A pregnant woman during a nationwide rally in support of abortion rights in Washington, DC, on May 14, 2022. Sarah Silbiger/Bloomberg via Getty Images

A pregnant woman during a nationwide rally in support of abortion rights in Washington, DC, on May 14, 2022. Sarah Silbiger/Bloomberg via Getty Images

Popular culture tends to focus on a few elements of pregnancy: morning sickness, the growing baby bump, and, of course, mood swings. But that ignores more dangerous, less well-known conditions associated with pregnancy. Up to 10 percent of pregnant US women are diagnosed with gestational diabetes and uncontrolled high blood sugar; untreated, this can result in a difficult delivery, and risks developing into Type 2 diabetes years later. Meanwhile, 2 to 8 percent of women worldwide have symptoms of preeclampsia, a condition involving high blood pressure that can lead to fatal seizures if untreated, can damage the mother’s organs, and increases the risk of chronic disease later in life for the baby.

But even a supposedly normal, healthy pregnancy with no complications can lead to a lot more than just morning nausea. And the ordeal isn’t over when the baby is born; pregnancy changes one’s body permanently, and labor is often traumatic. If it weren’t taken for granted as a natural part of life, pregnancy could easily be considered a chronic illness or disability. Women with pregnancy-related impairments are legally a protected class under the Pregnancy Discrimination Act.

One way to quantify the full physical and psychological costs of pregnancy is to look at the compensation rates for surrogates, who carry a pregnancy on behalf of prospective parents who, often due to infertility or health conditions that make pregnancy unsafe, are unable to have children themselves. The bar to become a surrogate is high: Most agencies require that a potential surrogate have a child of their own whom they are raising. As well as passing an extensive health screening by the agency and being at low risk of complications, these women are likely selected for having had relatively tolerable past pregnancies, such that they consider the compensation worth it, despite the risks.

Yet the base compensation for surrogates generally starts at $30,000 or more, depending on the local state laws. (Medical expenses are paid in full by the parents of the child.) In California, experienced surrogates can earn as much as $75,000. This is before any additional payments to cover housekeeping, lost wages during the pregnancy or due to complications afterward, or other possible costs. Given the high cost of medical care in the US, the effective salary for going through the risk and inconvenience of a pregnancy is much higher.

This puts a new light on the recent Supreme Court decision in Dobbs v. Jackson Women’s Health Organization that overturned Roe v. Wade after almost 50 years, and particularly on Justice Amy Coney Barrett’s argument in the courtroom in December that the availability of adoption means that heavy restrictions on abortion access won’t necessarily affect women’s lives and futures. But even if “safe haven” laws mean that a person can surrender a child at birth and move on, the ability to relinquish a child for adoption does nothing to reduce the burden of pregnancy, nor does it ease the recovery afterward or lessen the resulting changes to a pregnant person’s body.

The challenges of pregnancy may be more than worth it for hopeful mothers who take home an infant, and acceptable for surrogates who know exactly what they signed up for. However, the Dobbs decision will inevitably mean that many people will be forced to carry a pregnancy to term, enduring all the hardships and potentially facing long-term medical consequences, but without having chosen that path, and without any reward or financial compensation.

So what does a supposedly normal, healthy pregnancy look like?

The internet provides a wealth of advice for pregnant people on what to expect when they’re expecting — and the list is long. Most physical symptoms are caused by either the wildly shifting hormones of pregnancy or the physical growth and pressure of the fetus and uterus.

From the first trimester, in addition to nausea — which isn’t necessarily just in the morning — most pregnant people will feel unusually exhausted. The fatigue can be seriously disabling. “People say, ‘I can’t get out of bed, I can’t do my job,’” says Dr. Tamika Auguste, an OB-GYN in Washington, DC. Due to hormone swings, constipation is very common. “Sometimes women go from having a regular bowel movement daily to having one every three or four days, and so it’s very uncomfortable,” she adds.

