A Cost Accounting of Birth


In contrast to the Old Testament, which blamed the pain of childbirth on sin, evolutionary biologists in the late twentieth century proposed the obstetrical dilemma: the human birth process was difficult and dangerous because the baby’s encephalized head had to pass through a mother’s bipedal birth canal. This hypothesis, well accepted through the turn of the century, and even still accepted by some, contended that the change in pelvic shape when humans began to walk, and the increase in brain size of the infant, pushed the birthing process to the edge of what was possible.

It’s an edge most birthing women have experienced. “The ring of fire,” they say of the moment the infant’s head crowns. Each of the times I give birth—clenching and shuddering on a hospital bed, and later biting the edge of a mattress—my body burns and rips and I think, This is what it feels like to die. I’m going to die. My body can’t do this.



The newborn cranium, broken into five not-yet-ossified plates that shift and slide against each other, protects a brain that is only 28 percent of its adult size, unlike most other mammals, who by birth have already developed at least 40 percent of their adult brains. Baby gorillas are blessed with 45 percent of their adult brains. The domestic llama: 72 percent.

Despite its relative smallness, however, the human infant’s cranium barely escapes the bones of the birth canal—a tighter fit, biologists admit, than most other primates.



When I am pregnant, health practitioners give me a long list of things to avoid, including but not limited to caffeine, alcohol, unpasteurized cheese, sushi, excessive exercise, and almost any medication stronger than Tylenol. I pee in a cup before each appointment, and midway through each pregnancy, I am told to drink a thick, sugary drink that makes me nauseous and brings on a migraine, all to test if I have gestational diabetes. I don’t, but as my blood pressure ticks up, the nurses frown and say we’ll have to watch for preeclampsia.

I’m not afraid of childbirth, but there is fear in this room, and it seems the danger is me.



In Brought to Bed: Childbearing in America, 1750–1950, Judith Walzer Leavitt describes childbearing as a “shadow” that followed women throughout their childbearing years: “Young women perceived that their bodies, even when healthy and vigorous, could yield up a dead infant or could carry the seeds of their own destruction.”

They of course had a reason. Early in the twentieth century, one mother died for every 154 births. Which means, from a group of thirty young women, childbirth would kill at least one.



In addition to death, women often feared physical debility. Some women suffered from vesicovaginal or rectovaginal fistulas: holes between the vagina and either the bladder or the rectum. Before physicians knew to repair these holes—and before J. Marion Sims, the so-called father of modern gynecology, perfected the procedure by practicing on enslaved African Americans—women simply suffered, living the rest of their lives with urine or feces leaking through the vaginal opening, impossible to control.

Walzer Leavitt writes in Brought to Bed that some of these fistulas resulted from “the violence of childbirth.” Others, however, were caused by forceps, the metal tool physicians clamped around the emerging infant’s head. Sometimes the forceps punctured the infant’s skull. Sometimes they tore through the woman’s flesh.



It makes no sense. For nine months, the fetus spins and kicks and shifts and grows in the womb. One would think, as its head grows to the point where it may not escape, that the female body would simply evict it earlier. Too big for the door? Out you go!

By the end of a full-term pregnancy, the mother simply cannot consume enough calories to support both herself and the fetus.

Recent work by evolutionary biologists, however, has disproved the obstetrical dilemma: a pelvis large enough to accommodate a newborn’s head would not, actually, limit a woman’s ability to walk. Instead, new research suggests that metabolism, perhaps even more than the pelvis, constrains fetal brain growth and triggers labor. By the end of a full-term pregnancy, the mother simply cannot consume enough calories to support both herself and the fetus.



When I am fourteen weeks pregnant with my second child and less than excited about the oncoming birth, my OB suggests an ultrasound might cheer me. She squeezes gel onto my belly, lowers the wand, and smiles as the fetus flickers before us. “See!” she says. “Doesn’t that help?”

