Allison Yarrow | Vox

The post-pregnancy belly problem that nobody tells women about

2018-05-12T07:48:35-04:00

“Abdominal separation is not about fitness; it’s about forces,” says biomechanist Katy Bowman. | Shutterstock

After Jenna Angst gave birth to her second child, she noticed that her midsection didn’t look right. “I was frustrated that my stomach looked so pudgy, even after I got back to my normal weight,” Angst, 37, says. So she asked her OB-GYN in Atlanta to take a look. The doctor brushed her off, telling her it was purely aesthetic.

But Angst wondered if it might be something she’d heard about in a yoga class once that went by the name of “mom pooch,” “mummy tummy,” or “baby belly.” So she went to doctors, specialists, and physical therapists in search of an answer. Finally, one told her that, yes, she had diastasis recti, a condition where the abdominal muscles separate so much that the stomach protrudes.

“I found it appalling that I had to go on such a journey to get answers — talking to friends, to my OB, to a [physical therapist] and four plastic surgeons,” said Angst, who eventually got treated for the condition. “The information is not readily available. It wasn’t until well after my son’s first birthday that I had some answers.”

Angst’s struggle to understand this postpartum condition is not unusual. Though research suggests that at least 60 percent of women have DR six weeks after birth and 30 percent of women have it a year after birth, most women have never heard of the term.

As with many other postpartum complications that affect women, there is little good research on the condition. Women aren’t routinely screened for DR at the one standard postpartum visit that occurs around six weeks after birth. And if they do get a diagnosis, they are often told that core work — for instance, tons of crunches — will tone the tummy and thus, close the gap.

But core work done improperly or alone won’t necessarily fix the problem. In fact, it can even make things worse. And over the long term, DR can compromise the stability and function of the core, and is linked to a host of other problems that can crop up even years after childbirth.

Given that so many women are forced to learn about DR on their own, here is a guide for how to try to prevent it and address it from those who treat it.

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Diastasis, defined

Diastasis recti is caused by the overstretching of the linea alba, the tissue or fascia at the center of the rectus abdominis muscles, the “six-pack” muscles to the right and left of the bellybutton.

The normal width of the linea alba between the rectus abdominis allows you to bend, twist, and carry a fetus. “There is a natural opening there whether you’ve had a baby or not,” says Brandi Kirk, an Illinois-based pelvic health specialist and educator at the Barral Institute. “It’s where the umbilical cord was.”

But too much pressure can stretch it out. Doctors diagnose diastasis recti when the distance between the two sides of the rectus abdominis muscle gets to be two centimeters or more.

DR can affect anyone — women, men, and children. “Coughing, laughing, pooping, breathing, birthing, and moving (i.e., your posture and exercise habits) are all things that can change the amount of pressure in your abdomen” and can, over time, cause DR, writes Katy Bowman, a biomechanist, in her book Diastasis Recti: The Whole Body Solution to Abdominal Weakness and Separation.

It’s most common in pregnant and postpartum women because of the load a growing fetus places on the linea alba, which Bowman likens to a shirt seam. The linea alba connects muscles the way the seam connects fabric, but it’s also the shirt’s weakest part, prone to splitting when stretched too much. “Abdominal separation is not about fitness; it’s about forces,” says Bowman.

Postpartum DR is underreported and undertreated

Clinicians who treat DR say they see it most in women who carry large babies or twins, have given birth multiple times, are petite or short-torsoed, or have tight abdominal muscles prior to pregnancy. Other women at risk include those with a history of surgery, C-section, constipation, or weak connective tissues.

Alicia Willoughby, a pelvic health physical therapist who has treated more than 100 women with DR, believes it’s more common than doctors acknowledge. She says the data we do have likely doesn’t capture the full extent of the problem, “because it is underreported, and many women are never screened for one.” Most often, women learn about it in an exercise class, or they self-diagnose after reading about it online.

DR can affect women even years after pregnancy and childbirth, and can lead to all kinds of problems and pain — like pelvic organ prolapse (when organs drop into the vagina), urinary and fecal incontinence, loss of stability, breathing and digestive problems, pelvic girdle pain, back pain, and pain or reduced sensation during sex.

