The paleo-fantasy of birth

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Homebirth midwives, doulas and childbirth educators have a problem. They are obsessed with a paleo-fantasy of birth that has nothing to do with the reality of birth. And because they base their efforts on the paleo-fantasy, instead of reality, almost all their empirical claims are flat out false.

What’s a “paleo-fantasy”? According to Professor Marlene Zuk, author of the new book Paleofantasy: What Evolution Really Tells Us About Sex, Diet and How We Live:

It is striking how fixated on the alleged behavior of our hunting-and-foraging forbearers some educated inhabitants of the developed world have become. Among the most obsessed are those who insist, as Zuk summarizes, that “our bodies and minds evolved under a particular set of circumstances, and in changing those circumstances without allowing our bodies time to evolve in response, we have wreaked the havoc that is modern life.” Not only would we be happier and healthier if we lived like “cavemen,” this philosophy dictates, but “we are good at things we had to do back in the Pleistocene … and bad at things we didn’t.”

Starting with Grantly Dick-Read, and extending to contemporary homebirth midwives, doulas and childbirth educators, natural childbirth advocates have adopted the belief that birth evolved under a particular set of circumstances and that changing the way we care for childbearing women without those women’s bodies having time to evolve in response, has wreaked havoc on women and babies.

Zuk is not writing about childbirth, but her thesis applies just as well to childbirth as to contemporary beliefs about diet.

Zuk detects an unspoken, barely formed assumption that humanity essentially stopped evolving in the Stone Age and that our bodies are “stuck” in a state that was perfectly adapted to survive in the paleolithic environment. Sometimes you hear that the intervention of “culture” has halted the process of natural selection. This, “Paleofantasy” points out, flies in the face of facts. Living things are always and continuously in the process of adapting to the changing conditions of their environment, and the emergence of lactase persistence indicates that culture (in this case, the practice of keeping livestock for meat and hides) simply becomes another one of those conditions.

In other words, hunter gathers were never “perfectly evolved,” they represented the best adaptations to conditions as they existed at that time. Conditions have changed dramatically over the past 10,000 years, which means that what was good for them, has no relevance for what is good for us. Moreover, and this is the critical point that is completely ignored by the paleofantasists, we have continued to evolve in keeping with our changing environment. For example, consider:

… “lactase persistence” (the ability in adults to digest the sugar in cow’s milk), a trait possessed by about 35 percent of the world’s population — and growing, since the gene determining it is dominant. Geneticists estimate that this ability emerged anywhere from 2200 to 20,000 years ago, but since the habit of drinking cow’s milk presumably arose after cattle were domesticated around 7000 years ago, the more recent dates are the most likely. In a similar, if nondietary, example, “Blue eyes were virtually unknown as little as 6000 to 10,000 years ago,” while now they are quite common. A lot can change in 10,000 years.

The idea that contemporary women should be attempting to emulate the births of their foremothers, ignores evolutionary science and is fairly idiotic to boot.

There was never a time that women were “perfectly designed” to give birth, because there has never been a time that any species has been perfectly evolved for anything. Every species, at every time, represents a host of compromises that, together, make that species competitive within a specific environmental niche. As soon as the environment changes, and it always changes, sometimes very rapidly, the species, while exactly the same as it was before, is suddenly no longer as competitive. That’s why most of the species of animals and plants that have ever existed are already extinct. They couldn’t change fast enough and died out as a result.

Human beings have the added advantage of technology. We can change our environment and we can change ourselves in ways that evolution would never allow. Ten thousand years ago if a woman began labor with her baby in a persistent transverse position, both she and her baby were guaranteed to die, a slow, agonizing death. Today, the mother would have a C-section and both mother and baby would survive. Ten thousand years ago, that mother and baby would have been evolutionary losers. Today they are evolutionary winners, because the currency of evolution is offspring. If your offspring survive, you win. If they die, you lose. It is just that simple.

There used to be an evolutionary advantage to being able to give birth vaginally. Now, with the advent of the C-section, there is absolutely no advantage, evolutionarily or otherwise, to a vaginal birth. Venerating vaginal birth and attempting to emulate it as it supposedly occurred in nature makes as much sense as polar bears venerating their original brown fur and attempting to emulate it. The environment has changed and the evolutionary winners and losers have changed as a result.

Scientists are sometimes caught out as paleofantasists as well. Consider the latest “research” about C-sections and the infant gut microbiome. There are scientists insisting that C-sections prevent infants from obtaining the “good bacteria” that they previously acquired during vaginal birth. If there is one thing that we can say for sure, it is that the microbiome of the female genital tract is nothing like it was 10,000 years ago, or even 1000 years ago, because no microbiome is like it was 10,000 years ago or even 1,000 years ago. Bacteria evolve far more rapidly than humans and the idea that there are “perfectly designed” vaginal flora that are “perfectly designed” for the infant gut is nothing short of absurd.

The bottom line is that in the game of evolution, she who has the most living descendants wins. There are no extra points for vaginal birth, or breastfeeding, or any other attempt to emulate our foremothers. The woman who has lots of C-section born, bottle fed, fully vaccinated children who survive to reproduce is the winner. That woman is “perfectly designed” for the environment in which we live. Everyone who is obsessed with trying to emulate our hunter-gatherer past is much more likely to be a loser.

  • Megan Keyser

    I don’t know that a paleo diet can be entirely thrown out the window as something that is completely ridiculous. (Though the whole “natural” childbirth movement IS idiotic to me). I am a celiac, I can’t have wheat, barley, rye or oats. More and more people are being diagnosed as having celiac disease or gluten intolerance. I am not hardcore enough to try a paleo diet, I love my bread, darn it! I feel well enough on a gluten-free diet to find that adequate.

    However, I’ve known people who’ve done well on a paleo diet and feel much better. I don’t know if it’s a good comparison to the natural childbirth movement, which in my opinion is completely ridiculous. We have technology that can save people who would otherwise die, and glorious epidurals that ease pain and allow a more productive birth, and c-sections to aid those like me (c-section scheduled for tomorrow! wish me luck!) who have a transverse baby who is also estimated to be 9 lbs 9 oz. There is no merit to the “natural” ideal of birth.

