Sapiens, page 10: The One With the "Obstetrical Dilemma" On It

One page at a time, I'm reviewing Sapiens: A Brief History of Humankind by Yuval Noah Harari. 

Already, what we've seen on the pages pairs nicely with something Rebecca Solnit wrote in her essay called Woolf's Darkness.

"Nonfiction has crept closer to fiction in our time in ways that are not flattering to fiction, in part because too many writers cannot come to terms with the ways in which the past, like the future, is dark. There is so much we don't know, and to write truthfully about a life, your own or your mother's or a celebrated figure's, [or a Plio-Pleistocene hominin's], an event, a crisis, another culture is to engage repeatedly with those patches of darkness, those nights of history, those places of unknowing. They tell us that there are limits to knowledge, that there are essential mysteries [...] Filling in the blanks replaces the truth that we don't entirely know with the false sense that we do. We know less when we erroneously think we know than when we recognize that we don't. Sometimes I think these pretenses are authoritative knowledge are failures of language: the language of bold assertions is simpler, less taxing, than the language of nuance and ambiguity and speculation."

Page 10

The first time I read Sapiens, back in 2015 or so, I was already 8 or 9 years into doubting and critiquing the "obstetrical dilemma". (What is it? Hang on... we're getting there! If you cannot wait, then read the picture where I scribbled "OD".) 

The first years of my antagonistic entanglement with the obstetrical dilemma were off the record. Then in 2011, I gave a conference presentation about the paper that I wrote with some colleagues that came out shortly after in 2012. Harari wrote Sapiens before 2011 and even if he had written it after our 2012 paper, there's no reason to expect him to have known about it or to have been convinced by it. The obstetrical dilemma was, and still is, as good as fact to so many people. It's a perspective on human evolution that is default or preferred by a significant number of researchers.

After that 2012 paper I kept going. Not only were there scientific issues at stake, but, over time, other issues piled on. In 2014, I gave birth and, when I did, I learned a thing or two about how childbirth works (or... does not) in hospitals. That experience did not line up with many assumptions in the "obstetrical dilemma" literature where the understanding of birth is largely based on what's reported of hospital births, and where the size of the pelvis and the baby are made out to be the basis for the difficulty and "danger" of birth. 

Then, years later, to process my traumatic hospital birth, I finally actually learned from the experts how childbirth works when it's unobserved, undisturbed, and uninhibited (which is a tad difficult to experience in a hospital). Six years overdue, I took birth classes from Flor Cruz and Lia Berquist. And I've been reading like crazy, like Ali Yarrow's excellent book Birth Control, and from so many other great sources like Intentional Birth, Latham Thomas, Rebecca Dekker for Evidence Based Birth, Henci Goer, Robbie Davis-Floyd, Orli Dahan, etc. I read about how people who birth outside hospitals and people around the world describe birth. It's not always "painful" to so many people. And I'm still learning as I watch birth in a steady stream on Instagram, thanks to @badassmotherbirther.

The learning never ends because there is a lot to learn about birth and there are lots of mysteries! But one thing we do know is that birth emergencies are rarely about the pelvis or a big baby (even if that's how someone, even a medical professional, describes the ordeal). 

And another thing we know is that, under healthy conditions which are typical conditions, being in a hospital, period, makes childbirth more challenging than not. If nothing else, it slows down the two bodies involved.  

A slow-down wouldn't be so bad if it didn't require more endurance on the part of the birther... and if the hospital staff weren't afraid of rare complications that they were (thankfully) trained to treat and if the staff weren't constrained by hospital budgets and liability. So, instead, that slow-down--caused by being observed, disturbed, and inhibited in a hospital--looks like a rare complication whose fix is what staff know how to do better than they know how to assist unmedicated birth (yes, this is often true). And that slow-down looks like something that can be fixed with a procedure that brings in the big bucks from the insurance companies. 

So, the hospital staff perform a c-section and then let the family believe it was necessary, life-saving surgery. And so, the myth of the poorly evolved female body, a problem needing a technical-medical solution, carries right on. 

Of course, I'm not talking about every hospital birth. I'm describing a trend. An overwhelming trend.

Unfortunately those truths about childbirth and so many more are not known to, I'd guess, most people in the U.S. or to many people around the world. And so much ignorance about normal healthy unmedicated birth, I'm sorry to say, extends to many nurses and doctors. That's because normal healthy unmedicated childbirth is decreasingly the normal healthy outcome in hospitals. Where would they learn about it? So, here we are, medical interventions in childbirth (including being in a hospital under the staff's control) have not only been normalized, but naturalized. 

In our culture, the mature, correct, scientific perspective on birth is not based on people in society actually knowing much about birth with personal autonomy and informed consent. Their knowledge comes mainly from Hollywood dramatizations, highly controlled (read: inhibiting) hospital conditions, and very rare complications that benefit from medical care. None of those are normal healthy unmedicated birth. What's obviously natural to these folks, because it's so obviously necessary to their minds, is techno-medical assistance. Ironically, if you talk about "natural" birth you're seen as the ignorant one! And you're assumed to be against all medical involvement. You're a hippie or a tin-foil hattie for knowing something about actual birth. I'm not going to lie. The whole thing is enraging.

If everyone learned more about actual birth, not just people who will birth, might birth, or could ever possibly give birth, but EVERYONE who knows anyone who might, then everyone who actually does the birthing would have a much much much much much much better time of it. And wouldn't that be lovely? 

