In the spirit of the EST/Sloan Project’s commitment to “challenge and broaden the public’s understanding of science and technology and their impact in our lives,” we offer this essay on some of the scientific and historical background to BUMP by Chiara Atik, the current EST/Sloan mainstage production. BUMP begins previews on May 9 and runs through June 3. You can purchase tickets here.
Background essay by Rich Kelley
Apes and chimpanzees give birth in one to two hours. Human moms average ten to twenty. Why does our labor take so long?
Blame our large brains. And our preference for walking upright. We are the only mammal to walk on two legs. That comes at some cost. In 1960, physical anthropologist Sherwood Washburn identified “the obstetrical dilemma.” Evolution, it seems, sometimes involves tradeoffs. Some seven million years ago, walking upright offered our ancestors an advantage. Our arms could reach higher branches, our hands became free to carry food and to make tools. Walking on two legs uses less energy to cross long stretches of grassland. And we could run.
Diagram relates the size of the maternal pelvic inlet (outline) and the size of the neonatal head (dark circles) in selected primate species
But to walk upright our pelvis needed to change its size, shape and positioning. And this changed how human females gave birth. Non-human primates have pelvises and birth canals that resemble a ring or a hoop. The primate infant’s head is usually smaller than the birth canal, which is positioned forward on the body. This makes birthing simpler. Delivery can take one to two hours and the baby emerges face up, guided out by the hands of the mothers to immediately begin nursing. Primate mothers can manage this by themselves and usually give birth away from others, in seclusion.
Midwife's view of the birth canal in a chimpanzee (P. troglodytes), A. afarensis (A.L. 288–1, ‘Lucy’) and a modern human female. Note the necessary rotation of the head in the human female.
Our human pelvis has to solve a tricky problem. For us to walk it needs to be narrow; but our brains are large and the female pelvis needs to be able to deliver the newborn’s head. As Tina Cassidy describes it in Birth: The Surprising History of How We Are Born:
“Today, the upper opening of the pelvis is wide from side to side . . . the lower pelvis, however, the baby’s exit, is widest from front to back. And therein lies the problem . . . human birth is, quite literally, a twisted process. In order to pass through the birth canal, the baby’s head—the largest part of its body—must rotate as it descends in a grinding pirouette. . . . Assuming the baby is not breech—being born feet or buttocks first—its head must enter the pelvis facing up toward the pubic bone, with the widest part of the head—ear to ear—lining up with the widest part of the pelvis—hip to hip. But that has to change quickly. The baby must begin to turn sideways, as much as forty-five to ninety degrees, in order to align its body with the widest pelvis outlet, its head emerging face down rather than face up.”
Sequential changes in the position of the child during labor.
But why is labor so painful? The chimpanzee brain is about one-third the size of the human brain. Because of the human infant’s large head, the cervix of the human female must dilate three times as much as other primates. Chimpanzee mothers dilate 3.3 centimeters before delivery. Human mothers must dilate 10 centimeters, which takes more time, and is significantly more painful. According to the Mayo Clinic, mothers describe the last three centimeters as being the most painful part of giving birth.
Because of the difficulties of human delivery—and the care the child needs during its second nine months—anthropologists Karen Rosenberg and Wenda Trevathan have argued that “assisted childbirth” is probably as old as bipedalism:
“Because the human fetus emerges from the birth canal facing in the opposite direction from its mother, it is difficult for the mother, whatever her position, to reach down, as non-human primate mothers often do, to clear a breathing passage for the infant or to remove the umbilical cord from around its neck. If a human mother tries to assist in delivery by guiding the infant from the birth canal, she risks pulling it against the body’s angle of flexion, possibly damaging the infant’s spinal cord, brachial nerves, and muscles.”
In a survey of 296 cultural groups, Rosenerg and Trevathan found that “assisted birth comes close to being universal.”