    I’m an oddball, I’m on the fence about some modern concepts. I feel that pharmaceuticals are overused and people are over-medicated for conditions that might otherwise we controlled by eating well, losing weight, and being active. There is merit to some “natural” concepts. However, there are also many people sick by no fault of their own, and modern medicine makes it possible for them to live well. I think it boils down to logic. There is no logic in being a martyr and possibly harming the life of a child by trying for the “ideal” vaginal birth and I just feel sorry for women who feel like it is preferable to endure incredible pain during childbirth because our ancestors did. I’m also more than happy to have a c-section because it means my transverse baby will be born safely.

    • Sue

      Megan – if you have diagnosed celiac disease, by all means avoid gluten.

      The idea of a universal “paleo” diet doesn’t make sense, however. In ancient times, diet depended on what was available locally – ranging from the tundra to the tropics to the arctic. Hot places had rice, colder places had wheat. Some sort of grain evolved from wild grasses that were adapted to different locations. The Innuit survived on hunting and fishing, with more protein than carbohydrates because few grasses grew.

      • Eddie

        Yes, and the foods available changed over relatively quick time periods due to agriculture … what we know of as corn was quite different even thousands of years ago, for example and that is just one example. It would be silly to suggest that gluten is bad for everyone, exactly as you say. For those without celiac disease, there is no evidence that whole wheat is inappropriate or not the best or damaging.

  • Suzanna Kruger

    Do you tell yourself stories to accompany yourself on long walks or bike rides? In my mind, yes, I am living here in my coastal home but prior to Columbian contact, and so I look out at the landscape and wonder what the mountains looked like then, or what the shape of the south spit at the estuary would have been like, and would I be eating razor clams or smoked salmon that evening? When I am cold on the winter and I have to go to work in the dark and come home in the dark, in the rain, I pretend that I live on the African savanna where it is warm and there is no daily 40-mile commute with the kids in their car seats, or homework to do, and so forth. My other persistent daydream is 500 years from now, maybe on Mars, maybe in a starship, where indeed I could say, “Tea. Earl Grey. Hot.” The trick is to remember not to project your daydreams into the past and mistake them for the truth. Pregnancy, labor/delivery and lactation have all been bottlenecks in terms of human evolution. And still are – reading about the Addis Ababa Fistula Hospital in Ethiopia makes that so very clear. I think we forget how easy our modern lives are, comparatively.

  • http://www.facebook.com/profile.php?id=509803249 Lindsay Beyerstein

    I distrust paleo-fantasy as much as the next skeptic, but I’m not sure Zuk’s argument about recent evolution is relevant to many of the alleged diseases of civilization that paleo-fantasists blame on our modern diet. New mutations crop up all the time, but most of them don’t spread because they don’t confer a selective advantage. It makes sense that lactase persistence would spread because it confers a survival advantage starting as soon as a baby is weaned. If you can take advantage of a rich source of calories and nutrients that other people can’t eat, you’re more likely to grow up, reproduce, and pass that gene on to your offspring. More calories might even make you more fertile than the next person.

    Zuk is implying that we might have evolved genes that help us process grains, sugars, and other relatively recent additions to the human diet without falling victim to chronic diseases like atherosclerosis and type 2 diabetes. But diseases like atherosclerosis don’t tend to kill people, or even make them sick, during their prime reproductive years. So, it’s hard to see how there would be a strong selective pressure in favor of mutant genes that protect us from many of the chronic diseases that the paleo crowd blames on novel food staples.

    • Eddie

      Genes that protect you beyond your prime reproductive years still confer a survival advantage if they enable you to help more of your grandchildren to survive by your being around to help your children. I’m not saying that’s the answer, but it is one possibility.

      • http://www.facebook.com/profile.php?id=509803249 Lindsay Beyerstein

        Definitely a possibility. But I wouldn’t expect a marginal advantage with atherosclerosis at 60 to produce the kind of strong selective pressure that could remake the metabolisms of huge populations in just a few thousand years.

  • INeverSaidThat

    The thing that gets me is that today in the modern world we have the unfortunate ability to compare and contrast modern Western obstetrics with very primitive “natural” pregnancy birth. It is very easy to look at the modern American experience and the very primitive conditions that exist in less developed countries. I have read the blogs of many drs and nurses in Asia, Africa, the Middle East and I am so unbelievably thankful for the vast medical options available to my family. Maybe some of these Paleo-fantasists should go look up the statistics and experiences in places like Afghanistan and India….

  • Amazed

    OT: Dr Amy, may I suggest that you write another post? I’ve watched two different documentaries about the Egypt Queen Hatshepsut, her ascending to the throne and her relationship with her stepson Tuthmoses III (a very great Tuthmoses, by the way). The documentaried contradicted each other theor by theory and word by word. What would I do of I had the mindset of a homebirth advocate, convinced that because it’s a documentary, it must be true? When there are two documentaries contradicting each other?

    I think King Tut’s death might be a good start. After all, he couldn’t have been killed by his prime minster, AND killed not by his prime minister, AND died of accident, AND died because of a hereditary anomaly, Yet there are documentaries supporting each and every one of these theories. They can’t be all true just because they are mentioned in a documentary. So maybe the BOBB shouldn’t be such a gospel, after all?

  • Cellist

    “The bottom line is that in the game of evolution, she who has the most living descendants wins”
    Michelle Duggar wins!!!!!!!
    (and yet she doesn’t believe in evolution!)

    • T.

      I weep for humanity <.<

      • Cellist

        Tell me about it :-(.

        The first two minutes of the film ‘Idiocracy’ say it all…

        (Youtube – ‘Idiocracy opening scene’)

    • The Computer Ate My Nym

      Nah. No one “wins” evolution. Evolution is like an old arcade style video game: If you “win” you just go on to the next challenge.

  • Amy

    OK, slightly OT but the blue eye thing piqued my interest…can anyone point me in the direction of something that explains /how/ scientists are able to estimate when they first appeared?

    • Suzanna Kruger

      Scientists use the rate of mutation in mitochondrial DNA to estimate when traits first appeared. For the blue-eyed gene, check out, “Blue-Eyed Humans Have A Single, Common Ancestor,” from Science Daily News, from January 31, 2008. For how genetic clocks are calculated, you can read the following news article from the journal Nature, “Studies slow the human DNA clock: Revised estimates of mutation rates bring genetic accounts of human prehistory into line with archaeological data,” by Ewen Callaway, from September 18, 2012.

      • Suzanna Kruger

        These are not peer-reviewed studies, but they are news articles about current research.

  • Sue

    YESSSSS!! This infuriating paleo-nonsense has also invaded dietary zealotism – the “paleolithic diet”! People who claim there is some sort of “natural” human diet make me ask “do you mean the “natural” diet of central Africa, of the Innuit, of Northern Europe or of the Pacific Islands?”

