Today, Carolyn S. Miles, president and CEO at Save the Children writes at the Huffington Post (ducks) about the latest findings regarding our ability to stop a preterm birth from happening. As anyone who’s given birth knows, it’s not easy to stop that process once it starts, and that persistent inability means devastating outcomes for some families. As Miles writes:
Over the last few months, the concept of birth control has been under great scrutiny in the American eye. Many politicians have been discussing it’s “moral” implications, and whether institutions or organizations should have the right to deny insurance coverage for hormonal contraception if it does not fall within the confines of their belief systems. And while American women have narrowly escaped legislation that would impede their reproductive health and freedom, politicians, mostly men, feel it necessary to make misinformed or even completely false statements about birth control.
For some strange reason, there is this erroneous idea that birth control is not a matter of health, but rather a means by which a woman can engage in careless and frequent sexual activity, with a man, and without the consequences of pregnancy. It’s clear that the picture these politicians are trying to paint is that of debauchery and immorality, which, of course, is a departure from the puritanical integrity they embody. But, rather than focus on this utter nonsense, I would prefer to highlight the significant impact birth control will have on the future of our civilization and our planet.
The human population has grown steadily since the beginning of our species. However, the rate of growth began to skyrocket after the industrial revolution, and our population has actually doubled over the last 50 years, reaching 7 the billion mark in March of this year. This is an astounding statistic since it took until 1804 – around 50,000 years – to reach our first billion.
World Population: 1800 – 2100 (Wikimedia Commons)
What makes these numbers really scary is the concept of carrying capacity, which is an ecological term used to describe the maximum number of individual members of a species that a certain habitat can support. In this case, the species is human and that certain habitat is planet earth.
Here’s the thing: the availability of our resources will not match the rate of population growth. Given our current technologies, there is only so much food we can grow, only so much water we can drink, only so much space we can inhabit, only so much waste we can safely rid, only so much energy we can harness. There will be a point that the human population will hit its carrying capacity on earth, and when it does, the chances of widespread famine will be great, and the delineation between the developing world and the developed world will be no longer.
Given this very serious issue, Britain’s Royal Society has recently convened to discuss the future of the human population and on April 26th, 2012, and published their findings in the People and the Planet Report [PDF]. For me, key findingnumber three struck a cord:
Reproductive health and voluntary family planning programmes urgently require political leadership and financial commitment, both nationally and internationally. This is needed to continue the downward trajectory of fertility rates, especially in countries where the unmet need for contraception is high. (emphasis theirs)
Political leadership and financial commitment – Did you see that, American politicians?? For those of you who are unnecessarily waging war on women’s reproductive rights, its time to get your giant heads out of your collective asses and realize the implications of legislation that would go against ensuring both the continued success of our species and the health of our planet. It is time to stop spending money on these regressive and oppressive campaigns guised under the false pretense of “religious freedom” and start making a financial commitment to the women (and by association, men) who live in our nation.
To drive this point even further, here is another excerpt from the People and the Planet Report (my favorite bit, found in Box 2.5 on page 33):
Women bear the main physical burden of reproduction: pregnancy, breastfeeding and childcare. They also bear the main responsibility for contraception as most methods are designed for their use. Men, it may be argued, reap the benefits of children without incurring an equal share of the cost. It follows that women may be more favourable to the idea of small families and family planning than their partners but unable to express their inclinations in male-dominated systems. Such views received international endorsement in the Program of Action resulting from the UN conference on population in 1994. Paragraph 4.1 states that “improving the status of women is essential for the long-term success of population programs”.
We currently live in a nation where 99% of women who are of reproductive age have used some form of birth control at least once. And when it comes to hormonal contraception, over 80% of sexually active women aged 15-44 have relied on “the pill” as a means to prevent unwanted pregnancies. This has contributed to an average of two births per American woman, which is considered to be the replacement rate for a population. Compare this number to countries where birth control and reproductive education is scarce – countries like Niger (7.52 births per woman) or Afghanistan (5.64 births per woman) – and one can see the impact of family planning through contraception. Furthermore, it has been well documented that women in developed worlds who are provided with the means to control their fertility are more empowered and their families are healthier.