Michele McGurk is a women’s health physical therapist specializing in abdominal and pelvic dysfunction in Brooklyn, New York. She says that a separation two and a half finger widths or wider is where she begins to see dysfunction in other areas of the body. Some 66 percent of women with DR also presented at least one form of pelvic floor dysfunction, like incontinence or prolapse, in a survey of urogynecology patients.

The most accurate way to diagnose DR is with ultrasound imaging, but pelvic health physical therapists and urogynecologists — the specialists who see the condition most — usually diagnose it manually. They say the best time to be evaluated is at least six weeks after birth, once tissue has healed and the uterus has shrunk to its pre-pregnancy size. During a screening, a woman lies supine, exhales, then lifts into an abdominal curl. Then a clinician measures the gap above, below, and at the navel with her fingers.

Why some people object to calling it “mummy tummy”

DR can give the belly a soft, protruding appearance. It can push the bellybutton out, or look like a visible gulch at the midsection when a woman bends or does an abdominal curl.

Courtney Wyckoff, the founder of the Momma Strong workout program, suffered from a large DR and related pain after pregnancy. But she argues the focus around DR should be on mobility and function, not aesthetics. For instance, can a woman bend and touch her toes? Can she wake up without pain? Is she peeing herself?

But most of the DR advice out there is on how to flatten the tummy and “bounce back” after pregnancy rather than how to strengthen the function of the core, pelvis, muscles, and organs. A recent NPR story, “Flattening the Mummy Tummy With One Exercise 10 Minutes a Day,” elicited a huge response, both positive and negative. Some women felt it reinforced the problematic cultural standard that women should have flat tummies. A follow-up NPR story addressed some of the comments and recommended additional exercises.

Still, few studies have evaluated DR treatment thoroughly enough for there to be definitive clinical guidelines about how to treat it.

Exercise may help, but you can’t talk about repairing DR without talking about the pelvic floor

The clinicians I interviewed who have diagnosed and treated hundreds of DR cases collectively agree that it can be treated. But they stress that the abdominals are only part of the equation. McGurk coaches women to reconnect to their pelvic floor and their transverse abdominis muscles, which can essentially turn off during pregnancy and childbirth.

“The transverse abdominis and the pelvic floor are best friends that need and can’t work without each other.”

Abdominal exercise, coaching, and visualization that incorporates the pelvic floor and proper breathing techniques (inhaling when relaxing, exhaling when contracting) can reestablish the connection between the muscles and the brain and strengthen not only the abdominals but also the pelvic floor, she says.

“Stabilizing diastasis during pregnancy and postpartum is all about reconnecting the brain with the deep abdominal layer called the transverse abdominis,” says Willoughby. “The transverse abdominis and the pelvic floor are best friends that need and can’t work without each other.”

A 2014 review of eight studies evaluating what impact exercise has on preventing or healing diastasis was inconclusive. Recent studies have tested two specific exercises on DR — abdominal crunches and an exercise called “drawing in.”

Drawing in involves inhaling to fill the belly with air, then exhaling and moving the belly back toward the spine. (Willoughby says the key is to inhale as you relax muscles and then engage as you exhale.) But in the study, the subjects were only measured doing the exercises in a lab, not over a period of time.

Wyckoff teaches a technique called bracing that involves contracting the abdominal muscles in concert with lifting the pelvic floor “like a claw crane.” If you’re not sure if you’re doing it right, see a trained professional who can test and feel if the proper muscles are engaging during the exercises.

New DR research is looking at techniques that go beyond exercise

Brandi Kirk has treated DR for a decade. She and others trained in visceral manipulation, a physical therapy technique developed by French osteopath Jean-Pierre Barral, have applied it to the small intestine and seen DR patients improve function and narrow their gaps. Kirk presented the findings of a very small case study of the technique at the American Physical Therapy Association conference, and will expand her study next year.

A controlled trial from Cairo University in Egypt recently discovered that women who used neuromuscular electrical stimulation, which uses electrical current to get muscles to contract, on their abdominal muscles in addition to exercise saw more DR improvement than women who did exercise alone.

