
Why Is Giving Birth So Hard? Revisiting the 'Obstetrical Dilemma' - chmaynard
https://www.theatlantic.com/health/archive/2017/12/why-is-giving-birth-so-hard/547340/?single_page=true
======
skadamou
Somewhat related, I thought Atul Gawande's take on why C. Sections are so
common now was fascinating. It's all in his book "Better: A Surgeon's notes on
performance" but I've linked to a summary of the obstetrics section below.

Relevant passage:

"In the 1960s fewer than 5 percent of deliveries were Cesareans and more than
40 percent involved forceps. And those numbers are related. Gawande makes a
strong case that in the hands of experts, forceps are safe (according to some
research, safer for mothers than Cesareans). But forceps are hard to learn to
use properly – a process that can take two years. And if forceps are used by
inexpert doctors, the results can be disastrous. Cesareans are easier to
master. And this has led hospitals to phase out forceps and, in many cases, do
C-sections instead. To discourage the inexpert from using forceps, Gawande
says, “obstetrics had to discourage everyone from using them.” This change has
come at a cost. Gawande notes that, as straightforward as Cesarean deliveries
can be, they can go wrong. The baby can be lacerated. If the head doesn’t come
free quickly, the child can asphyxiate."

[https://oneminutebookreviews.wordpress.com/2007/07/18/atul-g...](https://oneminutebookreviews.wordpress.com/2007/07/18/atul-
gawande-tells-what-you-can-really-expect-when-you%E2%80%99re-expecting/)

[https://www.goodreads.com/book/show/213233.Better](https://www.goodreads.com/book/show/213233.Better)

~~~
codingdave
Even more relevant passage from the article:

"Childbirth is difficult for many reasons, she writes—among them the 19th-
century switch from birthing in the upright position, which allows the pelvic
girdle to expand in response to contractions, to the supine position (still
common among women in the West) which often requires the use of forceps."

There are correct times and places for all tools. But comparing two
interventions that both bring risk is an odd way to approach the topic.

------
bambax
There is not a reason for everything.

The spotted hyena is one of the most successful carnivores in Africa; yet
females hyenas lack an external vaginal opening and therefore _give birth
through their narrow clitoris (...). During parturition, the clitoris ruptures
in order to facilitate the passage of the young, and may take weeks to heal._

[https://en.wikipedia.org/wiki/Spotted_hyena](https://en.wikipedia.org/wiki/Spotted_hyena)

One can only imagine the extreme pain and difficulty involved in this; yet
it's unlikely there's an evolutionary justification to be found. It's most
probably an accident -- a quite unfortunate one for the female hyena.

~~~
gehwartzen
One possible justification is that this genital configurations prevents
forcible rape, as the wiki article points out. This allows females to have
more control over the genetic traits of their offspring.

~~~
cratermoon
the term "forcible rape" is rife with difficult implications.

"Many experts now believe that rape is best understood as an act of unwanted
bodily invasion that need not involve force."

[http://www.nytimes.com/2012/08/24/us/definition-of-rape-
is-s...](http://www.nytimes.com/2012/08/24/us/definition-of-rape-is-shifting-
rapidly.html)

~~~
dogma1138
Since hyaenas are not going to promise to marry you or claim to be an Albanian
prince to get sex forcible rape is pretty accurate.

------
pavel_lishin
Dr. Karp, who is quoted at the beginning of the article, wrote an excellent
book and released an excellent DVD. If you are a new parent, I highly,
_highly_ recommend you at least watch the DVD about the "5 S's" \- it will
make an incredibly positive difference in how well your first few months with
a new baby will go.

~~~
Amorymeltzer
Couldn't agree more. The book they cite (Happiest Baby on the Block) goes
through the 5 S's and it's a life saver. His "4th Trimester" theory is just
about the most sensible description of newborn behavior.

------
ani87
> Warrener and her colleagues found that wider hips do not increase the cost
> of locomotion. Indeed, both women and men are equally efficient at walking
> and running

> I have a number of papers that show that women are great walkers, and in
> some particular tasks women are better—they don’t use as much energy, they
> don’t build as much heat, they can carry heavier loads with less of an
> energetic burden.

I am not a biologist, but those parts just don't click for me; how/why would
evolution have jump through all the costly hoops to differentiate the pelvis
of males and females so significantly if the result was to give a locomotion
system that was overall worse to the individuals who needed it the most for
their survival, without any benefit in return ?