While our situation in the US is significantly better compared to underdeveloped nations where rape and the cultural devaluing of women is commonplace, we still have a responsibility to uphold – a responsibility that would undoubtedly increase the quality of life for women (and men), as well as contribute to the overall health of the human population. Why would we want to go backwards and remove the ability of a woman to decide when, if ever, she would like to reproduce?
Having access to birth control empowers women and allows them to make greater contributions to society. And because contraception is primarily the responsibility of a woman, our society needs to ensure that birth control, reproductive education, and family planning resources are readily available to EVERYONE.
The United Nations predicts that the ten-billionth person will be born around 2050. Will we continue to fight this ridiculous fight against women’s rights or will we redirect our collective energy to developing technologies that will help our species and planet better cope with the increasing demands associated with a steadily rising population? Let’s stop allowing stupidity to prevail and let’s start doing the right thing: making sure that birth control is readily available to any woman who wishes to use it. Because, now more than ever, it is clear that birth control will save the world.
Note: In my readings for this article, I came across a wonderful resource for anyone interested in learning more about human fertility and population growth. Through the wonders of the internet, Academic Earth is offering a free (!) online course called Global Population Growth, given by Yale University professor Robert Wyman.
These views are the opinion of the author and do not necessarily either reflect or disagree with those of the DXS editorial team.
[Today's post first appeared at Dr. Kristina Killgrove's blog, Powered by Osteons. Kristina is a bioarchaeologist who studies the skeletons of ancient Romans to learn more about how they lived. Her biography at her blog begins, "When your life's passion is to study dead Romans, you often get asked for your 'origin story,' something that explains a long, abiding and, frankly, slightly creepy love for skeletons." Now that you undoubtedly want to know more, read the rest of her bio here, and then read below to learn why childbirth is so difficult and what the archaeological record has to tell us about outcomes for mother and child in the ancient world. For more about Kristina and her work, you can see her academic Website at Killgrove.org and find out about her latest research project at RomanDNAProject.org. You can also find her at herG+ page and on Twitter as @BoneGirlPhD.]
Basically since we started walking upright, childbirth has been difficult for women. Evolution selected for larger and larger brains in our hominin ancestors such that today our newborns have heads roughly 102% the size of the mother’s pelvic inlet width (Rosenberg 1992).
Yes, you read that right. Our babies’ heads are actually two percent larger than our skeletal anatomy.
Obviously, we’ve also evolved ways to get those babies out. Biologically, towards the end of pregnancy, a hormone is released that weakens the cartilage of the pelvic joints, allowing the bones to spread; and the fetus itself goes through a complicated movement to make its way down the pelvic canal, with its skull bones eventually sliding around and overlapping to get through the pelvis. Culturally, we have another way to deliver these large babies: the so-calledcaesarean section.
Up until the 20th century, childbirth was dangerous. Even today, in some less developed countries, roughly 1 maternal death occurs for every 100 live births, most of those related to obstructed labor or hemorrhage (WHO Fact Sheet 2010). If we project these figures back into the past, millions of women must have died during or just after childbirth over the last several millennia. You would think, then, that the discovery of childbirth-related burial – that is, of a woman with a fetal skeleton within her pelvis – would be common in the archaeological record. It’s not.
Archaeological Evidence of Death in Childbirth
Two recent articles in the International Journal of Osteoarchaeology start the exact same way, by explaining that “despite this general acceptance of the vulnerability of young females in the past, there are very few cases of pregnant woman (sic) reported from archaeological contexts” (Willis & Oxenham, In Press) and ”archaeological evidence for such causes of death is scarce and therefore unlikely to reflect the high incidence of mortality during and after labour” (Cruz & Codinha 2010:491).
