Do we need midwives?
First published in Great Britain by Pinter & Martin Ltd 2015
© 2015 Michel Odent
Michel Odent has asserted his moral right to be identified as the author of this work in accordance with the Copyright, Designs and Patents Act of 1988.
All rights reserved.
ISBN 978-1-78066-220-6
British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from the British Library.
This book is sold subject to the condition that it shall not, by way of trade and otherwise, be lent, resold, hired out, or otherwise circulated without the publisher’s prior consent in any form or binding or cover other than that in which it is published and without a similar condition being imposed on the subsequent purchaser.
Set in Minion Printed and bound in the UK by Ashford Colour Press Ltd, Gosport, Hampshire
This book has been printed on paper that is sourced and harvested from sustainable forests and is FSC accredited.
Pinter & Martin Ltd 6 Effra Parade London SW2 1PS www.pinterandmartin.com
1 A ludicrous question
2 A sensible question
Pre-midwifery societies
Biased knowledge
The specifically human handicap
3 A useless question
Towards a new understanding of normality
Preliminary signs of a new normality
Pre-labour versus in-labour caesareans
What if…?
4 primalhealthresearch.com versus NIH
From knowledge to awareness
A useful tool
Concordant results
Genesis of non-communicable diseases
Enlarging our horizon
Limits to primal health research
5 The driving force
Epigenetics
Informational substances and their receptors
Evolutionary biology
Twenty-first-century bacteriology
6 Bridges between scientific perspectives
Autism
Obesity
Interdisciplinarity
7 Meanwhile
Timing of the operation
Immediate skin-to-skin contact
Entering the world of microbes
Ironies
8 Homo Ludens from a primal health research perspective
From Plato to Kerstin Uvnäs Moberg
The primal health research perspective
9 At the edge of the precipice
A twentieth-century scientific discovery
Immediate practical implications
A transitory phase of our history?
10 The gaps between science and tradition
Countless examples
An unexpected way to learn about the crucial divergence
Another basic physiological concept
The still dominant paradigm
11 In pain thou shalt bring forth children
12 Will the symbiotic revolution take place?
‘Symbiosis’ as the antithesis of ‘Domination’
Reinventing Fire... and Birth
Flirting with utopia
13 What is the sex of angels?
Lesson from an analogy
After the paradigm shift
Addendum (To be read after July 2030): Can humanity survive medicine?
A premature question
Neutralised laws of natural selection
A vicious circle
Genetically modified human beings
Different orders of magnitude
References
Index
Special thanks to Liliana Lammers
She gave the title of this book… then I wrote the text.
Midwifery is among the oldest professions. It is one of the characteristics that set our species apart from other mammals: human females routinely seek assistance when they give birth. This is well known among primatologists, as well as in anthropological and medical circles. The specifically human mechanical difficulties are the bases for all sorts of interpretations. Countless articles and textbooks have reproduced the classical drawings by Adolph Schultz.1,2,3 These drawings show the size of the neonatal skull in relation to the maternal pelvic outlet among spider monkeys, proboscis monkeys, macaques, gibbons, orang-utans, gorillas, common chimpanzees and Homo sapiens.
The well-accepted conclusions of the evolutionary perspective are easy to summarise: the socialisation of birth is an adaptation to mechanical difficulties. This is, in part, a result of the fact that the human infant emerges from the birth canal facing the opposite direction from the mother, hindering her ability to assist in its delivery. The presence of another individual who can receive the infant during delivery is, therefore, quasi-necessary. It is claimed that, as bipedalism evolved, natural selection favoured the behaviour of seeking assistance during birth. Seeking companionship was driven by fear, anxiety, pain and desire to conform to behavioural norms. It is also commonplace to claim that the evolutionary process has resulted in heightened emotional needs during labour, which leads women to seek companionship at this time: this suggests that the desire for supportive, familiar people at birth is deeply rooted in human evolutionary history.
The interpretations offered by comparative anatomy are supported by anthropological studies. It would take volumes to review all the perinatal beliefs and rituals reported in a great variety of cultures. As early as 1884, Labor Among Primitive Peoples, by George Engelmann, provided an impressive catalogue of beliefs and rituals occurring in hundreds of ethnic groups on all continents.4 It seems acceptable to conclude from such studies that the socialisation of childbirth is universal.
The academic perspective is in perfect agreement with our cultural conditioning: we believe that a woman does not have the power to give birth by herself. Looking at the roots of the words is a way to illustrate our deep-rooted way of thinking. For example, the origin of the word obstetrics is ‘obstetrix’ (‘midwife’ in Latin), which literally means ‘the woman staying in front of ’ (from the verb ‘obstare’). It implies that when a woman is giving birth somebody must be in front of her. Looking at how we talk about childbirth in daily conversations is another way to illustrate the dominant way of thinking. If we ask a young mother who delivered her baby, we are not expecting the answer: ‘I gave birth’.