I am supposed to say yes. I am supposed to say the pain and discomfort of pregnancy are worth it and that the costs of bearing children pay off. That pregnancy creates a glow and is joyous. That infants are adorably cute and add meaning to life. And maybe that’s enough, and maybe they do. But as I leave the clinic—heavier than when I came in and holding a photograph that reveals how my body is being used—I begin to suspect the cost-benefit analysis is more complicated than that.



In “Human Evolution and the Helpless Infant,” from Costly and Cute: Helpless Infants and Human Evolution, editors Wenda Trevathan and Karen Rosenberg describe how newborns, though more helpless than monkeys and apes, employ “unusual behavior” that endears them to others. Fresh out of the womb, newborns scrunch their arms into their bodies, stare, and smile. Their chubby faces have an almost-universal appeal. Meanwhile, oxytocin and socio­endocrinological transformations alter the mother’s “affiliative responses.” Postbirth becomes “an opportune time for her infant to engage in ways that ‘prove’ that he is worth the prolonged investment that human young require.”



That prolonged investment includes the need to carry young. African elephants, which emerge from their mother’s birth canal with 38 percent of their brains developed, can quickly get on their feet and join their herd. Chimpanzee infants, born with 40 percent of their adult brains, can cling to a mother’s body while she forages for food. Newborn humans, on the other hand, with their meager 28 percent, can only grip a finger, nurse, and stare eight inches in front of their faces. In addition, their mothers’ hairless, vertical torsos further limit the newborns’ capacity to hang on. The result: human babies are caught in a helpless state of “secondary altriciality,” requiring just as much metabolically in their “fourth trimester” as they do in the third.



The cost of pregnancy: 300 kcal / day in the third trimester, for a total of 75,000 kcal.

The cost of breastfeeding: 500 kcal / day, for (on average) a total of 220,000 kcal.



Though primarily inert, as if hibernating, mammary glands awaken with reproduction. During pregnancy, blood flow to the breasts doubles. Estrogen and prolactin rise. Progesterone rises at the same time before decreasing at the end, a combination that makes maternal brains more receptive to “infantile cues.” After birth, infant suckling triggers nerve pulses to the hypothalamus. Paraventricular neurons then project to the posterior pituitary. Oxytocin is released. Prolactin is released. Both travel to the mammary glands and bind to myoepithelial cells and lactocytes. This binding triggers the cells to contract, forcing milk through the ducts. Blood flow decreases and then suddenly increases a minute or so later, often causing the sensation of a tweak or a twinge.

The result, according to renowned biologist Sarah B. Hrdy in Costly and Cute: “With the onset of lactation, mothers are on a ‘mammary leash,’ endocrinologically incentivized to nurture and far less inclined to abandon an infant.”



When I am lactating, my glucose levels dip if I haven’t eaten recently. My hands begin to shake and my thoughts scatter. Anyone talking to me is talking too loudly. I glare with daggers and push people away with my elbows. I reach for the refrigerator—for lactation cookies and yogurt and leftovers and sliced melon. I inhale them all, becoming a bearlike version of myself. I rumble through the house, leaving wrappers and empty Tupperware and peanut-­butter-coated spoons on the counter. Afterward, sated, with my son’s lips clamped and pulsing on my breast, it strikes me with the certainty of a newly sharpened knife: my body will do what it needs to sustain itself and this child.



At the turn of the twentieth century, concerned about the difficulties experienced by affluent, pregnant, educated (and, though he didn’t say so directly, largely white) women, Franklin Newell of Harvard Medical School wrote: “It seems to me that this overdevelopment of the nervous organization is responsible for the increased morbidity of pregnancy and labor which is apparent among these women of the overcivilized class.”