    And then they blog about it, on the perfectly unnatural internet.

    Why is it that it’s OK for our brains to change, but not the rest of our bodies? It’s “natural” for humans to have intellect and curiosity. That’s why I don’t get it when radcial NCBers, radical diet zealots and woo practitioners want to remain stuck in some favourite historial epoch, as if that period in human history should be crystallised for all time. We don’t do that with transport or communication, or fashion (except for some sects), or language, or shelter….

    • LukesCook

      Not only have the brains and bodies of humans evolved over the last 10,000 years, but so have the plants and animals we eat. Modern apples, steaks and almonds are not the same as the ones our Paleolithic forebears were eating.

    • Suzanna Kruger

      Well, really, I find that my body is healthier (including my weight, cholesterol and triglycerides) since I stopped eating refined sugar and all the starches I included in my “heart-healthy” vegetarian diet (lots of brown rice and legumes) and added animal fat and protein back in. Also, my skin improved and I no longer get fungal infections in my feet or vaginal tract, so I’ll take it, even if I miss sugar and pizza. Every body is different. My father has been pudgy most of my life, and as such I think neither he nor I handles starch or sugar in large quantities very well.

      • http://twitter.com/SlackerInc Alan

        Word to that. I’ve taken brown rice out of my family’s diet, though, out of concerns for its arsenic content.

        • Poison Ivy

          I’ve taken arsenic out of my diet until I can find some that isn’t contaminated with brown rice.

          • http://twitter.com/SlackerInc Alan

            Lol

      • Becky05

        But all health authorities recommend avoiding refined sugar.

        • Suzanna Kruger

          Becky yes, but all health authorities DON’T explicitly recommend removing grain, but instead encourage “whole grains”. I ate whole grains daily, in oatmeal (with peanut butter) for breakfast and brown rice (with beans) for lunch and dinner. It wasn’t healthy, despite being a “heart-healthy” vegetarian diet composed of a complete protein.

          • Sue

            With respect, Suzanna, perhaps you needed a greater variety and balance of foods. Vegetarian diets often need greater volume to get full nutritional needs. Did you follow the same diet of oatmeal, brown rice and beans every day?

          • Suzanna Kruger

            There were plenty of other fruits and vegetables, which I have retained as I have gotten rid of the starch and added animal fat and protein.

      • Sue

        ” neither he nor I handles starch or sugar in large quantities very well.”

        Suzanna – NOBODY handles starch or (added) sugar in LARGE QUANTITIES very well. No healthy diet has ever included lots of added sucrose without nutrients or energy expenditure balance. That doesn’t mean that there is any one “natural” diet, or that one should become obsessed with what is included or excluded.

        What “heart-healthy” diet recommended lots of refined sugar?

  • Disgusted

    I like that word, “paleofantasy”. I’m faced with people following the paleo diet all the time and I’ve learned I just need to keep my mouth shut and nod because it’s like a religion to them. But yes, the constant appeals to the constructed hunter-gatherer past. “We didn’t have as many heart attacks back in teh hunter gatherer days because everyone ate the perfect diet!” Er. They didn’t usually live long enough to die from diabetes or cardiovascular problems. They died: at birth; giving birth; from diseases we have vaccines for now; starving to death; freezing to death; from infected wounds; or being eaten by sabertooth tigers. We are blessed to live long enough to have to worry about our cholesterol count!

    • Renee Martin

      Their argument is that if the environment/trauma didn’t kill them, then they lived to be 80yrs old and healthier than modern man. They really do think this.

      • LukesCook

        Or that we live longer, but are unhealthier. Because healthy people definitely do drop dead more often than sick ones.

  • Becky05

    I’m not sure that I would agree that vaginal birth has no advantages over cesarean; it does have some proven advantages, but also some definite risks and disadvantages. Venerating it is absurd, but weighing risks and benefits in a particular scenario is not. In throwing out the naturalistic fallacy, I think you have to be careful to not assume that natural is never better, or that technology and intervention is always better. That’s why basing things on good evidence is so important.

    Otherwise, I do really like this post.

    • LukesCook

      What are the evolutionary advantages of vaginal birth?

      • Becky05

        Dr. Amy wrote, ” Now, with the advent of the C-section, there is absolutely no advantage, evolutionarily or otherwise, to a vaginal birth.”

        I agree that there’s no longer an evolutionary advantage to being able to give birth vaginally. A vaginal birth does often have real advantages, though, especially for the health of the mother.

        • Something From Nothing

          Such as?

          • Becky05

            Research shows that attempted vaginal delivery, when compared with elective primary cesarean, is associated with lower risks for maternal mortality and serious morbidity, shorter average recovery time and lower risks in any subsequent pregnancies.

            That doesn’t mean that the outcomes of vaginal delivery are never worse than the outcomes of a cesarean. They certainly can be. And it can be difficult to sort out all confounding factors, of course, especially for issues like maternal mortality. And there are some risks and issues that are more common with vaginal deliveries, like pelvic floor damage. On the other hand, this isn’t life threatening, unlike some of the problems increased with cesarean delivery (DVT, infection, AFE, etc.).

            I’m not arguing that vaginal delivery is appropriate for all women, or that cesarean is never appropriate. I’m just taking issue with the statement that vaginal delivery has no advantages over cesarean. That is not consistent with the evidence.

          • The Bofa on the Sofa

            Given that women are generally not reproducing during recovery, the “shorter recovery time” is not an issue evolutionarily.

            I don’t mean to imply that you have suggested otherwise, but it is important to note.

          • Becky05

            Right. I’m not arguing that there is still an evolutionary advantage, but Dr. Amy made a broader statement, claiming that there weren’t advantages “evolutionary or otherwise.”

          • AllieFoyle

            I think you really have to take those statements about one method being safer or better with a grain of salt. It all depends upon what is being measured and how risks are weighted. I have never seen the risks of vaginal birth adequately quantified in this sort of analysis.

          • AllieFoyle

            If you really look at what increased morbidity and mortality means in these studies much of it is this sort of stuff: shorter hospital stay, less use of pain meds, less bleeding, lower risk of infected incision… which is basically just pointing out the obvious. Routine complications of C-section get recorded, but many of those from vaginal birth are completely ignored. Is anyone recording, as a matter of course, blood loss in SVD? Or vaginal lacerations and subsequent infections and problems with healing? Hardly. I just completely reject the idea that the pain of a vaginal birth is worth nothing when weighed against the likelihood of needing analgesics for a few days, or that the only wounds that matter are the ones on the abdomen. Or that a woman’s continence and sexuality aren’t worth measuring or preserving.

