By Caty Brown
Art by Camille Yang & Kaitlyn Anderson
Humans, or at least something we can recognize as human, have been giving birth for two million years. With this long, long lineage of mothers behind each of us, I doubt I have anything new to say about birth, pregnancy, and babies. But man, does it feel like it. I can’t stop thinking about how my ovaries are full of slowly dying eggs, bound to a time clock that will at some point expire. About how I’ll have a three year window to get real busy between the end of residency and the age where I’ll have a geriatric pregnancy (35, if you’re wondering). About how the only pregnancy stories I’ve heard from my mother and grandmothers are horrible experiences, and maybe I will have a horrible pregnancy too. About how I’ll have to figure out if I can breastfeed while also being a doctor. About how I’m assuming I’ll even have a partner to make babies with in this golden window. Why do all these thoughts feel so new and unfamiliar? Why do I feel like the first person to ever think these things? Why do I feel such a strong pressure to write them down, to make people read them? Maybe I am terribly self-centered, but maybe it’s because women’s histories are no longer passed down, my grandmother’s life-world doesn’t go further than her. Though it isn’t just women who give birth, women exist at a unique nexus in the world, living with a harshly gendered expectation for moral reproduction as well as efficient production. By and large, it is women who bear the brunt of the ethical weight to produce the next labor force and give them all of the support and nutrients they need, while also being expected to act as productive laborers themselves. How does the business of baby-making ever happen under this weight? Especially without anyone to warn us, to prepare young women for the unique challenges of birth, babies, families, and maintaining an individual life.
Had I not asked my grandmother directly, I wouldn’t have ever known that she gave birth under the horrors of twilight sleep, treated as a reproductive body as doctors knocked her out, removed her baby from her body, and woke her up again. I wouldn’t have ever known that she believed in breastfeeding until three as an act of love and caring, setting her babies up for the best life she could. I wouldn’t have ever known that she learned to drive just so she could attend her obstetrician appointments that my grandfather was too busy working to drive her to. I wouldn’t have ever known that she thought something was wrong with her anatomy, and that’s why she had two Cesareans. Why aren’t these stories told anymore? When did birth become something unworthy of talking to your family about?
Me & My Rotational Birth Canal
Humans have difficult births, with risks of obstructed labor, hemorrhage, tearing, fistula… the list goes on. The entire discussion here could be about that, honestly, given the host of interconnected factors that affect how well birth goes for mom, and for baby. Compared to our closest primate relatives, we have significantly longer, more complicated, and more painful births. Some of those differences are deeply connected to why we are human. For example, humans are obligate bipeds. This evolutionary shift to stand upright required changes to our pelvis shape to stabilize our hips via decreasing the flexibility of the pelvic joints, changing the angle of our leg connection, and shortening the pelvis. This reduced the size of our birth canal, and made its stretch more difficult, creating a tight squeeze for the skull of the neonate. Human babies are born with unfused skulls (unlike most primates), which are often forced to deform as they flex and squeeze within our bony birth canals. This is likely an evolutionary adaptation to try to avoid the obstructed labor common in humans. Not only are babies born with big heads due to our giant brains, but also with wide shoulders, necessitating a rotation during birth in order to match their widest plane with the widest plane of the birth canal as they pass through it. Human babies, in contrast to most other primates, are therefore born facing backward relative to mom. Some argue that this brought about the oldest human profession, midwifery. Because mothers cannot reach down to pull out their own babies without risking damage to their spines, a birth helper was needed to help with this last stage. The word origins of midwifery mean “with woman,” describing the highly social, supportive role other humans play in keeping babies and mothers safe. No other primate species has help during birth, but it is a human universal. It’s hard for me to imagine going off on my own to have a baby, without anyone to reassure me, bring me water or hot towels, hold my hand. Much more than just baby catchers, midwives are part of our human family, making our difficult and dangerous births a little easier. Standing up straight and caring about one another are uniquely human behaviors that are intimately connected to the way we give birth.