Vocabulary that emerged during the second half of the twentieth century has reinforced our cultural conditioning. Among groups promoting ‘natural childbirth’ certain terms became popular. A ‘coach’ is a guide bringing her (his) expertise. The need for ‘emotional support’ implies that to give birth a woman needs some energy brought by somebody else. In the medical literature the term ‘labour management’ is widely used. The terms ‘coaching’ and ‘managing’ express the same way of thinking.
Since there is a perfect agreement between academics, tradition and contemporary culture, it is obviously ludicrous to raise a question such as: ‘Do we need midwives?’
Will our question remain ludicrous after looking critically at these two common assumptions? We’ll first ask whether the active participation of a birth attendant is really a universal human characteristic. Then we’ll consider whether morphological and mechanical factors are really the main reasons for difficult births in our species.
When studying inherent human nature, we should always take into account the spectacular turning point in the history of mankind that started about 10,000 years ago. Before that time human beings took advantage of what nature could offer, obtaining their food from wild plants and animals. An increased level of social tolerance was an evolutionary advantage. It is notable that Homo sapiens gradually developed characteristics suggestive of a process of ‘self-domestication’, such as facial diminution (a decrease in size and prominence of the facial features). Then, suddenly, our ancestors began to domesticate plants and animals in places as diverse and as far apart from each other as the Tigris and Euphrates valleys in the Middle East, South Asia, Central Asia, and Central America. The advent of agriculture and animal husbandry – the Neolithic revolution – radically changed the dominant human lifestyle. Our ancestors were obliged to be less nomadic and more sedentary. The concept of territory took on unprecedented importance, along with other reasons for conflicts between human groups. The new basic strategy for survival was to dominate nature and dominate other human groups. It became an advantage to develop the huge human potential for aggression.
It is acceptable – although simplistic – to claim that there have been two eras in the history of Homo sapiens, separated by the Neolithic revolution. Yet today even the most authoritative academics may be imprisoned by their own conditioning, which has gradually developed during the comparatively short period following this revolution. The way human babies are born offers an opportunity to illustrate this cultural blindness. Considering what has been reported about childbirth in pre-literate and pre-agricultural societies challenges the assumption that midwifery is universal, and that seeking assistance when giving birth is a human characteristic.
Pre-midwifery societies
One of the most useful written documents about childbirth in pre-literate and pre-agricultural societies is the 2008 book by Daniel Everett, Don’t Sleep, There Are Snakes.1 One of the reasons why this document is valuable is that the author – a male missionary and a linguist – originally had no personal curiosity about childbirth. He reports what he learnt about life and language among the Pirahãs, who live in the Brazilian Amazonian jungle by the Maici River. Neither the blurb presenting the book nor the numerous published endorsements mention what Everett wrote about the way Pirahã women give birth. It is only in the middle of a chapter entitled ‘Material Culture and the Absence of Rituals’ that precious information is incidentally provided. The report is authoritative, since Daniel Everett spent nearly 30 years of his life among the Pirahãs.
The Pirahãs have kept many characteristics of pre-agricultural (Paleolithic) societies. Preparing and planting fields of manioc is a new development, introduced by the American linguist Steve Sheldon, who preceded Daniel Everett in the study of the local language. The use of imported machetes is also recent.
In such a context, Daniel Everett’s account of childbirth deserves our attention. A Pirahã woman usually gives birth by herself, and there is no special place to be in labour. It depends upon the season.
In the dry season, when there are beaches along the Maici, the most common form of childbirth is for the woman to go alone, occasionally with a female relative, into the river up to her waist, then squat down and give birth, so that the baby is born directly into the river. This is cleaner and healthier, in their opinion, for the baby and the mother.
Not only is there no concept of a birth attendant, but labouring women’s use of water is described, suggesting that it may be an instinctive human behaviour. This is probably the only written document about an ethnic group where birth under water is common.
During the time Steve Sheldon spent among the Pirahãs, a woman died when giving birth. It was a breech presentation. It is significant that she was alone giving birth at the river’s edge. It is also significant that when the labouring woman’s screams were heard, Steve Sheldon wanted to go and help her. He was told not to. For the local people, who probably understand that one cannot help an involuntary process, any interference would have increased the risk of a disaster. The reflex of the visitor, on the other hand, was to do something. This is an illustration of our powerful post-Neolithic cultural conditioning. What kind of help might an American linguist have provided in this particular case, in the middle of the Amazonian jungle?
There are obvious common points between the report by Daniel Everett and what Marjorie Shostak and her husband Melvin Konner wrote about the ‘solitary and unaided births’ among the African hunters-gatherers the !Kung San, who live in the Kalahari desert in Namibia, Botswana and Angola.