I. N. Love, a founding faculty member of the Marion Sims College of Medicine, wrote in 1883:

We all know that the pregnant woman is prone to having her nervous system out of joint; in fact, the condition in itself is a severe test to the female nervous system. It is needless to recall to your mind how the very beginning of pregnancy is announced in many cases by peculiar nervous phenomena. During the entire term the imagination of the woman often becomes exalted or depressed. Her disposition is irritable. In many cases she is continually between two fires; upon the one side the greatest gloom, upon the other an excessive joy. Suspicion, jealousy, general sensitiveness are present, which under other conditions are never dreamed of. Nervous pains abound, migraine, facial neuralgia, toothache, itching in various parts of the body, together with smarting and other evidence of irritation of the peripheral extremities of the nerves.



Newell and Love were two of the nation’s first obstetricians. Their field emerged in the 1880s when physicians began taking over home births, long overseen by midwives, and birthing women eventually moved into hospitals. Most obstetricians, like Newell and Love, believed women were the weaker sex.

Physicians offered forceps, which saved women from complicated deliveries. They also offered pain medication: laudanum, ether, and chloroform.

Many women believed physicians were more learned and had access to a knowledge that women and midwives did not. Physicians offered forceps, which saved women from complicated deliveries. They also offered pain medication: laudanum, ether, and chloroform. The mass movement to hospitals, in fact, was initially driven more by women than physicians. Fearful of the pain of birth, and alive during a time when most women knew at least one person who’d died from birth, women were increasingly interested in pain medication—in the way they could simply go to the hospital, fall asleep, and wake up with an infant, everything over.



That is, unless they didn’t wake up. In the 1800s and 1900s, birthing women were plagued by puerperal fever, a bacterial infection in the uterus. It is estimated, now, that most cases of puerperal fever were transmitted by physicians and early obstetricians who did not yet understand germ theory and carried the bacteria on hands they plunged into women’s cervixes or on the metal planes of their forceps. The mass migration to hospitals, in fact, caused an increase in maternal death. Maternal deaths did not actually decline until the discovery of antibiotics.



In 2017, NPR and ProPublica shocked the world with a report on maternal mortality. Although the United Kingdom, Canada, and France all boasted maternal death rates below ten for every one hundred thousand live births, the United States’ rate had doubled over the past twenty-five years and now rested at 26.4, with rates particularly high for Black women and women of color.

According to NPR, “Babies are monitored more closely than mothers during and after birth,” and although a baby is “whisked off” to a neonatal unit at the first sign of trouble, hospital staff overlook maternal complications, expecting the mother to be fine.



I do not want to fall into the trap of biological determinism or essentialism and imply that mothers have no agency or choice: that human biology simply results in a difficult birth; that mothers are strung out and dictated by hormones they cannot control. I do not want to imply that Love is at all justified in his observation that pregnant women are “nervous.” He is not.

But still, I have questions. Questions that sometimes keep me up in the dark, quiet periods between my infant’s night wakings.

If pregnancy and birth can, indeed, be painful and dangerous, is there some truth to the story the Old Testament tells about Eve? Are women inherently resigned to a difficult lot?

If pregnancy and birth can, indeed, be painful and dangerous, and if caretaking exhausts us, does this mean women are weak and in need of assistance?

If I don’t want to see myself as weak or in need of assistance, am I ignoring the very real ways my childbearing body demands others’ support?

What does it mean to have a body that asks so much of me?

What does it mean if it means nothing at all?



On YouTube, one can find birthing videos. Videos of vaginal births and C-­sections, videos of home births or hospital births with women dazed from epidurals. Videos of women squatting and videos of women screaming. The videos of women screaming seem to get the most hits, with viewers commenting, Anyone else get turned on?

Other videos are softer. In one, a woman gives birth by a river or creek. In the video, she squats and kneels and prostrates herself on a yoga mat that rests on river rock. Birds chirp in the background. She is quiet save a few soft grunts and some panting near the end. No one, until the delivery, aids her. In a statement that stays with me because I long for that experience myself, she writes, “It was the singular most transforming event of my life and my most conscious act as a woman to date.”



Prior to the overtaking of birth by male physicians, Walzer Leavitt says, most women gave birth at home, tended by trained midwives and female relatives and friends who would often stay for days or weeks, helping with household tasks and caretaking. The women celebrated life together. They suffered and mourned their losses together. They created a “social childbirth” that “united women and provided . . . one of the functional bonds that formed the basis of women’s domestic culture.”

