Birth


A Tale of Moths and Mothers – Is Vaginal Birth an Evolutionary Advantage or an Outmoded Natural Function?


Janette C Allotey Midwifery Lecturer, Department of Nursing, Midwifery and Social Work, University of Manchester


Abstract


Since the mid-20th century, the efficiency and utility of Caesarean section (CS) in England and Wales has evolved immensely. While there is clearly a case for performing major abdominal surgery in extenuating circumstances, there is also the suggestion that ease of access may be leading towards over-use and, as a consequence, negative gain. The decision to perform a CS is based on obstetric clinical judgment and, while all practitioners share a genuine concern for childbearing women, a polemic has emerged. This involves some obstetricians and midwives wishing to curb Caesarean births, while others attempt to normalise them to the point of promoting ‘natural, woman-centred caesarean sections’. This article offers an additional dimension to the Caesarean debate, adopting a slightly controversial evolutionary perspective. The paper begins with a brief overview of the history of CS and then ponders possible long-term implications from an evolutionary perspective, re-visiting the challenging obstetric hypothesis that increasing CS rates, if taken to the extreme, could potentially strengthen the future human gene pool. It then ponders whether this could equally weaken it and argues for more medical and midwifery support to be channelled into promoting the benefits of normal birth to the public.


Keywords History, obstetrics, Caesarean section rates, human reproductive evolution


Disclosure: The author has no conflicts of interest to declare. Acknowledgements: The author would like to thank Catherine Ebenezer for providing bibliographical and editorial assistance. Received: 21 March 2012 Accepted: 27 March 2012 Citation: European Obstetrics & Gynaecology, 2012;7(Suppl. 1):7–12 Correspondence: Janette C Allotey, Department of Nursing, Midwifery and Social Work, University of Manchester, Jean MacFarlane Building, University Place, Oxford Road, Manchester, M16 9PL, UK. E: janette.allotey@manchester.ac.uk


In the 20th century, assisted by a vast array of rapid parallel developments in science, medicine, surgery, neonatology, pharmacology and biotechnology, and further supported since 1948 by a system of free maternity services, rates of Caesarean section (CS) in England and Wales have escalated. As late as 1957, the percentage of CSs for all births was as low as 2.4 %.1


By 1970, the national average


rate was estimated to be 4.9 % and by 1980 9 %, while by 1998 it had risen to 18.2 % in England.2


In 2011, the CS rate had reached a national


average of around 25 %, varying significantly between NHS hospitals and between elective and emergency settings.3


In a consumer-oriented, litigious society, where CS has become the norm for around one in four birthing women, a polemic has emerged among the midwifery and medical professions, with protagonists debating the desirability of normal birth versus the normalisation of Caesarean birth – both groups claiming to provide what informed women want.4


that increasing the CS rate could potentially strengthen the human gene pool,6


Brief History of the Caesarean Section Early Attempts


In Greek medicine, obstructed labour was not clearly identified or articulated as a concept, and delay in labour and death of the foetus in utero was often simply attributed to its being a ‘weak and sickly’ infant unable to force its own way out into the world.7


Before the


While there is clearly a case for performing major abdominal surgery in extenuating circumstances, it is also possible that it may now have reached or passed its optimal rate of efficiency, so that the effects of a more extensive use of CS on women and on society will become less significantly advantageous.5


This article


briefly explores the history of CS from around 1500 until the present time, then turns to examine the procedure from an evolutionary perspective, considering some of the possible long-term implications of the increased use of CS. Finally, whereas it has been suggested


© TOUCH BRIEFINGS 2012


relatively recent success of CS on a live woman, it was rarely carried out for foetal reasons, a possible exception being to deliver a future heir or nobleman from its dying mother. Some of the first operations were performed in extremis, when all else had failed and there was nothing to lose, as the mother was almost certainly by then consigned to an untimely death. On rare occasions, a post-mortem Caesarean operation was reported to have retrieved an offspring from its dying or recently deceased mother. While a faint hope of saving the child might justify the operation, it was also seen to provide a brief opportunity for emergency baptism before the infant died, and allowed mother and infant to be physically separated before their burial.


During the early modern period in England and Wales, before forceps were in common use, internal podalic version was used to attempt to remove the foetus, legs first, from the uterus. This often proved difficult,


7


this article ponders the alternative possibility that it could serve to weaken it or lead to an evolutionary ‘dead end’.


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