A woman feels the initial stages of labour and makes no comment, leaves the village quietly when birth seems imminent, walks a few hundred yards, finds an area in the shade, clears it, arranges a soft bed of leaves, and gives birth while squatting or lying on her side – on her own.2
Having spent nearly two years with the !Kung in the early 1970s, Marjorie Shostak became intimate with some local women, particularly Nisa, who gave birth to four babies in the 1930s and 1940s, at a time when the local people were still living as their ancestors had done before them – gathering wild plant foods and hunting wild animals in their semi-arid environment.3 This is an extract of a conversation with Nisa:
I have always refused to give birth with anyone there. I have always wanted to go alone. Because, although people try to help you by holding and touching your stomach, they make it hurt more. I did not want them to kill me with any more pain. That’s why I always went by myself.
In 1978, at an ‘ethno-obstetrics’ conference in Gottingen, Germany, I had the opportunity to watch films by Wulf Schiefenhövel (from the Max Planck Institute), which he made among the Eipos, who live in the highlands of New Guinea.4 The Eipos were not perfectly representative of a pre-agricultural ethnic group, since they had gardens and pigs. However, they still had Paleolithic characteristics. Birth was not socialised and, in the films made discreetly by Wulf and his wife, women are seen giving birth in the bush, without any assistance.
One scene is highly significant. A labouring woman goes into the bush with her mother. They prepare a fern bed. Then the mother disappears, after giving her daughter a gentle pat, as if to say ‘Good luck!’ Within seconds the woman’s mother has transmitted two eloquent, non-verbal messages. The first is: ‘From now on I cannot help you’. The second is: ‘My presence might make the birth more difficult’. Soon after we see the young woman giving birth through a typical ‘fetus ejection reflex’. This means that there is no room for voluntary movements. A similar fetus ejection reflex may occur among modern women in exceptionally rare situations that are not, in general, culturally acceptable. It can occur, for example, when there is nobody around the labouring woman, apart from one experienced motherly and silent midwife keeping a low profile, just sitting in a corner and knitting. The documents presented by Wulf Schiefenhövel are unique and therefore precious because, in general, a film cannot show an authentic fetus ejection reflex: if a modern labouring woman knows that there is a camera around the fetus ejection reflex is transformed into a second stage of labour with a need for voluntary movements.
Where was the mother of the labouring woman after she had helped her daughter to prepare a fern bed in the bush? We can assume that she was not far away; invisible but aware of what was happening. She probably remained in a position to protect the space against the presence of a wandering human being or other animal. This might be the root of midwifery: a mother figure discreetly protecting the birthing place.
Biased knowledge
Our knowledge of life, including childbirth, in pre-agricultural and pre-literate societies, is limited and biased by the fact that only human groups living in-land, well above sea level, have been studied. The Pirahãs live thousands of miles uphill from the mouth of the Amazon river in the Atlantic Ocean. The Kalahari, where the !Kung San people have lived for 20,000 years, is far from the sea, and the Eipos live in the highlands of New Guinea. In general, groups of hunter-gatherers that could be studied by anthropologists live inland. This is true of the Ache, in Paraguay, or the Hiwi, who live in the savannahs of western Venezuela and eastern Colombia. When sea levels rose at the end of the last Ice Age around 10,000 years ago, we lost the chance to observe hunter-gatherer populations living close to the oceans. This bias has been reinforced by the effects of the colonisation of the American continents by Europeans. We know more about the Sioux of the Dakotas, Minnesota and Iowa, or about the Pirahãs or the Hiwi, than about those who were living close to the oceans.
Such bias is important, since a great part of humanity had probably been living by the sea. It is partly by hugging the coasts that our ancestors have colonised the whole planet. In the current scientific context, we have realised that Homo sapiens has all the physiological characteristics of a primate adapted to the coast. For example, having an enormous, highly-developed brain requires daily iodine.
Iodine is a ‘brain selective nutrient’ because of its essential role in thyroid hormone production, which in turn is needed for normal brain development. It is notable that iodine is the only nutrient for which governments legislate supplementation, so that iodination of table salt is mandatory. In spite of such widespread legislation and many public health strategies (such as dripping iodine into the water of Chinese irrigation ditches), iodine deficiency is the most common nutritional deficiency at a planetary level. It is the leading cause of preventable intellectual disabilities. It is difficult for humans to obtain sufficient iodine if their diet is lacking in seafood. These issues are particularly serious when considering the increased needs during pregnancy and lactation. Recently it was revealed that salts used in brine for pickling food – and also commercialised ‘sea salt’ – have no added iodine.