The examples of burials of pregnant women that tend to get cited include two from Britain (both published in the 1970s), four from Scandinavia (published in the 1970s and 1980s), three from North America (published in the 1980s), one from Australia (1980s), one from Israel (1990s), six from Spain (1990s and 2000s), one from Portugal (2010), and one from Vietnam (2011) (most of these are cited in Willis & Oxenham). Additionally, I found some unpublished reports: a skeleton from Egypt, a body from the Yorkshire Wolds in England, and a skeleton from England.
The images of these burials are impressive: even more than child skeletons, these tableaux are pathos-triggering, they’re snapshots of two lives cut short because of an evolutionary trade-off.
The wide range of dates and geographical areas illustrated in the slideshow demonstrates quite clearly that death of the mother-fetus dyad is a biological consequence of being human. But what we have from archaeological excavations is still fewer than two dozen examples of possible childbirth-related deaths from allof human history.
Where are all the mother-fetus burials?
As with any bioarchaeological question, there are a number of reasons that we may or may not find evidence of practices we know to have existed in the past. Some key issues at play in recovering evidence of death in childbirth include:
Archaeological Theory and Methodology. From the dates of discovery of maternal-fetal death cited above, it’s obvious that these examples weren’t discovered until the 1970s. Why the 70s? It could be that the rise of feminist archaeology focused new attention on the graves of females, with archaeologists realizing the possibility that they would find maternal-fetal burials. Or it could be that the methods employed got better around this time: archaeologists began to sift dirt with smaller mesh screens and float it for small particles like seeds and fetal bones.
Death at Different Times. Although some women surely perished in the middle of childbirth, along with a fetus that was obstructed, in many cases delivery likely occurred, after which the mother, fetus, or both died. In modern medical literature, there are direct maternal deaths (complications of pregnancy, delivery, or recovery) and indirect maternal deaths (pregnancy-related death of a woman with preexisting or newly arisen health problems) recorded up to about 42 days postpartum. An infection related to delivery or severe postpartum hemorraging could easily have killed a woman in antiquity, leaving a viable newborn. Similarly, newborns can develop infections and other conditions once outside the womb, and infant mortality was high in preindustrial societies. With a difference between the time of death of the mother and child, a bioarchaeologist can’t say for sure that these deaths were related to childbirth. Even finding a female skeleton with a fetal skeleton inside it is not always a clear example, as there are forensic cases of coffin birth or postmortem fetal extrusion, when the non-viable fetus is spontaneously delivered after the death of the mother.
Cultural Practices. Another condition of being human is the ability to modify and mediate our biology through culture. So the final possibility for the lack of mother-fetus burials is a specific society’s cultural practices in terms of childbirth and burial. In the case of complicated childbirth (called dystocia in the medical literature), this is done through caesarean section (or C-section), a surgical procedure that dates back at least to the origins of ancient Rome.
Cultural Interventions in Childbirth
It’s often assumed that the term caesarean/cesarean section comes from the manner of birth ofJulius Caesar, but it seems that the Roman author Pliny may have just made this up. The written record of the surgical practice originated as the Lex Regia (royal law) with the second king of Rome, Numa Pompilius (c. 700 BC), and was renamed the Lex Caesarea (imperial law) during the Empire. The law is passed down through Justinian’s Digest (11.8.2) and reads:
Negat lex regia mulierem, quae praegnas mortua sit, humari, antequam partus ei excidatur: qui contra fecerit, spem animantis cum gravida peremisse videtur.
The royal law forbids burying a woman who died pregnant until her offspring has been excised from her; anyone who does otherwise is seen to have killed the hope of the offspring with the pregnant woman. [Translation mine]
Example of Roman gynaecological equipment: speculum From the House of the Surgeon, Pompeii (1st c AD) Photo credit: UVa Health Sciences Library
There’s discussion as to whether this law was instituted for religious reasons or for the more practical reason of increasing the population of tax-paying citizens. In spite of this law, though, there isn’t much historical evidence of people being born by C-section. Many articles claim the earliest attested C-section as having produced Gorgias, an orator from Sicily, in 508 BC (e.g., Boley 1991), but Gorgias wasn’t actually born until 485 BC and I couldn’t find a confirmatory source for this claim. Pliny, however, noted that Scipio Africanus, a celebrated Roman general in the Second Punic War, was born by C-section (Historia Naturalis VII.7); if this fact is correct, the earliest confirmation that the surgery could produce viable offspring dates to 236 BC.
