed something else. “These women had changed the father,” he told me. The catalyst in these cases of preeclampsia, he eventually surmised, wasn’t the newness of pregnancy. It was the newness of paternal genetic material that, maybe, the mother hadn’t had enough exposure to before.

    Robillard’s idea was unconventional not only because it challenged the dogma of the time, but because it implied certain evolutionary consequences. Preeclampsia appears to be exclusive (or almost exclusive) to humans, and may have arisen as a by-product of the particularly aggressive ways in which our fetuses pillage their mother’s body for resources. So, Robillard and his colleagues posited, maybe the dangers it poses then pressured humans into developing a bizarre trait: being rather inefficient at conceiving offspring. Maybe, if humans aren’t terribly fertile, they need to have a lot of sex; maybe having a lot of sex repeatedly exposes a mother to her partner’s semen, inuring her to the molecular makeup of future offspring. If preeclampsia is a kind of immune overreaction, then perhaps unprotected sex is the world’s most unconventional allergy shot.

    That, at least, is what Robillard and his colleagues contend—a notion that’s “a bit controversial, and a bit awkward,” Inkeri Lokki, an immunologist and reproductive biologist at the University of Helsinki, told me. She remembers a senior researcher in the field once framing the upshot of the hypothesis as “pick your partner early, and practice.”

    Read: The pregnancy risk that doctors won’t mention

    Foreign genetic material aside, a mother’s body has every reason to be wary of a fetus. Pregnancy is an intergenerational struggle in which the fetus tries to pillage all the nutrients it can from the mother’s tissues, while the mother tries to keep some of her own resources in reserve.

    For most mammals, the two parties easily reach a lasting stalemate. Among humans, though, the fetus starts “with the upper hand,” Amy Boddy, an evolutionary biologist at UC Santa Barbara, told me. Whether it’s because of the extreme nutritional demands of our energy-guzzling brain, or just a constraint of how the primate lineage evolved, no other developing mammal invades quite as vigorously as the human embryo does: Through two waves of invasion, our placental cells burrow so deeply into the lining of the uterus that they breach its muscular layer, where they unfurl, melt, and rewire an entire set of blood vessels until they widen and relax. In the process, tissues liquify, and cells are forced apart, all to get an enormous amount of “blood delivered to the placenta,” Julienne Rutherford, a biological anthropologist at the University of Arizona College of Nursing, told me.

    The fetus thrives in these conditions—but it also asks so much of the mother’s body that it almost invites pushback. Preeclampsia, then, at least when it appears prior to 34 weeks of gestation, is arguably a manifestation of a human mother’s defenses wising up to the invasion, then kicking into overdrive. When researchers examine tissue samples in early-onset preeclampsia cases, they tend to find that the placenta has been prevented from invading the uterus thoroughly enough, Haley Ragsdale, a biological anthropologist at Northwestern University, told me. Now at risk of starving, the fetus tries to juice more from mom—in part by raising maternal blood pressure, preeclampsia’s hallmark symptom. (High blood pressure that arises in the last few weeks of pregnancy can signal late-onset preeclampsia, but researchers generally think the causes are distinct.)

    Why exactly the placenta’s invasion flags in early-onset cases remains contentious, Offer Erez, an ob-gyn at Soroka University Medical Center, in Israel, told me. One possibility, as Robillard and others argue, is that a mother’s immune system, unaccustomed to her partner’s particular blend of molecules, codes the fetus as foreign, and dispatches a fleet of defenses to waylay the threat. If that’s indeed the case, a logical workaround might involve familiarizing her body with those foreign substances—and nipping her overreaction in the bud.

    Read: Pregnancy is a war; birth is a cease-fire

    Semen could do the trick: It’s chock-full of paternal material, and introduced into the vaginal tract, where a legion of immune cells and molecules roam. It also contains signaling molecules that might be able to mollify the maternal immune system. Repeat exposures with no harm send a clear message: I am safe, says Gustaaf Dekker, who leads the department of obstetrics and gynecology at Northern Adelaide Local Health Network, in Australia, and who has collaborated for years with Robillard.

    In the past three decades, Dekker, Robillard, and their colleagues have amassed a large amount of evidence to support that idea. Across several populations, the risk of early-onset preeclampsia seems to be higher among couples conceiving for the first time; it’s also higher among people using donor sperm and eggs. The risk also seems lower among couples who have a lot of penetrative or oral sex before they get pregnant—at least, if they skip the condoms, some studies suggest. There’s even evidence that repeat exposures to seminal fluid can make female mice more tolerant of cells sampled from their mates.