          • Laural

            Yes, please measure and record the pain and long term effects of both ceseareans as well as vaginal birth. And then give women the right to informed choice.

        • Mrs. W

          What about the mother’s pelvic floor?

          • Becky05

            I said above about vaginal delivery, “it does have some proven advantages, but also some definite risks and disadvantages.”

        • http://twitter.com/SlackerInc Alan

          “I agree that there’s no longer an evolutionary advantage to being able to give birth vaginally.”

          What about the advantage of not making the survival of the species depend on there never, ever again being even a relatively short (say, 100 years long) “Dark Ages” in which technology and education does not allow successful non-fatal abdominal surgery?

          • Dr Kitty

            Ah, Alan, but how would you do this?
            Because, you see if you had an unnecessarean, you *could* still have birthed vaginally, and so your descendants would still be able to. only *necessary* CS that actually save mother and baby who otherwise would have died provide an evolutionary drive towards CS.

            The only way to remove an evolutionary pressure towards CS is either not to perform necessary CS and let women and babies die now, or to prevent women who have had CS, and their descendants, from ever breeding.

            I’m not sure you’ve thought this through.

          • http://twitter.com/SlackerInc Alan

            But I’m not proposing to “do” anything. And yes: it is families like mine, chock full of necessary c/s, that accelerate this potentially dangerous evolutionary trend most rapidly for now. But a 100% c-section rate would have an even more sweeping effect, for reasons I can get into if it doesn’t occur to you on second thought.

          • ratiomom

            Lemme see.. I should risk having a limp blue breech baby dangle from my vagina now so her descendants don’t get dependent on cesareans? Except that she won’t have any descendants.

          • http://twitter.com/SlackerInc Alan

            No, I’m not saying that. I was not advocating anything, just responding intellectually, narrowly, to the assertion that there is no evolutionary advantage to being able to birth vaginally.

          • Amazed

            Being able to birth vaginally HEALTHY children, Alan. Healthy children. I was born vaginally but extracted with a vacuum. I’ve seen pictures of myself as a baby. My head was bigger than my brother’s that age and mind you, he was the 10 pounder. I was only 9. There was simply no way this head could have passed through my mother’s pelvis naturally and still retain a functional brain. Big deal that I might have been born fully naturally. I don’t imagine there would have been many men ready to father the descendants of the woman I might have been without the blessed vacuum. Had I been born by C-section, my mother would have been a winner. The way I was born, she was a winner. Had I been born naturally… not so sure.

            And there is a certain evolutionary advantage to being able to birth by c-section. Staying alive, for one. It’s hard to have other children if you are dead, say, because of a transverse baby of a hemorrage after a very natural birth. Just ask Simon Teague, currenly a single father of two. Not because he’s divorced.

          • http://twitter.com/SlackerInc Alan

            Yes, birthing vaginally healthy children, good point. I agree that so long as obstetricians continuously remain among us in sufficient numbers, there are clear evolutionary advantages to not being limited to vaginal birth. The reason birth is so difficult for humans, which is something the natural childbirth community may not take fully into account, is the evolutionary pressure to have larger brains which requires larger heads. I absolutely believe my family line, starting with my grandfather, has taken full advantage of the removal of this evolutionary struggle between maintaining a pelvis size that allows women to walk and run effectively, and the advantages of larger and larger cranial capacity. We have huge heads and have demonstrated strong brainpower.

            So the issue is complex. One way to look at it is as a symbiosis between memetics and genetics. As long as the torch of obstetrics knowledge is passed, along with the necessary technological ability, the freeing of cranial size confers an evolutionary advantage. But the requirement that there never ever can be an interruption in the passing of that torch, necessarily makes our existence more fragile and less adaptable. It’s a trade off, so it is arguable as to which direction confers the clear advantage. My main point still holds though: the evolutionary advantage to being able to birth vaginally has not simply evapourated but has greatly diminished and become a conditional long-term advantage which has a trade-off in a short term disadvantage.

          • Amazed

            But the requirement that there never ever can be an interruption in the
            passing of that torch, necessarily makes our existence more fragile and
            less adaptable.

            But your supposition is that everyone who has utilized the advantages of modern obstetrics will have descendants who would unavoidably have to utilize them. Like, women whose pelvises were too small for their babies will have only descendants with the same problem. I don’t agree. And I see no reason why there must be an interruption in the passing of the torch, unless someone in power decides that letting the dirty genes of c-section mothers polute the genetic pool is a very bad idea, so we’d be better off if we just let them die an agonizing death along with their babies. C-sections work. That’s why they are still around and forceps deliveries are in retreat. When and if c-sections die away, it will be because something better has come along, not because we’d leave women to die under a tree like so many of our foremothers had. When the printed books started coexisting with another form of reading, it was an e-book, not carvings in stone.

          • http://twitter.com/SlackerInc Alan

            “But your supposition is that everyone who has utilized the advantages of modern obstetrics will have descendants who would unavoidably have to utilize them.”

            No, I was responding more narrowly, disputing the assertion that being able to birth vaginally conferred no evolutionary advantage. See the distinction? That said, I do think that over time, if everyone was born via c-section, genetic drift would ensure that the mechanisms in a woman’s body that accomplish vaginal birth would become vestigial from disuse.

            I hope your optimism is warranted, but it was only a thousand years ago that people would look in dumbfounded awe at architectural achievements of the Roman Empire and marvel that such engineering had ever been possible.

          • AllieFoyle

            This conversation is veering into absurdity. You can wring your hands about the potential long term evolutionary consequences of c-sections if you want, but the same argument can be made for the countless other ways in which we use technology or culturally transmitted skills to give ourselves a leg up on what nature provides. The bottom line is that to act ethically, you must do what is in the best interests of the individuals now, without regard for some imagined distant future situation.

            It should also be pointed out that there is no discrete “ability to birth vaginally” gene. The whole thing is an intersection of a number of different genes (pelvis size and shape, yes, but those are probably determined to some degree by genes that also control things like overall body size and composition, hormonal activity, and growth patterns, which have different selective pressures acting on them as well). Fetal size appears to be determined partially by a genetic arms race (short version: paternal genes promote growth, maternal genes moderate it so that the baby doesn’t get too large). There are many, many different genetic factors determining whether any individual baby can pass through its mother’s pelvis. Each event is a new shuffle of the genetic deck.