Exercises can only go so far if other daily movements don’t support the work, according to Bowman. “It’s not only about how or how much you exercise — there’s a whole bunch of non-exercise things, like how you breathe, how you hold your body (read: suck in your stomach), and even how you dress, that can place unnatural loads on your linea alba,” she explains in her book.

Some doctors opt to repair DR with laparoscopic surgery or abdominoplasty, often accompanied by liposuction. This can be a viable option for severe cases of diastasis and abdominal hernia. But research on the DR-repairing operations has found that surgical correction carries risks and is “largely cosmetic.”

The pelvic health therapists I spoke to stress that surgical repair won’t teach the muscles to function properly, and that women who undergo surgery should seek out rehabilitative physical therapy afterward. These surgeries are also costly and aren’t usually covered by insurance.

DR is technically healed once it measures two finger widths or less. But the pelvic health physical therapists are concerned with more than measurements — they want to see that the tissues support the abdomen, and that woman can function without pain elsewhere in the body.

Crunches done wrong can make DR worse

Some health care providers and fitness instructors believe that a flabby postpartum belly can be flattened simply with abdominal exercise, such as crunches — which many people with DR end up doing wrong and with too much force.

“A lot of women out there taking Pilates and yoga classes are not engaging the correct muscles,” McGurk says. “One of my primary concerns is to get the proper muscles firing. Are you feeling the two sides of the TA glide together? For the majority of women it’s not happening, or it’s asymmetrical.”

Particularly, crunches done wrong can encourage diastasis, or worsen it. PTs tell pregnant and postpartum women to avoid any sit-up-like motion or abdominal exercise in which the head or feet leave the floor. Upper body twisting, spinal extension (like in a bridge pose), and bearing down during a bowel movement can increase pressure on the linea alba and encourage muscle separation.

Anything that forces the belly to bulge can pose a risk for further separation or even abdominal hernia, when an organ protrudes through a gap. Willoughby says that a DR is not healed “if there is doming or bulging along the middle of the abdominals when a load is placed on the body, such as lifting a child.” Wyckoff recommends that women with separation lift themselves up from a supine position by rolling to one side and using their arm to push up, rather than curling straight up.

DR can be prevented during pregnancy

A common occurrence clinicians see leading to DR is when pregnant women ignore their core altogether. “During pregnancy the core muscles take a little vacation,” Willoughby explains. “We need them to work and stay functional. Keep those muscles active through exercise. That may help prevent DR or speed recovery.”

Bowman says OBGYNs often tell pregnant women to avoid abdominal exercise altogether because they, like many, are only thinking of crunches. Instead, they can do strengthening exercises like drawing in or bracing that engage abdominal muscles and pelvic floor muscles. (See the Momma Strong for more details on the exercises.)

Pregnancy can be one of the best times to work on diastasis prevention. “Your body, your baby’s body, your pregnancy, and your delivery could benefit greatly from working to restore functional, biologically necessary core strength while you’re pregnant,” Bowman writes.

The other good news is that it’s never too late to work to repair a diastasis, according to clinicians. And Wyckoff stresses that if unhappiness with a DR’s appearance is why women decide to address their stability and function issues, that’s fine.

“It’s okay to not want a pooch,” she says. “I think that’s a primal, normal way in. Once you feel that, the question becomes how am I going to support this, and what else does it mean for my body? It’s going to take a lot for us to start focusing on function.”

Allison Yarrow is a journalist, a TED resident, and author of the forthcoming 90s Bitch: Women, Media, and The Failed Promise of Gender Equality. Find her on Twitter @aliyarrow.

What no one tells new moms about what childbirth can do to their bodies

2018-12-26T13:22:12-05:00

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New moms very often have no clue there are treatments that could help them. | Getty Images/Veronica Grech

For the first time ever, women in their 30s in the US are having more babies than women in their 20s, according to recent data from the Centers for Disease Control and Prevention.

That’s significant because older women can have much more difficulty recovering from pregnancy and childbirth than younger women. And most women, regardless of their age, receive poor postnatal care in the critical first 12 weeks after birth known as “the fourth trimester.”

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In fact, postnatal care is one of the most underdiscussed and understudied issues in medicine. (One reason, among many, that more American women today are dying in childbirth than anywhere else in the developed world.)