For most of human history, those assisting at births were exclusively women. Until about a hundred years ago, delivery occurred in the home, in the bedroom or around the hearth. In Europe and early America, these attendants were called “God’s siblings,” later shortened to “gossip,” their chatter the basis for the word’s current meaning. After a successful birth, the gossips would organize “a groaning party,” a feast for midwife, mother and the assembled women, its name recalling the sounds of labor. Men penetrated the birthing sanctum at their peril. In 1522, a German physician, Dr. Wert, eager to learn more directly about the birthing process, disguised himself as a woman to try to enter a delivery room. He was discovered and reportedly burnt at the stake.
A Midwife’s Tale: Martha Ballard
Martha Ballard, a midwife in colonial Maine, kept a detailed daily account of her activities from 1785 until a few months before her death in 1812. Over those twenty-seven years she delivered 814 babies. Her mortality rate (excluding stillbirths) was 2.5 per 100—very impressive for that time. Being a midwife then involved canoeing down rivers and trudging through snow, sometimes delivering two or more babies within twenty-four hours in houses miles apart.
A page from Martha Ballard's diary, February 3 - 12, 1800.
Laura Ulrich Thacher notes, in her Pulitzer Prize-winning biography of Ballard, “In Martha’s diary, it is doctors, not midwives, who seem marginal.” One poignant entry records Ballard’s reaction when a new young doctor does not defer to her years of experience but rather “chooses” to participate himself in the birthing. From ancient times, male physicians were usually called in only for emergencies, when the life of the child or the mother was at risk, hence the adage, “When a man comes, one or both must necessarily die.” In those instances, the life of the mother was paramount. From the Hippocratic Writings we learn that the earliest medical tools related to childbirth were not tools to ease delivery but rather tools for the extraction of the dead fetus. Caesarian sections in ancient times were mostly performed so that the child and mother could be buried separately. The first record of a mother surviving a C-section was not until the 1580s in Switzerland (her husband, a professional pig gelder, performed the operation).
Forceps: A Family Secret
Peter Chamberlen the Third
When obstetrical forceps first appeared in seventeenth-century Europe, only members of the all-male barber-surgeon guild could legally use them. The invention is credited to Peter Chamberlen the elder, a French inventor and surgeon. He and his surgeon brother gained fame for delivering babies in difficult cases because of their use of a secret instrument. For 150 years, through several generations of man-midwives, the Chamberlen family kept secret exactly how that instrument worked. Due to etiquette, man-midwives had to operate within severe constraints. A large sheet covered the expectant mother, one end wrapped around her, the other tied around the man’s neck. Without looking beneath the sheet, the man-midwife was expected to deliver the baby by feel.
The Chamberlen forceps
The Chamberlens had a knack for theater. Two men would lug a large elegantly carved lined box into the delivery room. They then cleared the room and blindfolded the mother before slipping their device under the sheet. During its use, they would clang bells, hammers, and chains to cause further misdirection. It wasn’t until 1813 when some of Peter Chamberlen’s tools were discovered in an attic of a house that the ingenuity of his invention became clear. His forceps used hinged blades that allowed each to be positioned independently around the head of the infant, something not possible with tweezers.
In the 1950s, Swedish professor Tage Malmstrom developed the ventouse, or Malmstrom extractor. In its current version this device involves placing a suction cup onto the head of the baby. The doctor uses a handheld pump to gently apply suction and the suction draws the skin from the scalp into the cup. Handles on the device enable the doctor to pull the baby out. Over the last few decades, caesarean section and vacuum extractors have replaced forceps as the preferred means of delivery. Since 1985, the World Health Organization has maintained that the ideal rate of caesarean sections is between 10% and 15% of live births. Beyond 10% there is no added improvement in the maternal or newborn mortality rate. Yet from 1996 to 2014, the rate of caesarean sections of all births in the U.S. has risen 55%, from 21% in 1996 to 32.5% in 2014. A recent study by the British Medical Journal found that “C-section rates were lower among poorer women and increased with rising economic status.” High caesarean rates can result in negative outcomes: infection, hemorrhages, and surgical complications.