          • http://twitter.com/SlackerInc Alan

            I’m not saying it is the end of the world (I sure hope not anyway). Again, I was just narrowly responding to the claims made that there was no evolutionary advantage to being able to birth vaginally. I’m not saying that outweighs everything or even anything else, just that it is something that deserves to be mentioned when that conversation is had.

          • AllieFoyle

            But you were expressing concern for the future of humanity in the event of some kind of post-apocalyptic future where c-sections are not available. With so many other actual, pressing issues in the present and immediate future, I just can’t imagine being bothered at all about something like that.

          • Durango

            Right. A game of Apocalyptic What If is just silly speculation and I’m always amused when NCBers trot it out to try to justify their beliefs.

          • Siri

            See above. It didn’t seem silly to me, and I am not into woo.

          • MaineJen

            You all have been watching too much Walking Dead. If the Zombie Apocalypse happens, we will indeed be in trouble. Better stock your bunkers now. (/sarcasm) Seriously. Are people actually saying that we shouldn’t employ modern medicine because it is making our species less ‘fit’ to survive in the event of a worldwide catastrophe? Let’s all stop vaccinating, treating our illnesses, and taking care of the disadvantaged, too, and only the truly fit will survive…oh wait.

          • Siri

            As a midwife, routinely assisting at emergency and elective caesareans, it did used to worry me that so many women’s future health/survival depended on the availability of electricity, functioning and staffed operating theatres, relevant drugs etc. It made me feel grateful for my own obstetric history, which, as well as a horrible forceps delivery, also contained three spontaneous births.

          • AllieFoyle

            Well, it already kind of does depend upon the availability of those things.

          • Sue

            Siri – you do realise that the human race was able to propagate itself at a sustainable rate even BEFORE modern obstetrics? So, if by some strange event, we lost all ability to do anything that was invented in the last (say) three thousand years, we’d just go back to three-thousand-yr-old health outcomes, no?

          • Amazed

            “I hope your optimism is warranted, but it was only a thousand years ago
            that people would look in dumbfounded awe at architectural achievements
            of the Roman Empire and marvel that such engineering had ever been
            possible.”

            The good old medieval times were called Dark Ages for a reason. Unless we sprout a new Julian the Renegade (not quite sure what his nickname is in English, by the way) who just happens to be obsesses with eugenics, C-sections will, fortunately, continue to be around to help women who need it and aren’t brainwashed enough to lay down their lives or their babies’ lives at the altar of paleobirth fantasy.

            And your argument about the army of C-section moms invading the world is so absurd that it cannot possibly be a part of a normal discussion. The only way THIS could happen is if there is a massive conspiracy to prevent the vaginally birthing women from reproducing on par with the C-section chicks. You happened to talk to Michelle Duggar recently? Should we be concerned?

          • http://twitter.com/SlackerInc Alan

            Army of C-section moms? You must be referring to someone else’s comments, not mine.

          • Sue

            “We have huge heads and have demonstrated strong brainpower.” Again, one out of too aint bad.

          • http://twitter.com/SlackerInc Alan

            Two short comments attacking my intellect, two spelling mistakes. Nice.

          • Sue

            ” just responding intellectually, narrowly,..”

            Well, “narrowly”, at least. One out of two aint bad.

            By Alan’s logic, we should stop driving in cars, blogging, flying in aeroplanes, cooking food and using refrigeration, just to ensure that, some time in the future, a century of no cars, aeorplanes, computers, or electricity doesn’t kill of the human race.

          • Eddie

            To be fair, that’s not what he is saying. He’s identifying a risk — one we can worry about (I don’t think anyone is going to worry about it) or not. Identifying a risk does not imply mitigating that risk. THAT decision involves a cost/benefit analysis. The cost (doing away with all of that stuff) vs the benefit (a possible reduction in death rate in a hypothetical future dark age). None of us, including Alan, would say, “Let’s do without that stuff.”

          • http://twitter.com/SlackerInc Alan

            Disputing a claim that something has no evolutionary advantage is a far cry from advocating anything. Simmer down now!

          • Becky05

            That isn’t an evolutionary advantage right now, is it? Evolution can’t look to the future. It is happening right now.

          • http://twitter.com/SlackerInc Alan

            Evolutionary fitness is broader than “what gives me the most offspring right now, never mind future descendants”. Would you consider it an evolutionary advantage to have a mutation that allowed you to easily gestate quadruplets, with the price being that they are born without reproductive organs?

            For a more prosaic example, many scientists believe that “grandmothering” is to credit for human women’s unusual longevity after menopause.

          • Becky05

            Evolution can see forward into the future, though. Having sterile offspring wouldn’t be an evolutionary advantage now. Being able to give birth vaginally with ease is no longer an evolutionary advantage; the fact that at some future point circumstances may change doesn’t change the fact that right now, there is no selection pressure on those with small pelves due to current circumstances.

          • http://twitter.com/SlackerInc Alan

            The only real difference in the two scenarios is the length of the time frames. For another example, think of a frog that lives in a lake that completely dries up every 25 or 30 generations. If that frog has something in its DNA that allows it to burrow in the mud and survive that exceptional drought year, it will allow the species to survive potentially hundreds of generations or more. It does not, then there could be many generations in a row that have perfectly fruitful lives, but when the exceptional circumstance comes along, that will be extinction. It’s over, no coming back. Your statement that a trait or ability has “no evolutionary advantage now” is either shortsighted or just meaningless, depending on how you look at it.

            But yes, you are right that the selection pressure is not currently being applied (in advanced countries). That is quite different from claiming a lack of evolutionary advantage to being able to birth vaginally. Many extinctions, maybe most, have come about because a species was too dependent on a stable set of circumstances in its environment.

          • LukesCook

            “Many extinctions, maybe most, have come about because a species was too dependent on a stable set of circumstances in its environment”

            Your evidence for that statement?

            Evolution is a hard taskmaster, and every genetic adaptation comes the cost of another. It is not possible to be adapted to every conceivable future event or circumstance or to foresee which of an infinite number of combination of an infinite variety of possible adaptations might best suit an infinite number of combinations of an infinite variety of evolutionary pressures.