    From an evolutionary perspective, the theory goes even further. If it is important to indoctrinate the maternal immune system with semen, “that is a strong selective pressure” for humans to adopt a suite of behaviors to facilitate that exposure, says Bernard Crespi, an evolutionary biologist at Simon Fraser University, in Canada, who’s collaborated with Robillard. Our bodies’ combative approach to placentation could help to explain our semi-monogamous nature, our comparably low fertility among mammals, and our comparatively large testes, which can provide a generous supply of sperm. It may even have influenced the unusual ways in which the female human body conceals its own fertility. Unlike other mammals, we don’t regularly enter an obvious period of heat, or visibly signal when we ovulate—both traits that encourage more frequent sex in pursuit of reproduction. If repeat couplings are just kind of our thing, maybe it’s because they make our pregnancies that much safer.

    The paternal-immunity hypothesis is not the only possible explanation for early-onset preeclampsia, and for some researchers, it is far from the strongest one. Fathers could be playing a different role in the condition. Some evidence suggests that certain males pass down DNA that predisposes their offspring to implant a bit differently in the womb, Laura Schulz, a women’s-health researcher at the University of Missouri School of Medicine, pointed out to me. And Carlos Galaviz Hernández, a geneticist at CIIDIR Unidad Durango, in Mexico, told me that immune compatibility may matter, too: The mother might be able to better tolerate some partners, analogous to the way that organ transplants are more successful if certain molecular signatures match. In some cases, the mother’s DNA may be the dominant force. Certain women, for instance, seem genetically predisposed to developing the condition, regardless of whom they partner with.

    Jimmy Espinoza, a maternal-fetal-medicine specialist at UTHealth Houston’s McGovern Medical School, also pointed out to me that the idea Robillard has championed has its own scientific issues. In recent years, especially, other teams of researchers have found evidence that seems to directly contradict it—in some cases, finding that some people may reduce their chances of preeclampsia if they switch to a different partner for a subsequent child. (Dekker and Robillard argue that several of these studies had issues, including possible misdiagnoses and not distinguishing enough between early- and late-onset preeclampsia.)

    All of these ideas may have some truth to them—in part because preeclampsia, like cancer, is a catchall term for different disease pathways that manifest similarly at their tail end, Andrea Edlow, a maternal-fetal-medicine specialist at Massachusetts General Hospital, told me. And despite evidence to the contrary, “I still support the hypothesis,” Dekker told me. In his opinion, “nobody has come up with a better one.”

    Even if the semen hypothesis turns out to be correct, it’s hard to know what to do with that information. Breakthroughs are desperately needed: Although preeclampsia has been documented for millennia, diagnostics, treatments, and preventives are scant. Maybe better understanding paternal exposures will someday lead to preconception vaccines, or targeted immunotherapies for people deemed high risk. Today, though, the idea’s most actionable takeaways are very limited. In Robillard’s ideal world, clinicians would recommend at least six months of sexually active cohabitation, or at least 100 sexual encounters, before conception; pregnant people would also routinely disclose their sexual history with their partner to their doctor, and changes in partners would be noted in medical charts. Unsurprisingly, “it’s been an uphill battle” to sell some of those ideas to colleagues, Dekker told me.

    Edlow, for one, generally supports the idea of paternal tolerance. But “it’s not something I would talk to patients about,” she told me. Sarah Kilpatrick, the chair of the department of obstetrics and gynecology at Cedars-Sinai, in Los Angeles, feels similarly. There’s just not quite enough evidence to build a recommendation, she told me—and designing a large clinical trial to rigorously test these ideas is difficult, especially for a condition with such serious risks.

    Read: Childbirth is no fun. But an extremely fast birth can be worse.

    Plus, a pre-pregnancy injunction to have more sex to lower the risk of preeclampsia can only really apply to a very specific audience. It assumes heterosexuality; it implies monogamy. Even the amount of sex that Robillard advocates for could pose a challenge for some couples who meet those criteria. And heterosexual, monogamous couples hardly represent the full universe of people who are getting pregnant—among them people who are pursuing single parenthood, who get pregnant through intrauterine insemination or in vitro fertilization, who are seeking donor sperm or embryos, and who get pregnant quickly or perhaps unintentionally. And although the chances of preeclampsia may be slightly elevated in some of those cohorts, in the broadest terms, “why person X gets it, and why person Y doesn’t get it, we just don’t know,” Kilpatrick told me. Plus, a clinical strategy that pushes for, or even seems to justify, long-term sexual monogamy puts medical professionals in the position of actively prescribing a very specific and limited vision of human sexuality, Rutherford, the biological anthropologist, told me.