The physical symptoms are worsened by the isolation and uncertainty many pregnant people feel as they struggle to determine what discomfort is “normal” and what isn’t. Danika Severino Wynn, an advanced practice midwife with Planned Parenthood, reports that some of her patients find it uncomfortable to bring up these symptoms, even with their medical providers. “[The] changes in your bowel patterns, hemorrhoids, the nausea and vomiting — that’s never-ending, but you might not want to deal with it when you’re in the workplace,” she says. “I’ve had many patients who have been lucky to have offices, for example, and say they closed their doors half the day because they have to vomit so often.”

And the mood-related symptoms are anything but a joke. “I can speak from my own experience there,” Severino Wynn says. “The amount of depression that I dealt with during and after my pregnancies was crippling and was far more than I ever anticipated.” Postpartum depression is also a significant risk, affecting one in nine mothers.

By the third trimester — starting at about 27 weeks — pregnant people are often in significant discomfort. Especially if they were slim before the pregnancy, rapid weight gain (a woman of average weight can expect to gain 25 to 35 pounds during pregnancy) puts intense strain on hip and knee joints, causing pain and limiting activity. With the uterus pressing on the bladder, frequent urination and even incontinence are common, leaving pregnant women at a higher risk of urinary tract infections. Sleeping becomes difficult, and the resulting sleep deprivation can make it more challenging to cope with other symptoms. Women may notice a chronically stuffy nose, sensitive and bleeding gums, itchy skin, carpal tunnel syndrome causing numb and tingling hands, and frequent painful muscle cramps and spasms.

Many symptoms, even those that are considered “normal” and not medically dangerous, can still be alarming to experience. Heartburn and gastric reflux are common and can mimic the symptoms of a heart attack. Another symptom is round ligament pain, which can happen as hormones instruct the body’s ligaments to loosen in order to prepare the pelvis for giving birth. Women can experience unexpected and intense stabbing pains in their lower abdomen and groin, causing them to call their doctor in a panic.

Morgan, a storyteller with Planned Parenthood who volunteers to share her experiences to help other women, had some frightening experiences early in her second pregnancy with twins. (Storytellers can opt to go by their first name only or a pseudonym, which Planned Parenthood respects when connecting them to others.) “At 12 weeks, I had to go to the emergency room because I felt like I was having palpitations,” she says. “My heart rate was like 150.” She was diagnosed with an iron deficiency, a condition that affects as many as 30 percent of pregnant women in the US by the third trimester, and that when combined with dilating blood vessels and a body struggling to keep up with a growing fetus’s needs, can put strain on a woman’s heart and lead to dizziness and fainting.

Later in the pregnancy, Morgan also developed hemorrhoids so severe that she later needed them surgically removed. “That is not something that people talk about,” she says. “And I even forgot about it, I just blocked it out. But that was a huge deal for me and it scared the hell out of me. The first time it was happening, I called my mom and she’s like, ‘Oh, honey, that’s hemorrhoids.’”

As Severino Wynn puts it, “People think they have all sorts of different ailments because of some of what we call the ‘normal abnormal’ of pregnancy.”

And this is all still only the lead-up to giving birth, which is often one of the most painful and traumatic experiences of a woman’s life, even when women are lucky enough to avoid the all-too-common mistreatment or outright abuse from medical staff. Feeling out of control during labor is a major risk factor for later developing PTSD, but that loss of control over one’s body starts long before the birth. “Pregnancy in and of itself is a very intrusive and invasive condition,” Severino Wynn says, “because you lose control of parts of your body that you wouldn’t expect to. Even in a normal pregnancy, the impacts on your body are incredibly significant.”

The biology and consequences of a nine-month chronic illness

In a different context, the list of symptoms that pregnant people experience as a matter of course would be the result of a scary diagnosis, and hopefully gather just as much sympathy. In fact, the common symptoms of pregnancy overlap significantly with those of advanced chronic kidney disease. Kidney patients also complain of pain and discomfort, severe fatigue, depression, and limited physical capabilities, along with nausea and vomiting, constipation, poor sleep quality, frequent urination and heightened risk of UTIs, itchy skin, and even altered taste and smell, a symptom pregnant women often notice.