          • http://twitter.com/SlackerInc Alan

            Certainly, but it’s easy to see that my branch of the human family tree has become very dependent on a professional specialty which has only existed for a blink of an eye in evolutionary terms, and which requires a level of technology beyond what most humans require for survival (that is, if we suddenly found ourselves in the telegraph and locomotive era, most people would be fine but my family line would die out).

          • AllieFoyle

            But we’re only a blink of an eye away from telegraph and locomotive times too, and as you already acknowledged, evolution doesn’t work that quickly. Your family certainly hasn’t had time to become dependent upon anything, at least, not in evolutionary terms.

          • http://twitter.com/SlackerInc Alan

            I said it doesn’t work so quickly that we could be a different, unrecognisable species within 250 generations. And my relatives and I are recognizably human. But with a trait like head size, which first of all is not something entirely new but just an increased size of something that already exists, and also which had been pushing the envelope and rubbing up against the limits of pelvic size for a long time already, I do think that can happen quickly.

            And the proof is in the pudding, right? My paternal grandfather and his direct descendants make up a group of eleven individuals. Ten of us were born by caesarean; one (my oldest son) was born vaginally after a long induced labour (including six hours of pushing), but his mother required blood transfusions afterward. The eight of us alive today are confirmed to have head circumferences beyond the 99th percentile; photos and memories of my father and grandfather point strongly to the same being true of them. (The one unknown is my uncle who died as a child from polio.) How else to explain this–coincidence? The odds are astronomical.

          • AllieFoyle

            But your family group is just a single pocket of genes, evolutionarily. If large head size were such an advantage (and it has to be pointed out that large head size does not necessarily denote increased intelligence) and your family was evidence of some sort of ongoing selection for it, rather than just a coincidental grouping of traits, you’d also expect to see simultaneous evolution for changes in pelvic size/shape that would enable large-headed people to survive long enough to be reproductively successful.

            “How else to explain this–coincidence? The odds are astronomical.”

            What coincidence? I really don’t understand what you think is particularly special or instructive about your own family history.

          • http://www.facebook.com/lizzie.dee.71 Lizzie Dee

            I am probably being rather thick here. My interest in paleo-whatever, what our ancestors did and the genetics of birth is a bit sketchy and informed by scrambled and ill understood fragments of information. (My main interests are in the ideologies, politics and psychology of how reproduction is used to control women throughout their lives, where I am slightly better informed.) BUT – how many Sections are done because of CPD? I have read of tiny women giving birth to healthy large babies (You can’t grow a baby too big…di da di da.) Isn’t the position of the baby rather more relevant? Are there genetic reasons why a baby might want to come out face first?

            I had two CS, my daughter two vaginal births. Whether it was genes that caused us both to have pre-eclampsia is, I believe, a question still to be answered. And if it is genetic, whose genes? Isn’t one of the theories that the problems start with implantation, and that the immune response there can be beneficial in other ways?

            People attracted to NCB thinking seem to like to dream up nice, simple systems, that can sound ever so plausible, but in a complicated world seldom make sense. A favourite is that only defective women have problems, and a successful birth is automatically a sign of superiority. Don’t want to be too unkind, but if some of the people one can see on You Tube videos are examples of the Master Race of superior genes I think we may be in trouble.

            If one takes Dr A’s theory at face value, the original impetus for NCB and the birth doesn’t hurt if you do it right brigade was the fact that once intelligent women got control of their fertility they figured out that there were better ways of being empowered than a baby a year. From a eugenic/evolutionary stand point, that may well have been a potential problem. The solution of us valueing uterine muscles over intelligence still isn’t great.

          • AllieFoyle

            I don’t pretend to be an expert in obstetrics, but there are so many factors (genetic, environmental, plain old luck and chance) involved in whether any given baby happens to fit through any given pelvis on any given day that it seems pointless to talk as though a few generations of c-sections is going to eliminate the possibility of vaginal birth on a species level.

          • http://www.facebook.com/lizzie.dee.71 Lizzie Dee

            Ummm – has anyone definitively demonstrated a connection between large heads and IQ? And does a large head automatically indicate a large brain? Do some people have thicker skulls? (Boneheaded is not usually a compliment.) Far as I know, brains grow after you are born, and it does rather matter which part of your brain is enlarged. I read some research that said the hippocampus of London taxi drivers enlarges because of the vast amount of information they have to absorb on London streets (known as “Doing the Knowledge”). Or maybe only those with a large hippocampus can pass the tests and become taxi drivers. Einstein’s brain was apparently “normal” size, but had an enlarged frontal lobe.

            I think it would be fascinating if we ALL had MRIs. Advances in that field are changing some long held beliefs about what happens inside our skulls, like how language works, and memory.

            And I do wish a neurologist would join in the conversations here. Brains fascinate me, and I would love to know a whole lot more.

          • AllieFoyle

            There is a general link between brain size and intelligence, but you really have to be careful in extrapolating much from it. For example, it does seem to be true that species that have larger brains (especially when you look at the ratio of brain size to body size) are generally more intelligent. But there’s obviously a lot more to it than just overall size, and when you try to apply it to humans, it’s a very muddled picture. Microcephaly (extremely small head size) does usually correspond with limited cognitive abilities, but not always. There are cases where people with notable reductions have had normal+ intelligence; even people with only half a brain often function remarkably well, considering. Sometimes a large head is the result of a medical or developmental problem and associated with lower intelligence. Historically, many highly intelligent individuals had craniums on the small side of the scale. What seems to be more important than overall size is the development of the brain areas associated with cognitive ability–and even there it isn’t so much a question of size as it is things like neural architecture (number of connections, white matter vs. gray matter, etc.) and neuron density.

          • Eddie

            Also, men on average have larger brain size than women, simply because men on average are larger than women. (Learned this in psych 101 I believe) This does not translate in any way to being able to say that men or more intelligent than women, or for that matter that bigger people are smarter than smaller people. It depends on so many other things, as you say.

          • http://twitter.com/SlackerInc Alan

            There’s a lot in here I think Dr. Amy would like (sincerely):

            http://ngm.nationalgeographic.com/print/2006/07/bipedal-body/ackerman-text

          • The Bofa on the Sofa

            Why does anyone care about the “survival of the species”? Why do I care whether humans are still around 10 000 years from now? Granted, I am not in support of killing anyone off intentionally, but I don’t see any reason that I should be concerned that more people are being born, outside of my vain need for lots and lots of personal great-great-etc-grandchildren, who I won’t be alive to see anyway.