This practice in the Roman world is not the same as our contemporary idea of C-section. That is, the mother was not expected to survive and, in fact, most of the C-sections in Roman times were likely carried out following the death of the mother. Until about the 1500s, when the French physician François Rousset broke with tradition and advocated performing C-sections on living women, the procedure was performed only as a last-ditch effort to save the neonate. Some women definitely survived C-sections from the 16th to 19th centuries, but it was still a risky procedure that could easily lead to complications like endometritis or other infection. Following advances in antibiotics around 1940, though, C-sections became more common because, most importantly, they were much more survivable.
Caesarean Sections and Roman Burials
Roman relief showing a birthing scene Tomb of a Midwife (Tomb 100), Isola Sacra Photo credit: magistrahf on Flickr
In spite of the Romans’ passion for recordkeeping, there’s very little evidence of C-sections. It’s unclear how religiously the Lex Regia/Caesarea was followed in Roman times, which means it’s unclear how often the practice of C-section occurred. Would all women have been subject to these laws? Just the elite or just citizens? How often did the section result in a viable newborn? Who performed the surgery? It probably wasn’t a physician (since men didn’t generally attend births), but a midwife wouldn’t have been trained to do it either (Turfa 1994).
Whereas we can supplement the historical record with bioarchaeological evidence to understand Romans’ knowledge of anatomy, their consumption of lead sugar, or the practice of crucifixion, this isn’t possible with C-sections – the surgery is done in soft tissue only, meaning we’d have to find a mummy to get conclusive evidence of an ancient C-section.
We can make the hypothesis, though, that because of the Lex Regia/Caesarea, we should findno evidence in the Roman world of a woman buried with a fetus still inside her. This hypothesis, though, is quickly negated by two reported cases – one from Kent in the Romano-British period and one from Jerusalem in the 4th century AD. The burial from Kent hasn’t been published, although there is a photograph in the slide show above.
Interestingly, the Jerusalem find was studied and reported by Joe Zias, who also analyzed theonly known case of crucifixion to date. Zias and colleagues report on the find in Nature(1993) and in an edited volume (1995), but their primary goal was to disseminate information about the presence of cannabis in the tomb (and its supposed role in facilitating childbirth), so there’s no picture and the information about the skeletons is severely lacking:
We found the skeletal remains of a girl (sic) aged about 14 at death in an undisturbed family burial tomb in Beit Shemesh, near Jerusalem. Three bronze coins found in the tomb dating to AD 315-392 indicate that the tomb was in use during the fourth century AD. We found the skeletal remains of a full-term (40-week) fetus in the pelvic area of the girl, who was lying on her back in an extended position, apparently in the last stages of pregnancy or giving birth at the time of her death… It seems likely that the immature pelvic structure through which the full-term fetus was required to pass was the cause of death in this case, due to rupture of the cervix and eventual haemorrhage (Zias et al. 1993:215).
Both Roman-era examples involve young women, and it is quite interesting that they were already fertile. Age at menarche in the Roman world depended on health, which in turn depended on status, but it’s generally accepted that menarche happened around 14-15 years old and that fertility lagged behind until 16-17, meaning for the majority of the Roman female population, first birth would not occur until at least 17-19 years of age (Hopkins 1965, Amundsen & Diers 1969). These numbers have led demographers like Tim Parkin (1992:104-5) to note that pregnancy was likely not a major contributor to premature death among Roman women. But the female pelvis doesn’t reach skeletal maturity until the late teens or early 20s, so complications from the incompatibility in pelvis size versus fetal head size are not uncommon in teen pregnancies, even today (Gilbert et al. 2004).
