Partly for these reasons, women continued to shun hospitals well into the modern era. Into the 1930s, fewer than half of American women gave birth in hospitals. In Britain, it was closer to one in five. Today the proportion in both countries is 99 percent. It was the rise of penicillin, not improved hygiene, that finally conquered puerperal fever.
Even now, however, there is huge variability in maternal mortality rates among countries of the developed world. In Italy, the number of women who die in childbirth is 3.9 per 100,000. Sweden is 4.6, Australia 5.1, Ireland 5.7, Canada 6.6. Britain comes only twenty-third on the list with 8.2 deaths per 100,000 live births, putting it below Hungary, Poland, and Albania. But also doing surprisingly poorly are Denmark (9.4 per 100,000) and France (10.0). Among developed nations, the United States is in a league of its own, with a maternal death rate of 16.7 per 100,000, putting it thirty-ninth among nations.
The good news is that for most women in the world childbirth has become vastly safer. In the first decade of the twenty-first century, only eight countries in the world saw their rates of childbirth deaths increase. The bad news is that the United States was one of those eight.
“Despite its lavish spending, the United States has one of the highest rates of both infant and maternal death among industrialized nations,” according to The New York Times. The average cost of childbirth in the United States is about $30,000 for a conventional birth and $50,000 for a Cesarean, about three times the cost for either in the Netherlands. Yet American women are 70 percent more likely to die in childbirth than women in Europe and about three times more likely to suffer a pregnancy-related fatality than women in Britain, Germany, Japan, or the Czech Republic. Their infants are no less at risk. One of every 233 newborn babies dies in the United States, compared with just one in 450 in France and one in 909 in Japan. Even countries like Cuba (one in 345) and Lithuania (one in 385) do much better.
The causes in America include higher rates of maternal obesity, greater use of fertility treatments (which produce more failed outcomes), and increased incidence of the rather mysterious disease known as preeclampsia. Formerly known as toxemia, preeclampsia is a condition in pregnancy that leads to high blood pressure in the mother, which can be a danger to both her and her baby. About 3.4 percent of pregnant women get it, so it is not uncommon. It is thought to result from structural deformities in the placenta, but the cause is still largely a mystery. If not headed off, preeclampsia can advance to the more serious condition of eclampsia, when a woman may experience seizures, coma, or death.
If we don’t know as much as we would like to about preeclampsia and eclampsia, it is in large part because we don’t know as much as we ought to about the placenta. The placenta has been called “the least understood organ in the human body.” For years the focus of medical research on childbirth was almost exclusively on the developing baby. The placenta was just a kind of adjunct to the process, useful and necessary but not very interesting. Only belatedly have researchers come to realize that the placenta does much more than just filter wastes and pass on oxygen. It takes an active role in the development of the child: stops toxins from passing from the mother to the fetus, kills parasites and pathogens, distributes hormones, and does everything it can to compensate for maternal deficiencies—if, say, the mother smokes or drinks or stays up too late. It is in a sense a kind of proto-mother for the developing baby. It can’t work miracles if the mother is truly deprived or neglectful, but it can make a difference.
At all events, we now know, most miscarriages and other setbacks in pregnancy are because of problems with the placenta, not the fetus. Much of this is not well understood. The placenta acts as a barrier to pathogens, but only to some. The notorious Zika virus, for instance, can cross the placental barrier and cause terrible birth defects, but the very similar dengue virus cannot cross the barrier. No one knows why the placenta stops one but not the other.
The good news is that with intelligent, targeted prenatal care, outcomes for all kinds of conditions can be greatly improved. California addressed preeclampsia and the other leading causes of maternal death in childbirth through a program called the Maternal Quality Care Collaborative, and in just six years reduced the rate of childbirth deaths from 17 per 100,000 to just 7.3 between 2006 and 2013. During the same period, alas, the national rate rose from 13.3 deaths to 22 deaths per 100,000.
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The moment of birth, the starting of a new life, really is quite a miracle. In the womb, a fetus’s lungs are filled with amniotic fluid, but with exquisite timing at the moment of birth the fluid drains away, the lungs inflate, and blood from the tiny, freshly beating heart is sent on its first circuit around the body. What had until a moment before effectively been a parasite is now on its way to becoming a fully independent, self-maintaining entity.
We don’t know what triggers birth. Something must count down the 280 days of human gestation, but no one has worked out where and what that mechanism is or what makes its alarm go off. All that is known is that the body begins to produce hormones called prostaglandins, which normally are involved in dealing with injuries to tissue but now activate the uterus, which begins a series of increasingly painful contractions to move the baby into position for birth. This first stage will go on for about twelve hours on average during a woman’s first birth but often becomes faster for subsequent births.
The problem with human childbirth is cephalopelvic disproportion. In simple terms, a baby’s head is too big for smooth passage through the birth canal, as any mother will freely attest. The average woman’s birth canal is about an inch narrower than the width of the average newborn’s head, making it the most painful inch in nature. To squeeze through this constricted space, the baby must execute an almost absurdly challenging ninety-degree turn as it proceeds through the pelvis. If ever there was an event that challenges the concept of intelligent design, it is the act of childbirth. No woman, however devout, has ever in childbirth said, “Thank you, Lord, for thinking this through for me.”
The one piece of assistance that nature gives is that the baby’s head is a bit compressible because the skull bones have not yet fused into a single plate. The reason for these contortions is that the pelvis had to undergo a number of design adjustments to make upright walking feasible, and that made human birth a much more trying and protracted business. Some species of primates can give birth in literally a couple of minutes. Human females can only dream of such ease.
We have made surprisingly little progress in making the process more bearable. As the journal Nature noted in 2016, “Women in labour have pretty much the same pain-relief options as their great grandmothers—namely gas and air, an injection of pethidine (an opioid) or an epidural anaesthetic.” According to several studies, women are not terribly good at remembering the severity of the pain of childbirth; almost certainly this is a kind of mental defense mechanism to prepare them for further births.
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