A Productive Enterprise
Why do we even give birth at all, if it’s so difficult and dangerous? Though I would love to answer that women decide to become mothers because it brings them joy, I fear the answer is far more complex than that. In some languages, the word womanhood is synonymous with motherhood, meaning that a childless woman isn’t a woman at all. For example, in Egypt, the word “أنوثة” can translate to either womanhood or femininity. Childlessness therefore erodes the identity of the woman herself, who is blamed and held responsible for her reproductive “failings.” This is also the case in Bengali, where womanhood is a synonym for femininity. Bangladeshi women are viewed as successful women only if they are successful mothers. This is felt most strongly by poor Bangladeshi women (whose livelihoods rely more strongly on agriculture and children as labor, which will be discussed below), but even affluent Bangladeshi women feel guilt and experience stigmatization if they fail to prove their fertility. There is the expectation that a good wife will “prove her usefulness…contribute to the prosperity of her in-law’s family” by giving birth to many babies. If she fails to prove her fecundity, she will remain a stranger to her new family, never gaining acceptance, and in the case of poor women, even being denied food and being abandoned. This same sentiment is felt across cultures in a global patriarchal system, even when womanhood and femininity are recognized as being distinct. For example, affluent women who struggle to get pregnant in highly medically developed regions often turn to in-vitro fertilization. IVF often constructs the reproductive body as failing, while the clinics pride themselves on their success statistics for women who couldn’t get pregnant the old-fashioned way. The hopeful women compare themselves to other patients in the clinic: “and wonder who will make the statistics. The woman next to you tells you she has fifteen eggs, yesterday you’d been told you had five but one was bigger than the others… You beg those little ones to grow.” Don’t fail, eggs, don’t fail, uterus. Don’t fail, woman.
Birth is never just birth, because babies are never just babies. Babies are labor power, and women are the productive and reproductive entities that bear the burden of the next generation of workers. This view is by nature incredibly generalized, but it does explain many of the population dynamics cross-culturally and across time. “Around the world today, the general picture is of declining fertility…lowest overall in Europe and East Asia, where below replacement fertility (meaning that women are having fewer children than are required to replace population) has become the norm.” In contrast to days past where “women have had an average of five or more live births each,” women now are largely choosing to have fewer children. The regions where this is not true are primarily “sub-Saharan Africa, some countries in southwest Asia and the Arabian peninsula, and Papua New Guinea.” What is the difference between the majority of women now, versus the women in these areas and the women of the past? A whole host of things, all of which tie into the idea of reproductive costs. Pregnancy is hard, birth is hard, and raising a baby is really hard. This might be worth it if that baby proves to be a boon to your family, an additional laboring body that helps to raise crops or tend the herd (explaining some of the very high fertility rates seen amongst agriculturalists and pastoralists). It might not be worth it if the woman herself is already acting as a laborer (explaining how increasing women in the workforce decreases fertility rates) or if she wants to pursue higher education (explaining why increasingly educated women have fewer children). If I were to have a baby right now, I would probably manage to finish undergrad here at Dartmouth, but I would probably never be able to make it through medical school, given that I would have a two-year-old during my first year. I simply don’t have the time.
Babies in lower-fertility regions act to decrease some of the social and economic mobility of their mothers not only while they are infants, but also throughout their teenage years and early adulthood. I am still dependent on my parents, economically primarily, even though I’m of reproductive age myself. Having a child, for many women across the world, is not an economic benefit, especially since most of us aspire to ensure our children’s social success, providing them with all of the expensive opportunities to succeed, like university education. It’s no surprise that birth control is so important to so many women, allowing them to decide whether or not to have these very costly children on their own time.
Between you and me, I don’t know how I’m ever going to manage having a baby. My life plan, as I’ve alluded to, is pretty tightly scheduled out. When I graduate from undergrad in a few months, I’ll be 22. I’ll move away from Hanover, spend two years working at a research lab before almost certainly moving again, to wherever I’ll go to medical school. I’ll be 24. I will (cross your fingers!) spend four years there, before moving again to wherever I will complete my residency. I’ll be 28. Residency, at minimum, will take four years. I’ll be 32, and that’s the beginning of my window. Let’s all cross our fingers that amidst all the moves I have a partner at that point to get to the baby-making with. There will be three years during which I can try for a baby, and hopefully (cross your fingers, if you still have some to cross) I have no problems getting pregnant.
Woot woot, baby time! Just kidding. Now begins the actual pregnancy part! Much of which will be taking place during the final phase of my doctor-planning, where I’ll be a long-awaited attending physician. The real deal, exciting new phase of my career where I’m sure I’ll be respected as a do-it-all wondermom by my colleagues and patients while pregnant. During this, I will be navigating the ethics of what to eat (get your folate!), what not to eat (you would eat raw fish during pregnancy?), how much to eat (don’t gain too much weight!), can I even eat (morning sickness getting to you?), and so much more. Pregnancy grows ever more morally charged, necessitating a strict script for behavior that is almost impossible to follow. At the end of it, I will be rewarded with the chance to have a difficult birth just like my mother and grandmothers. Cross your fingers!