There are various theories of why human childbirth is so much more painful, not to mention dangerous, than what many other animals go through. Historically, each birth incurred a 1 percent risk of death for the mother, or higher. In the US in 2020, the maternal mortality rate was still 24 per 100,000 live births, triple the rate in other high-income countries like France and Canada.

But even before birth, human mothers-to-be are at risk of health complications due to an evolutionary arms race between the mother and fetus over nutrients and resources, with the fetus invading the tissues of the uterus and pouring its own hormonal signals into the mother’s bloodstream, and the maternal body compensating for this. Preeclampsia, which even when treated can cause lasting damage to the mother’s organs and affect the long-term health prospects of the baby, is a disease essentially confined to humans. It’s not fully understood, but one theory is that it happens when the implantation process and development of the placenta go wrong.

Unlike kidney disease, the chronic illness that is pregnancy will mostly end after nine months, and for parents carrying wanted pregnancies, joyfully welcoming a newborn at the end of it often more than makes up for the suffering. But for those who never wanted a pregnancy and don’t want to give birth, it’s a lot to ask.

As with any major ongoing illness, the burden of symptoms during pregnancy is joined by the time and monetary cost of frequent medical visits. Auguste, the OB-GYN, estimates that most women will attend as many as 12 prenatal visits, even in a perfectly healthy pregnancy; the time includes not just the visit itself, but scans, bloodwork, time spent in the waiting room between these procedures, and, of course, the commute. Since clinics and doctor’s offices are often only open during the workday, appointments usually require taking time off work, presenting an additional challenge for women with employment insecurity or in financially precarious circumstances.

The women who aren’t able to afford time off work, transportation, or the financial cost of prenatal appointments are often already at higher risk of health problems during pregnancy, and lack of prenatal care only adds to the burden. A 2020 report by March of Dimes found that 7 million US women of childbearing age live in maternity care “deserts” or in areas without ready access to the specialists they need; in some rural counties, hospitals without obstetricians on staff may even turn away women in labor.

From Severino Wynn’s perspective, the medical system is failing these people. “Historically, hospitals and providers used this term of ‘noncompliance’ to describe people who don’t come in for prenatal care,” she says. “There’s been a movement afoot to just throw that term out the window because at the end of the day, we are not set up for people to be able to take care of themselves.” Missing prenatal care appointments can result in higher risk to the mother and baby.

Morgan, whose second pregnancy was with twins and was classified as higher risk, estimates that she spent 10 hours a week at, or in transit to and from, medical appointments. She describes how, given her issues with heart palpitations and fainting, her doctor wrote a note stating that it was medically unsafe for her to be required to stand, and asking for her workplace to provide accommodations. Despite the fact that pregnant people are legally recognized as a protected class and entitled to reasonable accommodations under the Americans with Disabilities Act, her retail workplace refused. Illegal pregnancy discrimination affects thousands of workers every year.

As with so many other health issues that primarily affect women, pregnancy can be neglected by the medical community — for example, when pregnant people are excluded from clinical trials, as they often are, drug safety for the fetus is left unclear, which can cause women to avoid necessary treatments out of fear. Pregnant people can also run into problems when doctors fail to take their concerns seriously, both during and after a pregnancy.

Morgan, after her twins were born, continued to have health issues, but it wasn’t until five years later that she was diagnosed with an autoimmune condition. She feels that doctors were often condescending toward her. “I appreciate they’d gone to medical school and they’ve gotten the requisite training to be able to diagnose and treat me properly,” she says. “But at the same time, I’ve lived in my own body for 38 years. I know when something doesn’t feel right, I know when things are outside the norm, and I should be given more of a say.”

There are other policy changes that could help those in this situation: greater access to prenatal care, programs to support pregnant people in precarious life circumstances, and stronger enforcement of their existing legal rights and protections in the workplace. But ultimately, nothing will alter the fact that pregnancy is a serious medical ordeal with lasting effects, even when all goes according to plan, which is far from guaranteed. Women, who have the most context on their own lives, and judge that carrying a pregnancy to term would be damaging to their lives and future plans are often going to be right. The Dobbs verdict, in taking away the option of abortion, will inevitably end up condemning thousands to suffering through these consequences largely against their will.