Lately, though, we’ve begun to learn about the experiences of postpartum women, thanks to the 4th Trimester Project, a groundbreaking study led by a team of doctors and researchers at the University of North Carolina Chapel Hill. For two years, they have been following postpartum women and health care providers to learn how new moms are served — and how health care for them could be better.

Strikingly, they’ve found that new moms very often aren’t aware of possible complications, are too embarrassed to discuss their symptoms, and have no clue there are treatments that could help them. They get just one medical visit six weeks after birth, and that’s often woefully insufficient for the issues they’re dealing with.

It’s worth diving in to understand why women deserve much better than what they’re getting.

The typical postpartum symptoms women experience can be severe

Isa Herrera, a New York City physical therapist specializing in pelvic pain, says new moms are often unprepared for the aftermath of childbirth. “There’s this fantasy. Your body is going to come back together. Your organs are going to be in place. It’s an illusion,” she told me.

Among the typical symptoms women face in the first week after childbirth: heavy bleeding, abdominal cramping, constipation, hemorrhoids, chills, night sweats, difficulty going to the bathroom, engorged breasts, back pain, headaches. And it goes on: pain in the perineum (the diamond-shaped sling of muscles in the pelvis), incision pain (if the woman has had a C-section), pain and difficulty walking (after an episiotomy or tear), depression, anxiety, and exhaustion.

About half of women who give birth are still in pain weeks later. More than 40 percent of women who delivered vaginally reported perineal pain, and nearly 60 percent who had C-sections experienced incision pain within two months of childbirth, according to a 2013 survey of 2,400 women called Listening to Mothers, by the group Childbirth Connection. Nearly 80 percent of mothers surveyed said pain interfered with their daily activities. One in three reported urinary or bowel problems.

OB-GYNs and midwives who deliver babies don’t often find postpartum problems like nerve damage and incontinence because they aren’t looking for them. As Kari Bø, a pelvic floor expert at the Norwegian School of Sports Science, explains, “Gynecologists, urologists and colorectal surgeons concentrate on their areas of interest and tend to ignore the pelvic floor common to them all.”

Rather than focusing on the “three holes in the pelvis,” practitioners owe it to women to see the “whole pelvis.” Since they don’t, pelvic pain or dysfunction often goes overlooked. Nearly a quarter of women have a pelvic floor disorder. The prevalence increases with each child a woman has.

Women aren’t told of more serious postpartum complications

In some instances, childbirth can cause more serious complications including hemorrhage, infection, incontinence, symphysis pubis dysfunction (pelvic girdle pain, which can be debilitating), and pelvic organ prolapse (when weak muscles allow organs to fall into the vagina).

With conditions like pelvic girdle pain and prolapse, women often think what they’re experiencing is normal and don’t seek help until their condition worsens. Some 60 percent of postpartum women have a separation in their abdominal wall called diastasis recti, and plenty have weak or injured pelvic floor muscles but haven’t heard of these things until related problems like pain or incontinence crop up.

According to Kristin Tully, a researcher with the 4th Trimester Project, women in the cohort weren’t aware of treatments that could help them and were too embarrassed to discuss symptoms that medical professionals hadn’t brought up with them first. “Women didn’t know the range of what’s normal, when to seek guidance, and whom to ask,” she said. Women don’t know about serious complications because their providers don’t always tell them.

Tully points out that postpartum women’s emotional well-being is also ignored by the current system. Perinatal mood and anxiety disorders like postpartum depression, anxiety, and psychosis have received more attention in recent years but are still not always caught by doctors and nurses. Even when screening is universal, like it is in New Jersey, not all women who are tested get the help they need. Some 80 percent of postpartum women feel “baby blues,” according to one report. Postpartum depression affects one in seven women.

Postpartum health care in America is minimal to nonexistent

Moms are usually not the focus of attention after birth at the hospital. Alison Stuebe, an associate professor of maternal-fetal medicine at UNC Chapel Hill and a lead researcher on the 4th Trimester Project, says the focus is on the baby.

“Babies get NICUs [neonatal intensive care units] and mommies get, ‘Your blood pressure is high, why should we check it again?’” Stuebe said. “The baby is vulnerable and precious and has resources devoted to it, and American culture doesn’t appreciate that the mommy is recovering from a process.” This point was driven home in the recent ProPublica/NPR story about the death of a neonatal intensive care unit nurse 20 hours after her daughter’s birth.

