New Worlds: Childbirth

(This post is part of my Patreon-supported New Worlds series.)

In Aztec cosmology, warriors who died in battle or sacrifice were rewarded with Huitzilopochtli’s heaven, accompanying the sun in its journey from rising to noon.

The western half of the sky, from noon to sunset, was the domain of women who died in childbirth. Because to the Aztecs, that was the equivalent of dying in battle — and for good reason.

Evolution has not been kind to us when it comes to childbirth. As a species, we have two characteristics that don’t play well together: we’re bipedal, and we have very large brains. The former means our pelvises are relatively narrow (in order to walk more efficiently), which in turn means the birth canal is narrow. Have you ever wondered why human infants are so unspeakably helpless, compared to other animals — why it takes years for us to be anything like capable of surviving on our own? It’s because in order to make it out of our mothers, we have to be born well before our brains are done developing. And even then, we have to execute a ninety-degree turn midway through the process: the geometry requires it.

It’s possible for something to go wrong with the birthing process in any species. But we humans have remarkable difficulty with it. I’m not going to attempt a comprehensive survey of all the complications that can occur; for most books it will be enough to note that mother, child, or both can die in the process, from a wide assortment of causes. In the past, this was horrifyingly common, and even today, it happens all too frequently.

We can avoid some of the more perilous complications by performing a caesarean section, cutting open the mother’s body to extract the fetus. These days that’s quite common, at least in the West; something like a third of all deliveries are by caesarean, though the exact percentage varies depending on where you live. In the past, though, it was the kind of operation you only performed when the mother was either dead already or assumed to be beyond saving. There are tales of women surviving . . . but even in the late nineteenth century, eighty-five percent of all mothers who underwent this surgery died.

Partly that’s because the odds of surviving surgery in general weren’t great back then. Hygiene was often non-existent; even normal vaginal deliveries carried a high risk of puerperal (childbed) fever, caused by bacterial infections. Rates of that spiked horribly in the eighteenth and nineteenth centuries, when maternity hospitals became a thing and women were frequently examined and attended by physicians who hadn’t washed their hands, using contaminated instruments. In Vienna in the mid-nineteenth century, some women preferred to give birth in the street rather than be admitted to a clinic where the maternal mortality rate was one in ten.

So how risky childbirth is in your fictional world depends in part on what the standards are for hygiene, rather than on technological sophistication. But there’s also a simple device that can sometimes improve the odds of both mother and child — and here I have to warn you that I’m about to rant.

Obstetric forceps look a bit like scissors, except with gently curved loops instead of blades. With them, you can reach up the birth canal to grip the head of a baby and assist in its movement. There are risks to doing this, but on the whole, forceps greatly reduce certain complications and improve the odds for both mother and child. They were invented by the Chamberlen family of surgeons in the early seventeenth century . . . who proceeded to keep their device secret for over a century.

Which doesn’t mean they didn’t use their invention. No, they did — after first escorting everyone from the room except physician and mother, then blindfolding the mother. Only then did they open the box in which the forceps were kept. This miraculous device, which had the potential to save any number of lives, was controlled by a single family for generations. Only in the mid-eighteenth century did the idea start to spread and become available for other physicians to use.

Returning to the ordinary process of childbirth: everything I said in the previous essay about the rituals and beliefs surrounding pregnancy applies here, too — as you might expect, given the perils — plus there are differing options and opinions on the practical questions, too. What kind of pain relief is safe and appropriate, and when should it be administered? Should the mother keep walking around during the early stages of labor, or conserve her strength? For delivery, what position should she be in? Western societies default to putting the mother on her back (the origin of the term “lying-in” for childbirth), which is most convenient for the attendant, but often not the best for the mother. Various upright or semi-upright positions, such as standing, squatting, kneeling, or braced on all fours can make the process easier, by widening the birth canal (by up to a third!), reducing the muscular effort required, and taking advantage of gravity’s assistance. Many societies have made use of a birthing chair, or just had the mother sit in the midwife’s lap. Water birth has also become more popular of late, though the evidence for its benefits in the later stages of labor is inconclusive at best, and it carries its own risks.

Delivery of the baby isn’t the end of the process, though. Some children are born with a “caul,” a piece of the amniotic sac clinging to their head; this is often seen as an omen of some kind, often (but not always) a beneficial one. In such cases it may be preserved as a good-luck talisman for later in life, or sold to people such as sailors, who believed it would protect them against drowning. The mother also has to deliver the placenta or “afterbirth;” ordinarily this is disposed of, but in some cultures it’s consumed instead. The umbilical cord, which connects the infant to the placenta, also needs to be cut. All of these things can be attended by suitable rituals.

The final question is who else participates. Women have occasionally delivered their children all on their own (with the chances of success being higher if they’ve given birth before, as that often makes subsequent deliveries easier). Under most circumstances, though, a woman in labor usually has someone to assist her. Historically, and still in many parts of the world, that’s often one or more older female relatives who have gone through childbirth themselves. There are also midwives, trained nurses who specialize in childbirth; they’re almost always women. The shift toward physicians began in Europe in the eighteenth century, and had the odd effect of putting the work of managing childbirth into the hands of men, because women at the time could not become physicians. This is especially peculiar because men were often not permitted in the birthing room otherwise; even the father would be exiled to wait outside. Only in the later twentieth century did it become expected in the U.S. that the father would attend the mother during labor.