The long history of iodised salt is in itself highly significant. French chemist Jean-Baptiste Boussingault recommended iodised salt for goitre prophylaxis in the 1830s. He had demonstrated that the ‘marine smelling’ fluid from the salt deposits in the goitre-free Antioquia (South America) could reduce endemic goitre in the neighbouring regions.
There are many other human characteristics confirming our adaptation to the coast. Another one relates to the specific nutritional needs of the brain, particularly the developing brain. In simple terms, the human body is not very effective at making a molecule of fatty acid that is essential for the brain. This molecule is pre-formed and abundant in seafood, but is not found elsewhere. Let us translate that into the language of biochemists: one of the most significant characteristics of Homo sapiens is the association of an enormous, highly developed brain with a weak delta 4 enzymatic system of desaturation.5 This suggests that Homo sapiens is adapted to an environment providing pre-formed docosahexaenoic acid (DHA).
The genetic perspective is also challenging when we are looking for evidence that Homo sapiens is physiologically adapted to the seashore, since only in-land populations are easily studied. We understand how early inland migrants adapted to other environments, including life at altitude.6 For example, we understand how the Tibetan version of the gene called EPAS1 spread rapidly about 30,000 years ago as an adaptation to the lack of oxygen. We know about the genome – and even the epigenome7 – of archaic humans (including Denisovans) who were living about 40,000 years ago in the remote Denisova Cave in the Altai Mountains in Siberia. But geneticists and epigeneticists cannot provide precise data about those living along the Asian coasts at that time.
In spite of these limitations and biases to our knowledge of pre-agricultural Homo, we have sufficient information to claim that the participation of a birth attendant is not a universal human characteristic.
The specifically human handicap
We also have good reasons to challenge the assumption that mechanical factors are the main reasons for difficult births in our species. There are women with no morphological particularities who give birth quickly without any difficulty. There are anecdotes of women who give birth before realizing that they are in labour. There are countless anecdotes of teenagers who, at the end of a hidden or undiagnosed pregnancy, just go to the toilet and give birth within minutes. These facts alone suggest that the main reasons for difficult human births are not related to the shape of the body.
The best way to clarify the nature of the specifically human handicap during the period surrounding birth is to consider the case of civilised modern women who have given birth through an authentic fetus ejection reflex. It is exceptionally rare in the context of socialised birth. The birth is preceded by a very short series of irresistible, powerful and highly effective uterine contractions, without any room for voluntary movement. After an authentic fetus ejection reflex, many babies are ‘born with the caul’, which means with intact membranes.
The important point is that when the ‘fetus ejection reflex’ is initiated, women are obviously losing neo-cortical control – control by the thinking brain, the brain of the intellect, the part of the brain that is highly developed only among humans. Women may suddenly talk nonsense. They can behave in a way that usually would be considered unacceptable for a civilised woman, for example screaming, swearing, biting the midwife… They can find themselves in the most unexpected, bizarre, often mammalian, quadrupedal postures. They seem to be ‘on another planet’. A reduced neocortical control is obviously a prerequisite for an easy birth among humans. In other words, the main reason for the human handicap during such a physiological process is the inhibitory effect of an active, powerful neocortex.
It is easy to explain why the concept of fetus ejection reflex is not understood after thousands of years of socialisation of childbirth. It is precisely when birth seems to be imminent that the birth attendant has a tendency to become even more intrusive. If, for example, the labouring woman says: ‘Am I going to die?’ ‘Kill me!’ or ‘Let me die…’, instead of keeping a low profile, the well-intentioned birth attendant usually interferes, at least with reassuring, rational words. These rational words can interrupt progress towards the fetus ejection reflex. The reflex does not occur if there is a birth attendant who behaves like a coach, or an observer, or a helper, or a guide, or a ‘support person’. And it is exceptionally rare when the baby’s father participates in the birth. The fetus ejection reflex can also be inhibited by eye-to-eye contact or the imposition of a change of environment, as would happen, in our modern world, when a woman is transferred to a delivery room. It is inhibited when the intellect of the labouring woman is stimulated by any rational language, for example if the birth attendant says: ‘Now you are at complete dilation. It’s time to push.’ During an authentic reflex, the mother is in a quasi-ecstatic state and does not even realise that the baby is coming. Any interference tends to bring her back ‘down to Earth’, and tends to transform the fetus ejection reflex into a second stage of labour, which involves voluntary movements.7
The term ‘fetus ejection reflex’ was coined by Niles Newton in the 1960s, when she was studying the environmental factors that can disturb the birth process in mice.8 She had revealed the importance of cortical activity, even among non-human mammals. Twenty years later, with her support,9 I suggested that we save this concept from oblivion; I was convinced it could be a key to facilitating a radically new understanding of the specifically human difficulties during the process of parturition.10