The typical postpartum hospital stay is less than 48 hours. Women are usually sent home with ample resources about their babies and little guidance about how they can care for their own bodies, and how their partners, friends, and families might help them.

If women have problems after they are discharged from the hospital, they often don’t know who to call — their OB-GYN, the person who delivered them, their general practitioner, or hospital nursing staff? And their next official point of contact with health care system isn’t usually until more than a month later.

Routine postpartum care in America usually consists of just one visit with the doctor or midwife who delivered the baby at around six weeks after birth. During the appointment, practitioners perform vaginal and breast exams, check C-section incisions, and feel the uterus to ensure it has shrunk back to its pre-pregnancy size. They greenlight sex and exercise if things look good. They offer birth control. That’s pretty much it.

The women in the 4th Trimester study group reported receiving “didactic” one-size-fits-all information from doctors, “but they don’t talk to you.” The consequence of this, according to the research, is that the visit can occur too late to catch a complication. “Waiting [40 days] to check in doesn’t make sense,” Stuebe said. (Its origins may be in the Bible. Jesus was brought to the Temple at 40 days, and many cultures institute a 30- to 40-day lying-in period for postpartum women to aid their recovery.)

How do other countries fare on postpartum care?

Many other developed countries allow women access to more care in the early days after birth, even in their own homes. France pays for perineal reeducation therapy, which helps women strengthen muscles to improve their overall vaginal health. It is also said to prevent problems that can arise even years after childbirth, like incontinence and sexual dysfunction. Switzerland and China offer new mothers longer hospital stays. In Europe, midwives commonly make house calls after birth to check up on women.

Some communities mandate a monastic existence for postpartum women — 30 to 40 days of rehabilitation and rest. In China, this period is called confinement; in Mexico, cuarentena. In both practices, new mothers are nourished with broths and wrap their bodies to ward off chills. Family members or hired help attend to their needs so that they can rest and feed their newborns.

In some places, the workplace is more flexible for new mothers. Nordic countries offer generous maternity leave that working moms can use to heal and care for their children. This is completely opposite from new moms’ experiences in America. Here, women return to work almost immediately — 23 percent of those employed go back just 10 days after they’ve given birth.

What better health care for women in the US after childbirth might look like

The 4th Trimester researchers at UNC want providers to collaborate to treat postpartum moms and their babies together during the initial 12 weeks after birth. Moms and babies are “as connected as they were in the weeks and months before delivery, but it just looks different,” Tully said.

Herrera wants pelvic floor therapists at women’s hospital bedsides immediately after birth. Lactation consultants in pediatricians’ offices could help ease breastfeeding difficulties — moms are headed there anyway in the early days with their newborns. A variety of health care providers who see postpartum women could screen them for perinatal mood disorders. And pediatricians could also be available to new moms.

One effective model Stuebe points to is the Monarch Centre in Ottawa, Ontario. It is an outpatient clinic that delivers many aspects of maternal and newborn care in one place — like lactation, physical exams and mental health — and sees women between 24 and 48 hours after they give birth.

The World Health Organization recommends that all postpartum women and babies receive three home visits from health providers as a routine part of care. This model has been adopted in Durham, North Carolina, where the grant-funded program Durham Connects provides all women who give birth in the city home visits. Director Ben Goodman said that of the 10,000 moms the program has seen since 2009, 95 percent “have some level of nurse-identified risk or need” during the fourth trimester.

There are signs that women in the US may get better care in the future as well. In April, the American College of Obstetricians and Gynecologists released a new “committee opinion” on “Optimizing Postpartum Care,” which offers a broad set of recommendations for doctors caring for women in the fourth trimester.

“To optimize the health of women and infants, postpartum care should become an ongoing process, rather than a single encounter, with services and support tailored to each woman’s individual needs,” the committee opinion reads.

Understanding that a fourth trimester exists is only a starting point. “In an ideal world women would get home visits or their family members would get paid leave to attend to them,” Stuebe said. “If we’re not going to have that, we need some touchpoint from the health care system to replace that village that is no longer part of our culture.”