For now, we've got to read human evolution books that talk about birth with such confidence from a place of such ignorance. 

And Harari's rendition of the "obstetrical dilemma" is, as they say, *chef's kiss*:

"An upright gait required narrower hips, constricting the birth canal—and this just when babies’ heads were getting bigger and bigger. Death in childbirth became a major hazard for human females. Women who gave birth earlier, when the infant’s brain and head were still relatively small and supple, fared better and lived to have more children. Natural selection consequently favoured earlier births. And, indeed, compared to other animals, humans are born prematurely..."

But can you blame him for stating the "obstetrical dilemma" as if it's fact? I mean, I know he's been stating speculation as fact, already in the earlier pages. But about the OD, I can't blame him. It's still, more than ten years after he wrote this book, a fact to so many scientists and beyond. It's still being taught in universities and medical schools as the perspective on the evolution of birth and helpless babies.  And, before I turned against it, the OD was the fact that I taught my students back when I was a graduate student teacher and that I wrote into a 2007 reference volume. [Human Origins 101, a book on human evolution whose publisher graced the cover not only with the guy from that Metallica video (love) but also with a dinosaur skeleton (stupid)]. 

My perspective on the OD changed in 2006 when I taught my very first course as the head instructor. Because I was now a teacher of my field's understanding of human evolution that meant that I was now responsible for more than my little dissertation on fossil ape feet. So, I looked into the evidence for the OD and saw none. 

And so... let me, as pithily as I can, share a little of what I meant when I wrote that there is no obstetrical dilemma and there is no evolutionary obstetrical dilemma.

Let's breakdown the story:

1. "An upright gait required narrower hips, constricting the birth canal—and this just when babies’ heads were getting bigger and bigger."

You can have a legit scientific evolutionary perspective and not believe that what evolves was needed, as in what exists evolved because it was necessary for the lineage to keep evolving and not go extinct. And so, that's why I can say the following: we can't know if an upright gait "required" narrower hips. Or, said another way (as is often done), we don't know whether hips cannot evolve to have a more capacious birth canal. That's just not something we can know, not about the past and not about the present and, when we're in the future, we also won't know. We cannot know the limits to evolution. That's god stuff, if you're into that. So, already, our premise is fraught. 

It's true that, as adult brain sizes increased in the fossil record, we can assume that newborn brain sizes did too. That's fine. that's in line with the pattern we see across living primates. The ones with big adult brains have big neonatal brains too. Of course, fossil organisms are weird, so we can't know for sure, but our babies' brains are bigger than any other primates' and so our babies' brains had to have gotten bigger and bigger over time. Harari's good there. 

2. "Death in childbirth became a major hazard for human females."

No one knows this or could ever know this. But it's what everyone believes isn't it? And deaths in childbirth today are overwhelmingly NOT about the tight fit between pelvis and baby.  

3. "Women who gave birth earlier, when the infant’s brain and head were still relatively small and supple, fared better and lived to have more children. Natural selection consequently favoured earlier births. And, indeed, compared to other animals, humans are born prematurely..."

No. The belief that we're born early is false. I've written against it in the links above. Even the people who see the evolution of childbirth with the OD perspective agree that human babies are not born early or prematurely and so they have redefined the OD to omit that "solution." 

Our long childhood is explained by our large adult brains. It takes more time to grow a big brain than to grow a smaller one. 

Our babies are weird, too. Not under-developed though! The feet don't grasp like other baby primates'. Their whole bodies are so adorably fatty. And, their head is huge and heavy, to boot. But it holds a brilliant brain. 

Being a human baby is not easy and that's interesting and has probably had profound consequences on human development and parenting over the course of our lineage. Harari is onto that, though asserting so confidently that mothers could not forage for themselves and their babies is just foolish. That's not even true now, so why would it be true back in our ancestry? We can both be amazingly selfless, sharing and caring apes while retaining female competency. We can have it all. 

We don't need the OD story to get to to revelations about the profound consequences of our big brains. Evolution is still true without the OD. Our helpless babies and our lovely parenting of them, our long, intense period of childhood learning, and our extremely cooperative nature are all still true without the OD.

Look, I know that focusing on the dangers of childbirth is a tactic to fight for abortion rights. I think we can fight for abortion rights without telling tall tales about what an evolved "dilemma" the female pelvis and the big fat human baby face. I think we can fight for science to pay attention to female bodies without telling tale tales about how "garbage" the female body is. 

So all that (plus so much more that I left unsaid today) is why, when I read Harari's words, "women paid extra", I can't help but answer with some prickly questions...

How do you mean? 

Like, we paid extra when our ancestors evolved bipedalism + big brains by (supposedly) having fucked up, weaker, inferior bodies compared to men? 

What about all the "extra" that women have paid by living in a culture that has believed that about women? 

The last graf is also something else. Scientists are all done assuming that we are the only creatures for whom the nature-and-nurture experience applies. Other animals also have a brilliant becoming in the world. They are not meat-robots. They learn like crazy in their bodies in the world. "Instinct" is now understood to be a problematic term and concept. If you prefer to take that sentiment about instinct from a luminary in animal behavior like Frans de Waal, please do. It's in his books. 

Whew. Happy to have this page behind us. Was dreading and procrastinating about this page. Don't 100% love revisiting my trauma for science. Hope people who love people will visit the links I included in this post and learn more about childbirth. It is a wonderful thing to learn about! It saved me! It makes me love the world, too. If you don't, then maybe learning about birth will make you love the world too. 

Page 11 is next! To be continued...