~~~
throwaway_2718
Why is sexual differentiation necessarily costly in every case? There are many
sex differences that give an advantage for one gender that would have been an
advantage, or no cost, for the other gender, but weren't as strongly required
and so don't exist. Sexual differentiation may be less _likely_ for any given
trait, but traits tend to pop up on random chromosomes, or the side effects of
sex hormones be farther-reaching than necessary and evolution just "didn't
bother to correct," and so I'd expect that some traits that don't necessarily
need to be dimorphic (but are needed by one gender or the other) might become
dimorphic just by chance.

Men have deeper voices than women. What would be the disadvantage for baritone
women? You could argue that a deeper voice makes you less easily heard by
prey... but then what's the advantage for women to have a higher pitched
voice? Why didn't we all continue this trend to speak at the registry of blue
whales? I suspect it's one of those things that "just sort of happened" and
then it became a positive feedback loop spurred on by sexual attraction as a
result of this initial differentiation, and now we're just at a pretty good
state spurred on by a combination of random chance, survival advantage, and a
little reproductive enforcement.

Increased sexual dimorphism (and a genetic/hormonal configuration that lowers
the cost and increases the odds of sexual dimorphism happening for any given
feature) is actually a positive thing for some animals depending on their
social and reproductive strategies. When sexual dimorphism is high, you tend
to see more random differences that pop up between the sexes but that may or
may not provide any evolutionary advantage beyond "well, the other sex is just
attracted to it now so let's keep this party going." When dimorphism is low,
differences generally have to provide a stronger survival advantage.

Evolution isn't always straightforward or "carefully thought out." The hoops
it jumps through aren't always costly and don't always have a rhyme or reason.
It's often chaotic and and takes weird turns and it's not like humans are at a
"final state" anyway. We're evolving.

I'm not _necessarily_ disagreeing with you (although it's probably ultimately
easier to look at the physics, not biology, to prove or disprove your point)
but I'm just saying that I think the situation is vastly more complicated than
"sexual differences are costly." I don't think they're necessarily costly,
simply less likely. A subtle, but important difference.

~~~
ani87
> but then what's the advantage for women to have a higher pitched voice?

Living in a neighborhood with a lot of teenagers, I will dare a guess; this
loud, high pitched scream was probably a very efficient call for help.

But I see your point, and I agree that the answer could be just as simple as
randomness of genetics. It just feels rather unsatisfactory for a change who
must have taken far more than one single mutation to be that common. Feels
like someone winning the lottery a dozen times in a row.

~~~
erroneousfunk
Known genes associated with hip bone size in women (but not men) are found on
chromosome 2
([https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2522269/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2522269/)).
But the expression of those genes is likely controlled by estrogen
([http://www.sciencemag.org/news/2016/04/woman-s-pelvis-
narrow...](http://www.sciencemag.org/news/2016/04/woman-s-pelvis-narrows-she-
ages))

Individuals who have androgen insensitivity syndrome (XY chromosomes, but that
don't respond to testosterone and are, for most intents and purposes, sterile
females) will have large hips/pelvic bones.

So, yes, hip size takes a few modified base pairs (although probably all
within one gene, or pretty close together on the same chromosome), but
evolution only needs to "decide" (heavy emphasis on the quotes there) that
this physiological change is hormonally triggered. Many skeletal changes are
hormonally triggered, so this may have even been the easiest/most likely path.

------
solidsnack9000
> ...and in hunter-gatherer societies, women walk, on average, 5.5 miles per
> day, often while carrying and feeding infants as well.

Quoting a one-sided statistic like this is something the editor should have
caught. The 5.5 miles figure doesn’t support anything if the figure for men is
ten; it’s great support if that figure is four; but without either figure what
does it mean?

------
kwhitefoot
None of my three children were born in the supine position and the eldest is
now almost thirty so I am a little surprised to read that it is still common.
And while my wife found it painful to some extent it is quite clear that she
also enjoyed the process to a fairly large degree. But this was in a maternity
unit that had essentially no rules beyond do what makes mother and baby happy,
and have the capability to deal with a crisis if it should occur. My wife felt
free to arrange herself in whatever position was most effective and to make as
much noise as she liked when it got tough.

I think that many women end up going into labour in a fearful frame of mind
because of the constant reminders that it will be painful and this coupled
with midwives intent on following timetables and doing things their way
results in a stressful time for all.

As everyone else mentions, I am aware that my sample is not large and that
there are many who have had a different experience.

------
chmaynard
This article was originally published in Undark Magazine:

[https://undark.org/article/obstetrical-dilemma-hips-risk-
chi...](https://undark.org/article/obstetrical-dilemma-hips-risk-childbirth/)

------
matt_wulfeck
Not only how difficult labor is, but how helpless a child is for _so long_.
Years before they can walk, for example. Compare that to a fawn, which stands
up and follows its mom after just a few minutes into the world.

~~~
war1025
Babies start crawling at about 6 months, and walking somewhere between 9
months and a year. I have a two year old, and she is far from helpless.