Even with help, though — and even with modern medical science — childbearing remains a risky endeavor. So stop and appreciate that every one of us is the product of someone taking that risk . . . and given what the history looks like, marvel that we’re here at all.

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About Marie Brennan

Marie Brennan is a former anthropologist and folklorist who shamelessly pillages her academic fields for inspiration. She recently misapplied her professors' hard work to the short novel Driftwood and Turning Darkness Into Light, a sequel to the Hugo Award-nominated Victorian adventure series The Memoirs of Lady Trent. She is the author of several other series, over sixty short stories, and the New Worlds series of worldbuilding guides; as half of M.A. Carrick, she has written The Mask of Mirrors, first in the Rook and Rose trilogy. For more information, visit, Twitter @swan_tower, or her Patreon.


New Worlds: Childbirth — 14 Comments

  1. Thanks for writing about this! This seems like a good place to link my post about how “protagonist’s mother dies in childbirth” is much more a trope than it is realism (Mary Shelley is probably the best historical example.)

    • I’m a little unclear — do you mean that you don’t think it’s realistic for a protagonist’s mother to have died in childbirth? I agree that it’s become something of a cliche, but that isn’t the same thing as saying it’s unrealistic. Lots of people’s mothers did indeed die that way, and while Mary Shelley may be a famous example, she’s far from the only one.

      • I do think it’s far less common than people might realize for someone whose mother died giving birth to them to make it into the history books. The list of 16 people I posted was literally everyone I could find from a quick search — if you know where to find more, let me know. I was expecting more royals, since male heirs are valued.

        Which isn’t to say that death in childbirth is unrealistic — as you say it happened all the time, just to say that if in your world women only die in childbirth giving birth to future protagonists, that’s unrealistic. (I understand that GRRM doesn’t actually do this.)

          • Exactly! Or these were often premature births, and more likely to lead to health problems later on. Which shouldn’t disqualify someone from being a protagonist, but apart from Tyrion Lannister, all the fictional examples I can think of are able-bodied and healthy.

            Also “death in childbirth” often means death of puerperal fever or other complications, which can happen up to a month later.

            • Ah, I see — it isn’t the general idea of “women dying in childbirth” that’s overrepresented, just the frequency with which that’s used as the backstory for a protagonist/somebody who grows up to be super important. That, I would agree with. (They should be watered down with more protagonists whose mothers died in childbirth . . . for a subsequent child, who may well have died with them. As opposed to “oh, the angst, my mother died giving birth to me and now my father hates me!”

      • Yes, it was far from unknown, but Jane Austen was poking fun at how ludicrously often it happened to heroines.

  2. It says something that the primary European text on what we would call Ob-Gyn for centuries was written in the 12th century by a woman named Trotula di Ruggiero, a teacher at the Scuola Medicina di Salerno*, the first medical school in Europe. The Trotula (three texts on women’s health) were published and re-published and used to teach doctors (most of whom did not handle women’s health and childbirth, but were expected to have some knowledge in case the local midwife screwed things up)l; like a lot of medieval medical practice, it’s a fascinating combination of solid practical advice, good herbalism, bad herbalism, and woo-woo.

    Another factor in maternal death in childbirth was exhaustion–not just the exhaustion of the process, but exhaustion of the, um, hardware. I was looking at the obit of one of my New England forebears: nineteen pregnancies. Fifteen live births of which thirteen kids survived past 5 years (and three of those died in an unspecified epidemic before reaching adolescence–makes the concept of an heir and a spare make more sense). With the wear and tear on her body it is perhaps not a surprise that my great-great-great died in- or right after childbirth, at the age of 38. Having been through the process of birthing a child twice, I am impressed that we’ve managed the overpopulate the earth to the extent we have.

    *when I learned that women were not only doctors, but professors, at the Scuola Medicina, I based a whole damned book around it, because how could I not?

    • The wear and tear is absolutely real. My reading for this post led me into discovering the modern idea of a “resuscitative hysterotomy,” which is basically a type of C-section performed in the hopes of restoring normal circulation to a mother who’s gone into cardiac arrest — the fetus places pressure on certain blood vessels, with occasionally lethal results. Whole systems of the body are stressed by pregnancy and labor, not just the reproductive ones.

  3. One wonders how much of the danger of childbirth to the mother lurks behind the notorious Disney “dead mother” meme!

    The history behind the forceps, and in particular the Chamberlens, is a great example of the Law of Unintended Consequences — of guildmaster secrecy as the only means of keeping “base copyists” away from innovations, of the (largely asleep) legal system in Europe regarding “theft” of anything intangible that didn’t involve the Crown, of religious bigotry (Huguenots v French Catholic establishment), and of unrestrained personal advantage as sufficient and necessary motivation. It’s ugly, and far from the ugliest example, not even of Huguenot v French Catholic establishment in healthcare (the pre-Pasteur history of microbial theory is even more disheartening… and probably had an even higher death toll).

    • The “dead mother” meme is also partly driven by the Grimms putting wicked stepmothers into their stories (necessitating the prior removal of the original mothers).

      • Fair enough to an extent… but a substantially higher proportion of Disney features have missing mothers who are in some way relevant than in Grimm, and that’s a really grim statistic.

        • Actually, I think a lot of the Grimm as well as the Disney thing was that they didn’t want to think of actual mothers doing awful things to the kids, so the job fell to step-mothers.

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