More interesting than the young age at parturition is the fact that both of these young women were likely buried with their fetuses still inside them, in direct violation of the Lex Caesarea. So it remains unclear whether this law was ever prosecuted, or if the application of the law varied based on location (these young women were both from the provinces), social status (both young women were likely higher status), or time period. Why wasn’t medical intervention, namely C-section, attempted on these young women? It’s possible that further context clues from the cemeteries and associated settlements could give us more information about medical practices in these specific locales, but neither the Zias articles nor the Kent report make this information available.
Childbirth – Biological or Cultural?
Childbirth is both a biological and a cultural process. While biological variation is consistent across all human populations, the cultural processes that can facilitate childbirth are quite varied. The evidence that bioarchaeologists use to reconstruct childbirth in the past includes skeletons of mothers and their fetuses; historical records of births, deaths, and interventions; artifacts that facilitate delivery; and context clues from burials. The brief case study of death in childbirth in the Roman world further shows that history alone is insufficient to understand the process of childbirth, the complications inherent in it, and the form of burial that results. In order to develop a better understanding of childbirth through time, it’s imperative that archaeologists pay close attention when excavating graves, meticulously document their findings, and publish any evidence of death in childbirth.
D.W. Amundsen, & C.J. Diers (1969). The age of menarche in Classical Greece and Rome. Human Biology, 41 (1), 125-132. PMID: 4891546.
J.P. Boley (1991). The history of caesarean section. Canadian Medical Association Journal, 145 (4), 319-322. [PDF]
S. Crawford (2007). Companions, co-incidences or chattels? Children in the early Anglo-Saxon multiple burial ritual. In Children, Childhood & Society, S. Crawford and G. Shepherd, eds. BAR International Series 1696, Chapter 8. [PDF]
C. Cruz, & S. Codinha (2010). Death of mother and child due to dystocia in 19th century Portugal. International Journal of Osteoarchaeology, 20, 491-496. DOI: 10.1002/oa.1069.
W. Gilbert, D. Jandial, N. Field, P. Bigelow, & B. Danielsen (2004). Birth outcomes in teenage pregnancies. Journal of Maternal-Fetal and Neonatal Medicine, 16 (5), 265-270. DOI:10.1080/14767050400018064.
K. Hopkins (1965). The age of Roman girls at marriage. Population Studies, 18 (3), 309-327. DOI: 10.2307/2173291.
E. Lasso, M. Santos, A. Rico, J.V. Pachar, & J. Lucena (2009). Postmortem fetal extrusion. Cuadernos de Medicina Forense, 15 (55), 77-81. [HTML - Warning:Graphic images!]
T. Parkin (1992). Demography and Roman society. Baltimore: Johns Hopkins University Press.
K. Rosenberg (1992). The evolution of modern human childbirth. American Journal of Physical Anthropology, 35 (S15), 89-124. DOI: 10.1002/ajpa.1330350605. J.M. Turfa (1994). Anatomical votives and Italian medical traditions. In: Murlo and the Etruscans, edited by R.D. DePuma and J.P. Small. University of Wisconsin Press.
C. Wells (1975). Ancient obstetric hazards and female mortality. Bulletin of the New York Academy of Medicine, 51 (11), 1235-49. PMID: 1101997.
A. Willis, & M. Oxenham (In press). A Case of Maternal and Perinatal Death in Neolithic Southern Vietnam, c. 2100-1050 BCE. International Journal of Osteoarchaeology, 1-9. DOI:10.1002/oa.1296.
J. Zias, H. Stark, J. Seligman, R. Levy, E. Werker, A. Breuer & R. Mechoulam (1993). Early medical use of cannabis. Nature, 363 (6426), 215-215. DOI: 10.1038/363215a0.
J. Zias (1995). Cannabis sativa (hashish) as an effective medication in antiquity: the anthropological evidence. In: S. Campbell & A. Green, eds., The Archaeology of Death in the Ancient Near East, pp. 232-234.
Note: Thanks to Marta Sobur for helping me gain access to the Zias 1995 article, and thanks toSarah Bond for helping me track down the Justinian reference.