The year my body revolted, I read all 1,296 pages of War and Peace. I did very little else. My body had become stuck in a perpetual rinse cycle, wringing itself out day and night. Becalmed on the sofa, too nauseated to mindlessly scroll, I found an unlikely emergency exit in the bloody Battle of Borodino. In between puking jags, I would prop the book open on my chest, squint at the tiny text, and drift into a Tolstoy-induced torpor. It occurred to me that clouds of saltpetre and the booming of cannon weren’t ideal conditions for a growing baby, but I had to go somewhere.

At 6am my husband left for work and I began another gruelling day on the front; purging viscous pond slime from my empty stomach and keeping up with the Cossacks on their flanking march. In the throes of extreme pregnancy sickness, I found strange comfort in the privations of 19th-century military life; in soaked bandages and musket fire and impromptu field hospital amputations. And even, or especially, in the seeming endlessness of the book itself. For the months that I starved, I lugged my starving Russian comrades with me, from the upholstery-chemical stink of the sofa to the sweet bleach-stink of the bathroom to the seamy oily-skin stink of the bed. Perhaps it was a derangement of dehydration and hormones, but I felt real solidarity with my gangrenous friends on the front – far more than with anyone in a “felt cute” sundress on the What to Expect When You’re Expecting app.

When the hyperemesis gravidarum began, throwing up 10 to 20 times a day had some degree of novelty. I was thrilled to be pregnant – only five weeks along and high on the discovery – and resolved to pay the price for the construction work my body was doing. “I am creating a whole central nervous system,” I thought, slumped and sweaty on the bathroom floor. But by the time we were on to fingernails and toenails, the adrenaline of the sprint had ebbed away. In the wake of what I imagined to be my martyred maternal heroics was panic. I suspected there were months of relentless nausea and puking still to come.

“Ah, poor pet” was the invariable response of my beatific, noninterventionist midwife when I described another week of struggling to consume enough for my baby and me to survive. “Nasty stuff. Don’t worry – baby will get everything she needs.” This was often followed up with a quick: “It’s just you that will suffer!” as if that were not the sort of problem that needed attention of its own. At one hospital admission after a particularly terrifying Exorcist-style night, the obstetrician told me to let the midwife know that my bump was measuring a bit small. I reported back, but my midwife resented doctors dictating what the pregnant body should and shouldn’t do. “Every bubba grows at its own pace,” she crooned, whisking the measuring tape off my belly.

I asked my mother-in-law if she had gone through anything similar. “Oh no, I never got sick like that,” she said, looking at me sceptically. “Actually, there was one time. I made myself a bacon sandwich and then I just couldn’t face it. I always remembered that, because I love bacon sandwiches.”

“I was so sick, too!” said my mother. “I couldn’t stand the smell of perfume counters. I could only eat beige foods for the first trimester.” I asked how many times a day she threw up, how she survived it. “Oh, I never actually threw up,” she said, “but I did feel just so awful.”

Every year, up to 3% of pregnant women worldwide are diagnosed with hyperemesis gravidarum, or HG – that is, not the garden-variety morning sickness of the first trimester, but what is considered to be excessive vomiting that can last for the duration of the pregnancy. In parts of China, the rate may be as high as 11%. Worldwide, that’s millions of women at any given moment. Put those numbers together, year after year, and one might suppose we were dealing with a problem of significant public concern. But, dangerously dehydrated, starving, isolated, frequently struggling with suicidal ideation and with barely a treatment protocol in sight, the suffering of these women and their babies has barely registered in the collective consciousness.

Not, that is, until the winter of 2012, when Kate Middleton vanished into a private Marylebone hospital. A medical crisis had been sparked in utero, and the palace was forced to announce the presence of a royal foetus far earlier than it would have liked. Prince George, as the bump would become, had leapfrogged Harry in the line of succession, and initiated a form of “severe morning sickness” in the princess that had the world’s tabloid journalists scrambling over potted summaries of the condition. I happened to read one such summary in the Evening Standard on the tube that afternoon, appalled to think such a scenario could suddenly unfold in a woman’s life. Eight years later, when I arrived at my local public hospital in Australia, 13 weeks pregnant in the midst of a pandemic, it was Kate’s name the nurses were whispering in their triage desk huddle.