Allison Yarrow is a journalist and author living in Brooklyn. Find her on Twitter @aliyarrow.

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What I wish people understood about sexism and TV news

2017-12-18T10:04:02-05:00

Matt Lauer at the NBC News Commander-in-Chief Forum on September 7, 2016, in New York City. | Justin Sullivan/Getty Images

I’ve sat through unsolicited back rubs. Walked quickly past leering colleagues. Endured demeaning jokes. Once, I was so embarrassed by lewd comments from an Oscar-winning actor on a red carpet that I didn’t do the interview I had been assigned. An older, married male colleague asked me to tell him my sexual fantasies. Fearing for my job, I didn’t respond at all.

These snippets from my experience producing and reporting in television and online news for more than a decade are nothing special. They are the all-too-common drip of indignities women suffer daily and across industries. Far worse occurs too, and in less glamorous-seeming jobs, without celebrities, cameras, and skin-brightening LEDs. But television news’s long hours, low salaries, tight quarters, and coverage of atrocities and tragedies can create a climate where, as one friend in the business put it, “people treat people like shit.”

There is a particular sexism that women in TV news face that is different than in other workplaces. I have witnessed it, experienced it, and likely abetted it with my silence. I may have complained to female colleagues, but never formally. Despite the torrent of #MeToo, I still feel uneasy writing about it. The ground is shifting and once-powerful and trusted news titans are getting fired — Matt Lauer, Charlie Rose — but the power structure that they profited from, and that stifles women throughout the industry, remains firm.

Sexism in TV news hinges on two big traits — aesthetics and power. For women on television, appearance (and colleagues commenting on that appearance) is part of the job. That means it can be difficult to determine when a comment has crossed the line from professional to personal. The strict rules around women’s appearance also make it harder for women to attain power in the industry — they get pushed out for not being young enough or thin enough or otherwise not meeting a particular physical standard. The physical standards for men are nowhere near as strict.

At the same time, television news is centered on celebrity anchors and hosts who wield a disproportionate amount of power. They can get away with tremendous abuses of that power because they are so valuable to the networks. And when those all-powerful hosts are disproportionately men, it’s no surprise that women are vulnerable to abuse — and fear reprisal for speaking out.

Appearance is as important as content, if not more so

Superficiality can be inherent in any visual medium, but it’s television news’s stock in trade. Discussion of appearance is out in the open in television news in a way that it isn’t in other industries like tech, finance, or even other newsrooms, like radio or print. A TV reporter’s appearance is a job credential considered alongside her ability to write, research, or interview. And women must adhere to a particular beauty standard on television that isn’t required of their male counterparts.

Staff routinely comment on a woman’s appearance if she works on camera. Hosts are asked to change clothes, wear a certain hairstyle, or apply more makeup. I’ve seen it done privately, but also publicly, in front of a control room full of people. Regardless of where it occurs, it’s always done under the auspices of bettering the news product.

Different outlets have different aesthetics that they champion. Women reporters on Fox look different from those on Vice. But the beauty standard for women on television has long been designated by men, who continue to run most of the industry and shape what is news and who delivers it.

Appearance matters in the broadcast newsroom because it also matters outside of it. Audiences constantly comment on and degrade the appearance of on-air talent, and women are far more often victims of this than men. Whoever sifts through a station or show’s snail mail or email regularly finds criticisms of an anchor’s face, blazer, or weight gain. Just ask any television newswoman with an inbox of any kind — she undoubtedly gets reams of feedback from viewers about her looks.

A particular appearance is more rigidly enforced for women than men

Unsurprisingly, it’s white, young, and thin.

I remember reporting a story I was proud of and then being yelled at by a superior for not wearing lipstick. Others have endured worse reprimands for their physicality than this, but it underscores the value a particular look holds for women in television news.

I was once in a screening with a high-profile anchor who told the producer to nix a shot that made her butt look big. It was done, no questions asked. Goodbye, shot — but also goodbye, sound bite and piece of the important interview that accompanied it. It’s not that women on television news broadcasts should ignore appearance; rather, the problem is a rigorous, limited standard of beauty that is both prized and reinforced on television. And this anchor knew this all too well. At the time, I thought she was being overly concerned with her image. Now I realize she was merely protecting herself in a business that would dump her the second she violated the code.