            I care about people who are alive now, and those who will be born, but if folks aren’t being born because of some decision we have made, I don’t care, even if it means the end of humanity as we know. Then again, in the year 9595, if man is still alive, there is no reason to think they will be any way related to “humanity as we know it” as it is.

            Of course, evolution doesn’t care about the survival of the species, either, only individuals.

          • http://twitter.com/SlackerInc Alan

            Dawkins says evolution does not occur on the individual level either, unless you mean the level of the individual gene. But I see this as a semantic issue anyway, because the various genes, like the individuals in society, have a vested interest in the species they are prevalent in, or perhaps exist only in, avoiding extinction.

            Personally, I would like the human race to have a long future, and also whatever it evolves to become (though I think you need to add a zero to your 9595 scenario: while evolution has accelerated in “recent” years, it is still not fast enough to make us something unrecognisable after only 250 generations). You are free to have a different opinion, but that doesn’t change the fact that an evolutionary advantage can manifest itself in the short *or* long term. Being able to “roll with the punches”, after all, is how our distant ancestors survived the meteor strike in the Yucatan that killed off so many other species.

          • The Bofa on the Sofa

            Dawkins says evolution does not occur on the individual level either, unless you mean the level of the individual gene.

            Shoot, not even the genes, but the alleles. And it really doesn’t even “care” that the allleles survive, nor do they. It’s just that alleles that do survive end up being passed on and those that don’t, aren’t. The only extent to which alleles “care” about surviving is that they don’t die spontaneously.

            Personally, I would like the human race to have a long future,

            Why? I really am curious, why do you care whether the human race exists in any way (“as we know it” or not) in 9595? What difference does it make to you?

          • http://twitter.com/SlackerInc Alan

            Mesage me on Twitter (@SlackerInc) and I would be delighted to discuss it. Here I have been dinged for going off topic, so I’d better not go down that road, as much as I’d like to.

          • LukesCook

            “the various genes, like the individuals in society, have a vested interest in the species they are prevalent in, or perhaps exist only in”

            Since the vast majority of alleles exist in many different species, this is hardly a consideration.

            How many species do you think were out-competed into extinction by the species eventually killed off by a meteor strike? Had any of them possessed any special meteor strike surviving qualities, how helpful do you think they would have been? In order to be one of the lucky few to survive the meteor, a species would FIRST have to have been one of the lucky survivors of countless other evolutionary pressures.

            For example, being a great runner won’t help you win, or even complete, a triathlon if you don’t know how to swim. Now imagine an event that consists of many legs, starting with a swimming leg, but you don’t know what the subsequent legs of the race will be when you start your swim. You could be faced with running, cycling, hurdling, skiing, archery, sailing, or none of them, but some totally new sport that you’ve never heard of and couldn’t even have imagined. Do you think it’s more important to be a good swimmer or a good archer?

          • http://twitter.com/SlackerInc Alan

            You make some interesting points; but it strikes me that the early portion of your comment in particular challenges at the fundamental level the general paradigm of natural selection. I’m not saying that is a bad thing, necessarily: I like to see dominant paradigms challenged and made to “earn their keep”, so to speak. But I’m not sure we can dig into all the ramifications of this challenge while staying on topic.

            So responding more to the latter portion of your comment, which seems more on topic: I dispute that the potential for a future “dark ages” with no obstetric practitioners would be equivalent to a completely unforeseen type of sport. We have an institutional memory of a time not so long ago when C-sections were not possible. We have the kind of information retention abilities that allow us to see that we are dependent on a highly skilled, technological field in order to continue to reproduce without vaginal birth.

            To concern ourselves with that state of affairs, and its ramifications, is not the same as trying to guess about a sport we are completely unfamiliar with; nor is it similar to the situation of species before the asteroid collision who did not have our analytic or information storage and retrieval abilities. (We can probably agree that we should be using those abilities, along with our technological prowess, to detect asteroid threats and then–Deep Impact style, try to avert them if possible.)

          • DiomedesV

            “But I see this as a semantic issue anyway…”

            It is not a semantic issue, because as posted above, things like antagonistic pleiotropy are real, as are many other kinds of conflict-mediated intra-genomic interactions. Selection happens at the level of the gene. Genes have populations made up of the total number of alleles, i.e., the frequency of each allele times the number of individuals that bear them. It’s absolutely not semantic because genes interact with one another in one organism.

            Finally, there is no “long-term evolutionary advantage” for a gene, especially given that with the rate of mutation, any given allele persists, usually, for only so long, unless there is very strong purifying or positive selection.

          • Siri

            And individuals with a scar on their womb are at greater risk in future pregnancies unless all those resources we take for granted are uninterruptedly available. Wars do happen, and supplies can run out. It was individuals I used to worry about, not the species.

      • http://www.facebook.com/lizzie.dee.71 Lizzie Dee

        All the “unfit” mothers and babies die horrible deaths, and we can have a superior breed of supermommies surviving. Of course it wouldn’t actually work out like that, but it is clearly a fantasy some enjoy.

        • LukesCook

          Not much of an evolutionary advantage to the mothers and babies concerned.

        • Gabriel

          Alas in evolution there is something called antagonistic pleiotropy. It has favored bigger heads, for example, because the bigger heads hold bigger brains, and this helps us to survive. But bigger heads have also increased the danger of birth. Changes to the pelvis to allow walking upright are another example of a trait that introduced lifelong benefits and new danger during childbirth.

    • Sue

      If I understand the evidence correctly, VB is better for the mother, CS is better for the baby (overall, on a population basis). Babies save hypoxia and physical injury for a small increase in temporary respiratory symptoms).

      • Becky05

        That seems to be roughly true. Planned cesareans tend to result in more short term neonatal morbidity and are more likely to spend time in the NICU, most due to respiratory issues. Many studies show no neonatal advantages to planned cesareans, because the conditions that cesareans best help prevent — hypoxic brain injury, brachial plexus injury, intrapartum mortality, are so rare in low risk women. For instance, see this small study: http://link.springer.com/article/10.1007%2Fs00404-010-1525-y?LI=true
        Or this much larger study: http://onlinelibrary.wiley.com/doi/10.1111/1471-0528.12129/abstract?deniedAccessCustomisedMessage=&userIsAuthenticated=false

        • Eddie

          Is there a cause-effect relationship between the planned CS and the respiratory issues, or is it that a high enough fraction of planned CS are multiples, or … ? Is this understood?