Like the millions of non-royals with HG, I was largely left to fend for myself, never knowing when my condition was considered “bad enough” to trouble a hectic emergency department for IV fluids. No blood tests took place to check for nutritional deficiencies (I couldn’t keep down prenatal vitamins), there were no weigh-ins, no extra check-ins, no counsellors and no special clinic to visit. Mostly, I was so weak and disoriented that moving from my huddle over War and Peace would have been too much in any case. And while folk and medical wisdom have been in staunch consensus that “baby gets everything she needs”, even from a mother who can’t keep down so much as a glass of water, troubling new research is emerging which suggests that baby may be suffering far more than we initially thought – and for longer.

The sternest sceptic may wonder if HG isn’t just a fabulated modern condition – a bid for attention by lily-livered 21st-century women who can’t endure what our forebears did. I had begun to fear something similar. If women had been suffering like this for centuries, surely we – or at the very least, our doctors – would know a great deal about it? The condition resolved entirely once my daughter was born, and the whole pregnancy was becoming increasingly pixellated – happily so. But some unresolved questions still niggled, and I was curious to know if my ancestors had been plagued by HG too.

One afternoon, while our now four-year-old daughter was serenading my husband with a strangely apposite song by punk icon Patti Smith (“Oh baby, I remember when you were born / It was dawn and the storm settled in my belly”), I decided to dig through the medical archives. I prepared myself to encounter very little – some derisory footnotes about hysteria, perhaps. After all, in 2025, women in rich and poor nations alike still experience major healthcare inequity, and one could hardly expect the gender bias to have been any better at the turn of the 20th century. So I was surprised to find that there were actually many serious, active discussions of what Toronto’s Dr Temple called the “very distressing and, not infrequently, fatal complication of pregnancy” in the top medical journals of the late 19th and early 20th centuries.

If you scan down the pages of Victorian British Medical Journals – past cases of syphilitic headache, senilic gangrene, tin poisoning from silk stockings, and sunstroke, you will come upon a section called Midwifery and Diseases of Women. It’s here where I discovered many cases of women in mid to late pregnancy appearing “in a dying condition” – as I had often imagined myself —and treated with a wild catalogue of remedies. I could find little coherent methodology or protocol, because although there was huge speculation about the causes, everyone still seemed mystified. More than 100 years before the invention of the twist-and-seal sickbag, women were dying of “pernicious vomiting of pregnancy” in large enough numbers to warrant real concern.

Predictably, some physicians did conceive of it as a nervous complaint. In Berlin, the foreboding Prof Kaltenbach found that threatening a woman with a grisly (and often fatal) surgical termination could often hasten her “recovery”, and was satisfied that HG could be cured by “a process akin to suggestion, like ordinary hysteria”. Some doctors in the 1920s were heavily influenced by nascent psychoanalytic theory, arguing that the vomiting was a “semi-conscious desire to end an unwished-for pregnancy”. But surprisingly, they were in the minority. On the whole, the condition seemed to be treated with far more gravity, attention and care than I encountered myself, more than a century later.

As early as 1880 – the year that female “hysteria” was first described in the medical literature – a demobbed American civil war surgeon was taking the suffering of his HG patients very seriously indeed. That year, William W Potter (who would definitely earn a grid spot on the Hot Victorians Instagram account) submitted the catchily titled “On rectal alimentation and the induction of abortion for the relief of the obstinate vomiting of pregnancy” to the American Journal of Obstetrics and Diseases of Women and Children. Potter had served as surgeon for the 57th New York, been captured by the Confederates, and “interviewed” by Gen Stonewall Jackson – presumably he had seen his fair share of suffering and gruesome medical scenarios. So the concerned solemnity with which he discussed and treated HG is all the more interesting. And he wasn’t alone. About 50 years before the saline drip was widely available, a number of gentlemen physicians were truly puzzled as to why otherwise healthy women were vomiting themselves into an early grave. Unlike his more laissez-faire 21st-century counterparts in my local hospital, one Glaswegian doctor reported: “A really bad case of hyperemesis is one of the most serious and trying things with which a physician has to grapple, and no time should be lost … if the patient’s life is to be saved.”