It’s honestly kind of a wonder anyone wants to get pregnant at all, given how much of an uphill battle it seems. And though healthcare has done a wonderful job decreasing the high maternal mortality rates worldwide, it hasn’t all been a blessing. Many of the advances in women’s healthcare have come at the cost of women, especially women of color. For example, J. Marion Sims’ research on vesico-vaginal fistula (a dangerous complication after vaginal delivery) relied on Black enslaved women, their bodies made into inert research objects used to advance the discipline of gynecology. The women’s personhood and health was secondary to Sims’ own notion of medical discovery, as evidenced by his use of their bodies for continued cruel experimentation and his returning of the women to their enslavers. The field of gynecology, and more broadly the field of women’s healthcare, began by privileging the enlightenment of doctors at the cost of women, constructing their bodies as objects that could be understood through surgery.
Much of biomedicine’s inherent premise relies on viewing the body as a machine, a functional unit that can be mechanistically interpreted and understood. Sometimes this serves to expand the biological boundaries of women’s lives. For example, in-vitro fertilization has allowed women to get pregnant who are old, who spent their prime reproductive years chasing career aspirations (potentially, women like me one day), who have bad eggs, or a bad uterus, or just bad luck. All of this is possible for quite a fee, of course. A functional body is hardly ever free. But this panoptic gaze of the medical establishment, capable of extracting my eggs, making magic, and putting them back inside for nine months of nourishment, has its flaws.
A body that is viewed primarily like a piece of machinery, with doctors as particularly talented mechanics, is bound to be one whose agency is minimized. And, using this mechanical mindset, our reproductive bodies are seemingly particularly bad machines, rife with construction issues (narrow birth canal causing obstructed labor, fistula, tearing) and faulty engineering (weak pelvic floor causing increased prolapse and incontinence). “Women’s bodies have been scientifically constructed as essentially faulty, their reproductive bodies as potentially dangerous to babies; childbirth so fraught with danger as to be unthinkable without biomedical surveillance and intervention.” Mothers are treated by scientific literature, by doctors, by healthcare systems, and often by themselves, as if they have little to add to pregnancy, beyond nutrients and a questionable exit route.
But perhaps this perception of women’s bodies is part of the problem of birth. Likely it's true that our big brains and bipedal locomotion are opposing forces, and that they cause uniquely antagonistic selective pressures on the birth canal that contributes to difficult labor, as the obstetrical dilemma hypothesis suggests. But expecting women to give birth on their backs, tethered to an electronic fetal monitor, with a cocktail of drugs to induce labor on a doctor’s schedule, might also be part of the problem. Silencing the signals from their own bodies, hormones speaking from millions of years of evolution overridden, suddenly much less important than a technocratic, scopically-empowered medical authority. Perhaps the way labor has been constructed, normalized, and scheduled, is so distant from birth the way our bodies intended that we make some of those bad outcomes happen. Speeding birth up with hormones to artificially induce contractions might cause tearing, putting women on their backs might be preventing optimal alignment of their birth canals. But hey, ladies, labor is your problem.
What’s Love Got to Do With It?
In classic neoliberal fashion, all of the problems with birth and babies belong to women and women alone. If my baby is too big, it’s because I’m obese, if my baby is premature, it’s because I am too anxious. If something goes wrong, it is my fault. Women are constructed as flighty and selfish landlords, and are increasingly criminalized for the outcomes of their pregnancies, whether that be abortion or babies born addicted to drugs. Women are “receptacles, not citizens,” where their “individual responsibility and competition trump equity and citizenship.” Not only are women constantly surveilled to ensure they are embodying the cultural ideal of good motherhood, but they are also expected to embody the neoliberal ideal of economic productivity. Tread the line ladies, if you can, just know that if the balance becomes too much, the “assumption is that women must sacrifice their needs and career aspirations” for their children. Consider how increasingly popular breast pumps are as gifts for new mothers, allowing them to return to the workforce to be productive entities, as they fulfill their reproductive duties to provide their newborns with nutrition. Perhaps it is enabling women to pursue careers while being mothers, but “perhaps promoting breast pumps and even allowing time for pumping at work, avoid[s] harder — and divisive and more stubborn — social and economic issues about parenting and the needs of women and their families.” Reproductive and productive bodies, reaped for all they are worth.
How did we get here? Am I damned to always think in monologues about birth as if it’s something that is both all my responsibility and all my fault? Wondering what it means to dream about my productive career potential and reproductive birthing potential, hoping I can do both and fearing where that leaves me, the person? I don’t want to be alone to give birth, and I don't want to be all alone thinking about it either. Humans aren’t meant for it. We give birth to backwards babies who can’t walk, crawl, or eat without help, and mothers can’t do it all alone. We need our midwives to catch babies, grandmas to watch them, partners to hold them. Part of the human condition is to have difficult births. And part of the human condition is to have people to support you, hold you, and love you. I hope I get that. I hope I can do that for my babies, when they are tiny and when they are just like me, thinking brand new thoughts for what feels like the very first time.
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