The emphasis on women’s appearance creates an environment where mean and sexist comments can fly. Today show staffers once likened anchor Ann Curry to Big Bird, photoshopped her in a yellow dress next to a picture of the Sesame Street character, and asked, “Who wore it best?” This kind of thing is pretty common in the business. TV news loves a good blooper reel — the montage of talents’ on-air mistakes and questionable wardrobe choices — and screens them at staff-wide gatherings. But this well-meaning tradition sanctions public embarrassment. It also reinforces that commentary on looks is just part of the job.

Men can age on television; women can’t

Be it at the news desk or in front of the weather green screen, women age out of television news jobs in a way that men don’t. From the second they set foot in the trade, they are racing the clock, the neck wattle, and the laugh lines. Men age and rise in the ranks, while women are passed over for top posts.

When 46-year-old Joan Lunden departed Good Morning America in 1997, she told viewers it was so she could spend mornings with her kids. The real reason was quite different. “The words are, ‘We’ve decided to make a change on the show,’ and so they found a 30-year-old version of me,” she told Oprah.

Peter Jennings anchored World News Tonight for 22 years; his tenure only came to an end when he died. Dan Rather helmed CBS Evening News for 24 years. Tom Brokaw anchored NBC Nightly News for 22 years. Their female equivalents don’t exist. Katie Couric anchored CBS Evening News for just five years — and she was replaced by a man. Discussion of her tenure often focused on her legs, and whether she was likable.

The producer-anchor relationship is inherently weird, power-wise

The current absence of women at the top creates a vicious cycle that makes it difficult for women to succeed in the future. At the network level, and at talent-driven local shops, the whims and opinions of hosts are prioritized — and those hosts tend to be men. Men like Matt Lauer are godlike figures. They greenlight stories they like, kill ones they don’t, and hold power over their production staffs.

At ABC, NBC, and CBS, men report three times as much news as women do, according to a 2017 Women’s Media Center report, which surveyed on-air appearances by reporters and anchors and producer credits in more than 24,000 news pieces in 2016.

When famous men are the faces and identities of stations and networks, it can be particularly problematic for female producers who are practically invisible to news consumers. Since the talent is the face and voice of a story, the average viewer is apt to assume that he also did all of the legwork, when in fact producers do it. I assumed this myself before working in the field.

This makes it difficult for female producers, editors, and camera operators, who are already less visible in the industry than famous men, to get credit for their work beyond the walls of their own offices. The approval of a male host is not only desirable, but it can be consequential for a woman’s career.

Compounding all this is the chasm of pay between talent and producers, editors, and camera operators who work so closely and symbiotically together. Even generous holiday gifts, like a massage or champagne, can’t remedy this. The average news producer salary is $40,000. Lauer reportedly earned between $20 million and $25 million per year. When women earn so much less than their male bosses, they are at yet another disadvantage when it comes to progressing their ideas and advocating for themselves.

There aren’t nearly enough women making the decisions at the highest levels of television news. That needs to change.

We are in the middle of a powerful reckoning that sexism has shaped how the news is reported and what stories are told. But it doesn’t have to be this way.

There are women fighting the status quo. I’ve worked with female talent who purposely wore certain clothes and minimal makeup to draw attention away from their appearance. Christiane Amanpour is well-known for this. In her book The News Sorority, Sheila Weller reported that Amanpour wore the same parka for three winters. A newsman source told her of Amanpour, “Most men on TV wore more makeup than she did.” Amanpour’s appointment to replace Charlie Rose feels like vindication, but it is only one step when many more are needed.

But these isolated examples aren’t enough. More women are needed throughout television news, but certainly at the highest levels. Women comprise 33 percent of news directors and 44 percent of newsrooms. Men in television news still control the lion’s share of stories that air, the way people look and what they say on television, and the off-camera work environment. And nothing will change until that does.

Allison Yarrow is a journalist, a TED resident, and the author of the forthcoming 90s Bitch: Women, Media, and The Failed Promise of Gender Equality. Find her on Twitter @aliyarrow.

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