That is “patient” singular. In pointed contrast to the current reality in the US after the reversal of Roe v Wade, in the days of Victorian medicine, a mother’s life was the primary consideration. One can even forget the existence of a second patient, so absent is it from the pages of deliberations and outcomes. Indeed, “emptying the uterus” – the euphemism for a therapeutic abortion – was frequently the treatment for intractable cases. It could be an instantly effective cure for the mother’s condition, bringing respite either in the end of her pregnancy, or the end of her days.

“Relief” could be obtained via the ominous-sounding “Bossi’s dilator”. This was mentioned so many times that I was moved to hunt down a picture. The unholy love child of a whisk and a winged corkscrew, it looked like something a butcher might have on hand for disembowelling deer. A Genoese inventor created the four-bladed tool, which has a tap head on one end for ratcheting, and four giant hinged arms on the other for “rapid dilation”. In this terrifying era of experimental surgery, I became fond of some of the HG heroes, like Dr Fordyce Barker, who “did not believe in the rapid evacuation of the uterine contents”. He had seen two persons die from shock after rapid delivery with the aid of Bossi’s dilator.

But death wasn’t the only ameliorative on offer. Unlike the modern pregnant woman who may take pains to avoid high-mercury fish, a healthy dose of mercury was a first-line remedy for pernicious vomiting. Far from languishing on the chaise longue without intervention, she could also receive the “rectal instillation” of morphine, laudanum or her own urine; an enema with soap, water and disinfectant; regular doses of adrenaline, arsenic, strychnine or deadly nightshade; an intramuscular injection of her husband’s blood; pessaries of hydrogen peroxide; injections of insulin or corpus luteum (the cells on the ovarian follicle that degrade and trigger menstruation); and regular stomach washes and gluteal injections of milk. Some of the treatments even had a droll regional twist; in Edinburgh there was a “rectal feeding regime” of milk, brandy and “meat juice”; in Texas, an obstetrician made the fabulously bullish declaration: “This author uses a strong solution of cocaine, and uses it in heroic doses.” Where cocaine failed, he also experimented with electric shock treatment, sending current up and down the spine and stomach of his patient. One intrepid physician even used radiotherapy on the lower backs of his pregnant patients, warning that great care should be taken to not overdo it and accidentally initiate an abortion (he adds a breezy postscript that it’s an effective way to terminate a foetus if you need to, though).

As I scrolled into the 1950s and 1960s, the energetic lists of medical interventions puttered out. There were no more pilot remedies, no worried physicians requesting the livers of HG patients to be sent in waterproof packaging for dissection. In fact, for the next few decades there was very little reference to HG at all. It took a few minutes for me to understand why. Because the word thalidomide never actually appears – only its UK brand-name: Distaval.

Thalidomide – the anti-emetic with “no known toxicity and free from untoward side-effects”, was prescribed in the late 50s and early 60s for mothers suffering even the mildest form of morning sickness. The severe birth defects and catastrophic human cost of the thalidomide scandal is well known, but there were other areas of fallout, too. Quite understandably, it not only damaged a woman’s confidence in the assurances of her doctor, but it also dented the doctor’s confidence to prescribe medicines for her patient, and the pharmaceutical companies’ confidence to develop and market medications for pregnant women. First, do no harm, of course. But what about when doing nothing constitutes a form of harm, too?

Thalidomide is only one piece of the puzzle. The neglect of millions of pregnant women with HG is a classic example of what policy wonks refer to as a “wicked problem” – a complex, multidimensional issue that resists easy solutions. It’s partly an issue of squeamishness – it’s tricky to build a sympathetic, interesting brand around Monty Python levels of vomiting. When I’ve tried to share some of this suffering with friends and family, the reactions are sometimes awkward and the subject is quickly closed. “At least that nastiness is over,” people will happily sigh, and reach for sunnier topics. But it’s also the name. Hyperemesis gravidarum sounds dreary, but the term “extreme morning sickness” is part of the problem, too.

Because it’s not just a matter of degree. A bit of polite morning sickness is a cinematic trope; our glowing heroine dashes to the toilet and returns, laughing and shaking her head. But this is not the same as lying bedbound, barely eating or drinking for the entire pregnancy. There’s no socially viable way for the HG sufferer to leap in and correct with her own little anecdotes.