~~~
matt_wulfeck
That’s just a personal anecdote. Some babies never crawl at all and some
toddlers don’t start walking until much later than 12 months. And your 2yo
toddler is still nothing compared to the mobility and world-awareness of a
two-month-old fawn, which has already learned to recognize and outrun
predators at this age.

The fact that there’s such a spread for these otherwise extremely important
life stages in humans shows a lack of maturity in their development compared
to other mammals, not the inverse. Something is a little different about us.

~~~
jriot
If we were to compares ourselves to actual animals. Personal anecdotes
wouldn't matter as fatality rates would increase without modern comforts not
afford to animals. The child doesn't crawl or start walking for another year,
child would die as the parents wouldn't care for weak off-spring.

It sounds harsh when discussing humans but the differences in development
occur because our death rate is low compared to wild animals. Thus allowing
weak genes to be passed e.g., not being able to crawl or walk for 3 years
double or triple the normal would not be tolerated in the animal kingdom.

~~~
Tenhundfeld
Not necessarily. It depends on why the offspring couldn't crawl or walk for
longer. If it's associated with something that increases survival in mature
members of the species, it might be tolerated, even selected for.

For example, if the child is delayed in walking because more metabolic
resources are being channeled to larger brain development, that could be a
survival benefit. I use that example, because that's essentially the theory of
what happened in humans, in comparison to chimpanzees. (Obviously not 1 child
randomly taking 2x or 3x to develop, but a slow evolutionary process.)

Chimps are relatively helpless when they are born too, relative to most
species. They nurse for years, stay with parents for years, are totally
reliant on them for survival, etc. But they are not so helpless as humans.
It's estimated human gestation would have to be about 18 months for newborns
to be at a comparable stage of cognitive development as newborn chimps.

So, from this perspective, we do take 2x the time in comparison to chimps, and
yet it was tolerated. I guess my overall point is that evolution is more
complicated than how quickly an offspring can crawl or walk or be independent.

------
up_and_up
Follow the money?

On one side, I believe Doctors get paid more by performing a C-section. [1]

On the other, it may involve less risk, which reduces the likelihood of
malpractice lawsuits? [2]

1 -
[https://scholar.princeton.edu/sites/default/files/dalexand/f...](https://scholar.princeton.edu/sites/default/files/dalexand/files/procedure_choice_6_15.pdf)

2 -
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3096673/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3096673/)

~~~
leojg
This is true, at least in my country there is a high amount of C-sections and
studies show that most of them are done for the money.

------
vmonx
Interesting article. But it doesnt really explain some key questions.i have
always wondered why are humans so ineffective at giving births. Cangaroo, for
example, gives birth to their baby at a much earlier stage, when it's only 1
inch big and then keeps it in the pouch. No pain, no extreme labor.

~~~
Santosh83
We _are_ very effective at breeding, especially with the help of science and
technology. The inefficiency of birth, if true, hardly matters.

~~~
setr
>We are very effective at breeding, especially with the help of science and
technology.

In what sense? Our production rate is substantially lower than most other
animals; mothers-to-be are made weaker than other animals during the process;
the threat of death in childbirth for both child/mother is hardly the lowest
of other animals

We have a relatively high population now, but its hard to imagine that its due
to an efficient breeding process; rather our survival rate post-birth,
lifespan and our phenomenal ability to edit the environment to increase
resource production to support higher populations are likely better
explanations

Put a pair of rabbits in a room and a pair of humans, with all needs met.
We're not even competitive

------
coldtea
Who said it is? Billions manage to do it just fine, with 1/100 the
preparation.

~~~
nkrisc
I don't who these billions are that you're talking about, but historically
giving birth has been a very deadly affair for women.

~~~
GlennS
I dug up some numbers which support what you're saying:

[https://www.indexmundi.com/g/r.aspx?v=2223](https://www.indexmundi.com/g/r.aspx?v=2223)
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1633559/figure/...](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1633559/figure/fig1/)
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1633559/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1633559/)

It looks like about 1% of pregnancies ended in death historically, and that
matches what's happening in the places with the worst healthcare today.

With good healthcare, the risk nearly vanishes.

------
j_s
No mentions of Genesis 3:16b yet: _I will make your pains in childbearing very
severe; with painful labor you will give birth to children._

~~~
mtanski
Talk about a shitty god.

~~~
klipt
"Birth is hard because we ate of the tree of knowledge" seems like a metaphor
for "birth is hard because we evolved big heads".

~~~
joshuahedlund
If anyone finds this sort of thing interesting you might enjoy Jordan
Peterson's lectures on the Old Testament. (podcast or youtube)