The Odon Device: Inspired by YouTube
In 2005, Jorge Odon, an Argentinian garage mechanic, bet a friend he could extract a cork from an empty wine bottle without breaking it. He won the bet thanks to a YouTube video he had seen that showed how to do this by inflating a plastic bag inside the bottle until it gripped the cork and then pulling both out. Odon then had the inspiration that this same technique could be used to deliver babies in distress. Having already patented several auto-related inventions, he set to work to realize his idea using a glass jar for the womb, one of his daughter’s dolls for the baby, and a fabric bag and sleeve sewn by his wife as the extraction device. Successful demonstrations to local obstetricians (always starting with the cork and bottle trick) led to consultations with doctors at CEMIC, the Center for Medical Education and Clinical Research in Buenos Aires. At first they thought he was pranking them, but eventually they responded positively and even recommended changes: doing away with the bag that surrounded the baby’s body and just having one bag to surround the baby’s head.
Jorge Odon demonstrating his device
Odon’s big breakthrough came in 2008 when he was granted ten minutes at a conference in Argentina to present his device to Dr. Mario Merialdi, director of Reproductive Health at the World Health Organization. Merialdi deemed the device “fantastic.” Their ten minute meeting stretched to two hours and led to both traveling that December to the birth simulation center at Des Moines University in Iowa for a successful series of tests. The WHO then agreed to conduct a series of hospital-based tests of the device in three phases in Argentina and South Africa. In 2013, Becton Dickinson and Company (BD) licensed the development rights of the Odon device and developed a new prototype based on their pre-clinical studies. The Odon Device now consists of two main components: a plastic sleeve and an inserter. The sleeve contains an air chamber that is inflated around the fetal head by a manually operated bulb pump. Once the sleeve has surrounded the baby’s head, air is hand pumped into the inner surface of the sleeve until the sleeve has a secure grasp of head. The inserter is then removed and the baby is pulled out. The simplicity and low cost of the device make it potentially revolutionary in reducing mortality in instances of prolonged labor in low-resource settings. Caesarean sections, by contrast, require expensive surgical theaters.
The sequences of an Odon Device extraction
In 2017, the WHO and BD conducted the third phase of testing. They prioritized three criteria: safe for mothers and babies, easy for different cadres of skilled birth attendants to use, cost-effective, and affordable in low resource settings. In March 2018, they announced the results of the latest round of tests. The Odon device was inserted successfully in 46 of 49 women (93%), and successful delivery with expulsion of the fetal head after one-time application of the Odon device was achieved in 35 women (71%). The report concludes: “Delivery using the Odon device is therefore considered to be feasible.” BD will next pursue a randomized pivotal clinical trial before potential introduction in clinical practice.
Gadding online
In her diary Martha Ballard identifies herself as a “gadder,” that is, someone who frequently visits neighbors to chat and exchange news, recipes, plant medicines, and stories. Today, what gadding goes on among mothers is more likely to happen online via message boards, forums, parenting networks, blogs, and Facebook, Yahoo, Google and Meetup groups. Many of these groups are centered around a physical community so that they can help a new mom find local resources, whether a Nanny, a doula, an OB/GYN or a great deal on strollers. The Bump, one of the largest and oldest (now ten years) online communities for new and expecting mothers, reports that 80% of working mothers use message boards or forums, with 75% naming them as one of the top two most valued resources for information, second only to talking to mothers face to face.
You can read more about BUMP and the brilliant playwright who wrote it in our interview with Chiara Atik.
The views expressed in this essay are solely those of the author. The Alfred P. Sloan Foundation funded BUMP in part because of the compelling nature of one of the stories that inspired it: Jorge Odon's invention of the Odon Device. Its support for the play should not be construed as endorsing the device or any of the products or services mentioned in the play or in this essay.