    Frankly, Edlow told me, “I don’t want to take this condition that affects pregnancy and make it all about men’s sperm.” There may yet be other ways to trigger tolerance, or keep the maternal immune system in check. Preeclampsia, for whatever reason, may be an evolutionary snarl our lineage got tangled up in. But to address it, or even solve it, people may not need to bend to evolution’s whims.

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    Katherine J. Wu

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  • Fall’s Vaccine Routine Didn’t Have to Be This Hard

    Fall’s Vaccine Routine Didn’t Have to Be This Hard

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    In an ideal version of this coming winter, the United States would fully revamp its approach to respiratory disease. Pre-pandemic, fall was just a time for flu shots, if that. Now, hundreds of millions of Americans have at their fingertips vaccines that can combat three cold-weather threats at once: flu, COVID, and, for a subset of us, respiratory syncytial virus. If everyone signed up to get the shots they qualified for, “it would be huge,” says Ofer Levy, the director of the Precision Vaccines Program at Boston Children’s Hospital. Hospital emergency rooms and intensive-care units wouldn’t fill; most cases of airway illness would truly, actually feel like “just” a common cold. “We would save tens of thousands of lives in the United States alone,” Levy told me.

    The logic of the plan is simple: Few public-health priorities are more pressing than getting three lifesaving vaccines to those who need them most, ahead of winter’s viral spikes. The logistics, however, are not as clear-cut. The best way to get vaccines into as many people as possible is to make getting shots “very, very easy,” says Chelsea Shover, an epidemiologist at UCLA. But that’s just not what we’ve set up this fall lineup of shots to do.

    Read: The flu-ification of COVID policy is almost complete

    Convenience isn’t the only issue keeping shots out of arms. But move past fear, distrust, or misinformation, solve for barriers such as insurance coverage, and getting a vaccine in the United States still means figuring out when shots are available and which you qualify for, finding and booking appointments, carving out the time to go. For adults, especially, who don’t routinely visit their doctor for wellness checkups, and whose workplaces don’t require vaccines to the extent that schools do, vaccination has become an onerous exercise in opt-ins.

    Bundling this year’s flu, COVID, and RSV vaccines into a single visit could, in theory, help ease the way to becoming a double or triple shotter. “Any time we can cut down on the number of visits for a patient to take care of them, we know that’s a big boost,” says Tochi Iroku-Malize, the president of the American Academy of Family Physicians. But the easiest iteration of that strategy, a three-in-one shot, similar to the MMR and DTaP vaccines of childhood, doesn’t yet exist (though some are in trials). Even the shorter-term solution—giving up to three injections at once—is hitting stumbling blocks. Pharmacies started receiving flu vaccines earlier this summer and are already giving them out to anyone over the age of six months. RSV vaccines, too, have hit shelves, and have been approved for people over the age of 60 and those 32 to 36 weeks pregnant; so far, however, they are being offered only to the first group. And although nearly all Americans are expected to be eligible for autumn’s updated COVID vaccines, those shots aren’t slated to make an appearance until mid-September or so, according to Kevin Griffis, a CDC spokesperson.

    Timing two or three shots together isn’t a perfect plan. Get them all too early, and some people’s protections against infection might fade before the season gets into full swing; get all of them too late, and a virus might beat the vaccine to the punch. Respiratory viruses don’t coordinate their seasons: Right now, for instance, COVID cases are on a sharp rise, but flu and RSV ones are not. Some data on the new RSV vaccines also suggests that co-administering them with other shots might trigger slightly worse side effects, or mildly curb the number of antibodies that the injections raise. Still, Levy argues that those theoretical downsides are outweighed by known benefits. “If someone is at clinic in the fall, they should get all the vaccines they’re eligible for,” he told me. Getting a slightly less effective, slightly more ornery shot a few months early is better than never getting a shot at all.