Like the night when I was 24 weeks pregnant and even after chemotherapy-grade nausea medication, vomited so many times in rapid succession that I wondered if this was it, if death was coming for me and my baby both, and rubbery-tasting chunks of something that wasn’t food started collecting in my bucket, and, having lost all control of my bladder, I slid in pools of marbled urine and vomit, trying to focus on breathing in between rounds, and when I continued vomiting – now blood – into the transparent bags in the ambulance, and cried out would the baby be OK, and the paramedic chuckled and said: “Nah, that’s nothing. I’ve seen more blood in vomit!” like he was a Crocodile Dundee cameo in a National Lampoon sketch.

If one hasn’t experienced it, it is hard to imagine the physical and psychological impacts of starvation and relentless vomiting – up to 50 times a day, for nine months. So studies fill in the gaps: bedsores, atrophied muscles, torn oesophagi, fractured ribs, detached retinas, intracranial haemorrhage, Wernicke’s encephalopathy, broken teeth, collapsed lungs, liver dysfunction, lost jobs and relationships, sterilisations to avoid future pregnancies, long-term PTSD and depression. And death. In 2022, Jessica Cronshaw, a 26-year-old primary school teacher from Lancashire, took her own life when 28 weeks pregnant. Her much-wanted daughter was delivered via C-section and died four days later. In the inquest report, the assistant coroner said the case “should serve as a reminder to healthcare professionals about the critical importance of addressing the wide-ranging impacts of hyperemesis gravidarum, including its mental health aspects.” According to a recent study, as many as 4.9% of women with HG have terminated a wanted pregnancy and more than a quarter have considered suicide as their only option to obtain relief. That’s a staggering number of women, year on year.

Last year, when our daughter was three, my husband came running into the kitchen waving his phone. On the screen, the geneticist Marlena Fejzo smiled out at me from Time’s Women of the Year round-up. Having identified a possible genetic culprit for HG – the hormone GDF15, which is also implicated in cachexia (the vomiting and rapid muscle wastage associated with cancer and chemotherapy) – Fejzo has become HG’s unofficial Avenger, often pictured hovering over a centrifuge in a white coat. The genetic variants she discovered can lead to abnormally low levels of GDF15 prior to pregnancy, which can make one hypersensitive to their surging levels during pregnancy.

Fejzo published one of the first studies on developmental delay in babies of HG mothers. “I started looking at some of the outcome studies because the issue didn’t seem to raise enough concern – just the mother’s experience throughout the pregnancy,” Fejzo told me.

She argues that, far from the “baby gets everything she needs” narrative, HG is actually detrimental to pregnancy. She told me about a study that showed HG mothers were more likely to have small infants than mothers with chronic hypertension, pre-eclampsia and even exposure to cannabis, tobacco, cocaine or amphetamines. There was also evidence of abnormal brain growth, neurodevelopmental delay, vitamin K-deficient embryopathy, autism spectrum disorder, childhood cancer and respiratory disorders.

Fejzo’s work on HG treatment and prevention is what she calls the “final chapter” in her own story. But like many classic narratives, it is a breakthrough that tragically comes too late for the protagonist. She had HG in the early 00s, but her doctor said she was exaggerating. With a PhD in genetics from Harvard, she was more likely to be believed than many – but still wasn’t. Her doctor said that he’d recently read a study that showed that pregnant women wanted to be infantilised by their mothers. And Fejzo’s retired parents had taken separate shifts to take care of her – to empty her bedpan, among other things. Speaking with her now – an award-winning academic at the top of her field – it’s hard to imagine anyone less likely to be patronised and gaslit. But she was too weak to argue, and lost her baby to chronic starvation in the second trimester.

“People used to say to me that it must be all in your head because animals don’t get it. And so I looked it up and that’s just not true. In veterinary journals, for cats, they say, if the cat doesn’t eat for one to two days, you should immediately call your vet. They’re more proactive about the care of the pregnant cat!” She jokes that a woman with HG would have more luck getting an appointment with a vet, and we both cackle in solidarity. But I think of our former selves, of her incalculable loss, of the Bossi’s dilations and the gaslighting and the hushing and the suicides, and of how neither of us really think it’s funny, not even a bit.