In Costly and Cute, Trevathan and Rosenberg argue that the only way the human species could have survived and sustained itself, considering the demands of reproduction and child­rearing, was by developing just this type of social bond: a system of extensive, cooperative caretaking that involved an entire community, not just parents.



Tamarins, from the family Callitrichidae, are also a social species of primates, requiring cooperative breeding and biparental care. It isn’t unusual for tamarin groups to consist of a half dozen or so males and more than one female, and all of the tamarins help raise the young.

In fact, if a pregnant or birthing tamarin does not sense she has enough assistance, she has been known to drop her infant on the ground, and on rare occasions, if that fails to elicit a community response, to bite the baby’s face and devour its brains.

In “Of Marmosets, Men, and the Transformative Power of Babies,” Sarah B. Hrdy says humans aren’t so different: “Callitrichine and human mothers have converged on a similar decision rule: proactively line up allomaternal assistance, but if that fails, bail out.”

Did we have sufficient health insurance? Could we afford daycare? Did we have family or friends nearby who could babysit?

When my husband and I discussed having a child, our discussions were not often about some innate desire for children but rather about resources. Did we have sufficient health insurance? Could we afford daycare? Did we have family or friends nearby who could babysit? Did we have the energy to get through those sleepless nights? Each time we deliberated, I hesitated at our already-tight budget, our distance from relatives, our demanding careers, and paused at the uncertainties, ready to abandon the venture.

Later, with my son crying, and my daughter crying, and my husband half an hour away at work, and no one else in our two-thousand-square-foot house but me, ragged from a lack of sleep, hands on my cell phone without anyone to call, I pause again, like a tamarin in a tree, ready to bail out.



Today, one human mother dies for every 3,788 births. Most of those deaths are from hemorrhage and preeclampsia. Sixty percent of those deaths could be prevented. Which of course means forty percent could not. In parts of Africa and Asia, women still die from fistulas, and even in the United States, women suffer in silence from childbirth-related incontinence. The American Pregnancy Association includes a webpage on how to write a will. The Department of Agriculture estimates the cost of raising a child at $233,610. Genesis still warns: “I will greatly multiply thy sorrow and thy conception; in sorrow thou shalt bring forth children.”



When I look at my body—a body that has felt a fetus’s soft kicks and the shift of an almost fully formed butt against the stretched skin of my belly, a body that has watched those large lumps move from side to side, a body that has felt an infant’s mouth latch onto my nipple before letting go in milky exhaustion, a body that has experienced the painful twinge of a let-down of milk and woken to a wet shirt, a body scarred with stretch marks and an inverted belly button—when I look at that body and ask, What does it mean to be a childbearing woman?, what I really want to know is what happens when the ideologies and structures we’ve used to understand our lives all fall away. Gender. Biology. Medicine. Religion. Does this take away some of the value we’ve given birth and women, or does it allow us to see things clearly? What words do we use to describe childbirth then? What tales do we tell?



Men have told me the pains of childbirth are a punishment, and that women are weak and animallike and can be discredited as hormonal, and that pregnancy is a pathologic process that requires careful monitoring in a hospital where we can pretend, for a brief moment, that the body can be controlled.

But what if birth simply is as it is—an infant’s head nearing the point where it can’t fit, metabolic costs tipping into instability—and my ability to give birth is solely that: an ability to give birth. Not a power struggle, but the purely physical. The pelvis. The birth canal. The hard surface of bone. The red and veined placenta. The process that sometimes benefits from human assistance—that has evolved, in fact, from human assistance—but also will continue expelling infants all on its own.



Though maybe that’s what terrifies us the most. How, when viewed over eons, childbirth erases us. Plunges us into a timeline where silence is better than words. Man? Woman? You? Me? It doesn’t matter. Just the ordinary, extraordinary need of the body to survive.