    All of that supposes that people understand that they are eligible for these shots. But already, family-medicine physicians such as Iroku-Malize, who practices in Long Island, have been fielding queries about the RSV vaccines from confused patients. Some new parents, for instance, have gotten the impression that the RSV vaccines are designed to be administered to infants, which isn’t quite right: Babies are the target of protection for the shots for pregnant people, but only because they temporarily inherit antibodies—not because they can get the injections themselves. Regulators also haven’t yet nailed down how often older adults might need the shot, though the current thinking is that the vaccine’s protection will last at least a couple of years. “It’s very hard to tell people, ‘I don’t know,’” says Jacinda Abdul-Mutakabbir, an infectious-disease pharmacist at UC San Diego.

    Other parts of the RSV-shot messaging are peppered with even more unknowns. The CDC has yet to release its final recommendation for pregnant people; for people over 60, the agency’s language has been “noncommittal,” says Rupali Limaye, a behavioral scientist at Johns Hopkins University. Unlike past guidelines that have straightforwardly recommended flu shots or most doses of the COVID-19 vaccine, RSV guidance says that eligible people may protect themselves against the virus—and are urged to first consult a health-care provider, which not all people have. The wishy-washiness is partly about safety: A few rare but serious medical events cropped up during the RSV vaccines’ clinical trials, including abnormal heartbeats and neurological complications. None of the experts I spoke with had qualms about recommending the shots anyway. Even so, some private health-insurance companies have seized on the CDC’s watered-down recommendation—and the fact that the agency hasn’t yet included RSV in its annual vaccine schedule for adults—as an excuse to not cover the shot, leaving some patients paying $300-plus out of pocket.

    For any of these shots, viral reputation matters too. Despite hospitalizing tens of thousands of Americans each year, especially at age extremes—numbers that, in some years, nearly rival those linked to flu—RSV is a lesser-known winter disease. People tend to take it less seriously, if it’s on their radar at all, Abdul-Mutakabbir told me. Which bodes poorly for future RSV-shot uptake. Annual flu shots have been recommended for 13 years for every American over the age of six months for 13 years. And still, just half the eligible population gets them in any given year. People tend to dismiss shots as subpar interventions against a disease that they don’t much fear, Limaye told me. With COVID, too, “people think it’s gotten mild,” she said. Only 28 percent of American adults are currently up to date on their COVID vaccine. And although older people have historically been more vigilant about nabbing shots, even vaccines against shingles—a notoriously painful disease—have reached just over a third of people who are 60-plus.

    Read: America’s flu-shot problem is also its COVID-shot problem

    To establish fall as an immunity-seeking season, shots would need to become an annual habit, ideally one easy to form. Mandates and financial incentives do prod people toward vaccines, but smaller nudges can persuade people to take initiative on their own. Some strategies may be as simple as semantic tweaks. Studies on HPV and flu vaccines suggest that telling patients they are “due” for a shot is better than offering it as an optional choice, says Gretchen Chapman, a behavioral scientist at Carnegie Mellon University. Other research suggests that carefully worded text-message reminders can evoke ownership—noting that a shot is “waiting for you,” or that the time has come to “claim your dose.” Noel Brewer, a behavioral scientist at the University of North Carolina at Chapel Hill, also thinks that vaccine deliverers could take inspiration from dentists who gently dog their patients with phone calls and postcards.

    Other interventions could be aimed at streamlining delivery. Government funding could make shots more available in rural regions, ensure access for those who lack insurance, and help local health departments offer shots in churches and hair salons, or even bring them door to door. More schools and workplaces, too, might try boosting uptake among students and employees. And although most shots are already given within the health-care system, there’s sludge to clear from that pipeline too. Better universal recordkeeping could help track people’s vaccination status through their lifetime. Kimberly Martin, a behavioral scientist at Yale, is researching ways to revamp medical training to help health-care providers earn their patients’ trust—especially among populations that remain marginalized by systemic racism. “The single biggest impact on vaccine uptake,” Brewer told me, “is a health-care provider recommendation.”

    An ideal vision of a fall in the future, then, would be turning vaccines into a default form of prevention—a more typical part of this country’s wellness workflow, says Saad Omer, the dean of the Peter O’Donnell Jr. School of Public Health, at UT Southwestern. After getting their vital signs checked, patients could have their vaccination status reviewed. “And then, if they’re eligible, you vaccinate them,” Omer told me. It’s a routine that pediatricians already have down pat. If adult health care follows suit, regular immunization is a habit we may never have to outgrow.

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    Katherine J. Wu

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