Fejzo and I both entered our pregnancies in a position of great privilege – educated, financially secure, able-bodied, relatively healthy women in rich countries, with strong social networks and access to healthcare. If we represent the ability to gain the greatest advantage from a cracked system, then what about those who do not? What about the women who don’t feel able to make demands or argue with their healthcare providers, or who lack the language to do so? There is evidence that Black and Asian women are already the victims of bias in their healthcare, including in pregnancy. What about those women, and the women who live in poverty and are nutrient-deficient at the start of their pregnancies, or the new migrants who live a distancefar from family, or the women who can’t take time off work, or the women in the global south?

“HG is the fourth leading cause of maternal death in Botswana,” Fejzo tells me, “and that’s just where we happen to have some data.”

Studies and trials based, in part, on Fejzo’s research are under way now, using drugs that increase levels of GDF15 prior to pregnancy in order to desensitise the patient, and those that block GDF15 signalling during pregnancy itself. But developing drugs for pregnant women is a long and complicated process, so an over-the-counter treatment based on Fejzo’s research is still a way off.

People tend to misunderstand the furore around medicalised misogyny and bias. They imagine arrogant male doctors wilfully and deliberately dismissing female patients, which is rarely the case. They exist, of course, but there are very few doctors who deliberately pursue a “women’s health is not important” policy, and no one enters medicine in order to mistreat and misdiagnose 50% of the population. Bias is very often unconscious, because most of us are not aware of the ways in which our core beliefs and expectations might exclude others or diminish their concerns. But research from a number of sources shows that women not only wait up to 33% longer in emergency rooms than men with the same symptoms, they are also more likely to be turned away in the middle of a stroke or cardiac event, and have to push harder and longer (sometimes years longer) to get a cancer diagnosis. But increased awareness of this disparity hasn’t changed it.

Women have internalised some of these biases, too. Girls growing up within a patriarchal framework absorb certain ways of thinking about their bodies and their identities. That includes female doctors and nurses, holistic midwives and female patients. Periods are meant to be excruciating. Pregnancy is meant to be gruelling. Mothers’ bodies are meant to be exhausted. Menopause is meant to be debilitating. Was there a gendered dimension to my not wanting to keep causing a fuss in the emergency room? A determination to struggle along silently because I was accustomed to doing so? It’s not unrealistic to imagine that HG research and treatment would be a priority if men suffered with it.

Hyperemesis gravidarum is an extreme type of suffering for women – torture even, that we turn a blind eye to. Now we know it was never true that only the mother suffered, but why did we think that made it OK in the first place? But there is some hope, and it has just been published in the same journal – renamed – where I discovered my civil war hero and his treatise on rectal alimentation. At the end of June, Fejzo and her colleagues published a new study that found that daily use of an affordable GDF15-increasing drug prior to pregnancy is associated with a greater than 70% reduction in the risk of HG. Metformin is mainly prescribed to lower blood sugar in patients with type 2 diabetes, but it has recently been touted as a “wonder drug” that may have many more applications. It is heartening and galling to think the solution may have sat on the shelves of my local pharmacy all this time. While more studies are needed, Fejzo’s work suggests generations to come may no longer have to suffer like we and our ancestors did.

As it says on the tin, War and Peace is not all cannon fire and amputations – there’s a lot of peace in it, too. All’s Well That Ends Well was its working title, and on re-reading, I remember that children fill the epilogue. We leave the surviving characters in the bosom of their families, dandling “the baby in his little hat, with his wobbly head” and remarking on the redemptive sweetness of their children. Natasha finds that “no one could tell her anything so soothing and sensible as this little three-month-old being, when he lay at her breast and she felt the movement of his mouth and the puffing of his nose”.

I joke now that the pregnancy was only so hard because I was hatching somebody so spectacular. I would do that pregnancy again, in every possible universe. My daughter has memorised all of the lyrics to that Patti Smith song about the tempestuous birth. I’ve sung it to her since she was born, subbing her name for Kimberly’s and ratcheting to the middle-eight like a rollercoaster. Now we sing it together in the car, in the living room, outside in the garden, getting louder as we inch toward the big payoff. “The palm trees fall into the sea / It doesn’t matter much to me / As long as you’re safe, Kimberly”.

One of my first duties as a new mother was to keep my child safe as she grew in my belly. But did I? I am haunted by the idea that, in minimising my own suffering, I minimised hers, too. If I had known her then, or Marlena Fejzo, or William W Potter, I would have dragged us to that hospital, day after day, and demanded the care we deserved.