          • Becky05

            Yes, for respiratory issues there is a cause and effect issue. Labor reduces the number of respiratory issues. It used to be thought this was due to mechanical means (“squeezing” water out of the lungs), but I think it is now believed to be based in hormones.

          • http://www.facebook.com/lizzie.dee.71 Lizzie Dee

            Labor reduces the number of respiratory issues.

            Which, if true and the reasons are transparently clear, is a strong argument in favour of avoiding a CS. But…what if in reality the choice is between lung function and brain function?

            Is there ANY truth in the idea that CS are being done in large numbers for absolutely no reason? My own, uniformed, view is that the escalation in CS is caused by two things – cEFM that can show when a baby is becoming distressed, and the fact that spinal anaesthesia removes much of the risk that GA caused. So, if a baby has some breathing problems is that entirely down to the effects of surgery? Or can it in fact be linked to the things that caused the surgery to be a better bet?

            My second baby was admitted to NICU overnight (to my fury) because everyone was being super-cautious after the disaster of my first. She was born at 37 weeks, had Apgars of 9 and 10, and no problems at all. She would still get counted on the morbidity statistics.

            What would happen, I wonder, if it turned out the evolutionary advantage lay entirely with CS, on the grounds that not having one’s head squeezed and oxygen cut off for lengthy periods increased the IQ of the human race rather more than the couple of points that bf brings? I believe there was a study some years ago that showed something of the kind….

            An easy vaginal birth has got to be better than surgery. Most women will optimistically go for that, regardless, for both good and extremely dubious reasons. But turning CS into some kind of tragedy rather than a perfectly viable alternative and failing to mention the downside if your vaginal birth is not straightforward seems very unwise to me.

          • Becky05

            “Is there ANY truth in the idea that CS are being done in large numbers for absolutely no reason? ”

            Well, over the last 10-15 years in the US, there has been a dramatic increase in cesareans, with an increase in maternal morbidity and possibly mortality, and without a correspondingly dramatic decrease in neonatal mortality and morbidity. So that’s a kind of evidence that the increase in cesaerans isn’t having a beneficial effect, that there are cesareans being done that really aren’t helping to improve outcomes.

            “An easy vaginal birth has got to be better than surgery. Most women will optimistically go for that, regardless, for both good and extremely dubious reasons. But turning CS into some kind of tragedy rather than a perfectly viable alternative and failing to mention the downside if your vaginal birth is not straightforward seems very unwise to me.”

            I absolutely do agree with this.

          • LukesCook

            A “possible” increase in maternal mortality is hardly “dramatic”.

          • theNormalDistribution

            Sources for this? I seem to remember Dr. Amy discussing in one of her posts hospitals with higher C-section rates having the lowest rates of neonatal mortality.

          • AllieFoyle

            Pauline Hull just had a post saying that morbidity and mortality have gone down as c-sections have increased. I suppose it’s a matter of what data you look at.

          • Becky05

            I looked at that, she was comparing rates in the 70s to rates today. I wouldn’t disagree that things are much better now than in the 70s! However, looking back over the last 15 years or so, there’d been a steady and significant rise in cesarean rate that only recently slowed and began to reverse, and the change in perinatal mortality was gradual and steady, without a correlation to the cesarean delivery rate, and there were some significant other changes in practice, like universal GBS screening.
            http://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_08.pdf
            http://www.cdc.gov/nchs/data/databriefs/db35.htm
            Population level research (which has lots of flaws, true!) doesn’t show a benefit to cesarean rates over 15-20% or so.

            We also know of specific groups, like cephalic preterm deliveries, where cesareans have become common due to beliefs that they improved outcomes, where that has recently been proved not to be the case.

          • AllieFoyle

            Thanks for the responses! You’re a real treasure trove of info. I’d just add that studies are useful, but you have to be careful how you extend the findings. I remember seeing a recent study on preterm delivery that didn’t show improved outcomes with c-sections, but I remember also thinking that a study like that was hopelessly flawed because it didn’t account for pre-existing differences that might have influenced delivery method (were the sicker babies more likely to be delivered that way, anyway?). Also, I think it’s often the case that there are just individual differences that have to be considered over and above the results of any study. One method might look better on average on paper, but might be worse for individuals, and forcing this kind of one size fits all policy on everyone can have negative consequences too. Pros and cons to evidence based practice guidelines.

          • Sue

            The “respiratory issues” are almost all short-term TTN (transient tachypneoa of the newborn) – which is generally benign and not limited to cesarean births. A high respiratory rate often leads to short-term observation in NICU, which then gives a self-fulfilling “higher rate of NICU admission” – but not necessarily long-term outcomes.

            Most families would prefer an overnight in NICU for temporary fast breathing to a lifetime of disability for hypoxic encephalopathy.

        • http://www.facebook.com/lizzie.dee.71 Lizzie Dee

          Articles like these drive me mad – for two reasons. The main one is that I am aware that I do not have the background for reading them properly – particularly the statistics, which quite often leave me baffled. The second is what they very often DON’T say.

          I am also getting sicker and sicker of that useless piece of shorthand “low risk women” Would anyone like to offer a precise definition that could be even remotely useful? It is of course true that the list of complications you give are rare in women who can still be categorised as low risk once their child is safely born. I happen to believe that they would be even more rare if this idea of “low risk” was a bit less relied on.

          My child had an Apgar less than 7, and acidosis. These were not the consequence of CS – they were the REASON for it. As for the arguments that say there is an increased risk of infection, other accidental wounds etc – is that an argument against CS, or an argument in favour of BETTER cs?

          I had quite a few complications after my first, none at all after my second. None of these complications had long term effects – and the alternative was absolutely a dead baby. And, like many others, I was extremely low risk until I wasn’t. The lethal complications to a baby – like cord accidents, failing placenta, malpositioning etc don’t have that much to do with the risk level of the mother.

          The implication of these kind of reports if read superficially (as sadly I do) is that there is some kind of epidemic of CS being done for the fun of it. Given that most women would rather avoid surgery, what is the point of letting that idea take hold? If it were possible to guarantee that all “low risk” women would escape unscathed from vaginal birth, it would make sense – but it isn’t possible. Can we please stop pretending it is?

          • Charlotte

            I hate the “low risk” label too. I was low risk until I suddenly had pre-e and HELLP.

        • AllieFoyle

          Just looking at the abstracts, but from the first one: “Neonatal complications were generally low in both the groups with no significant differences being observed (p > 0.05)”

          The second one showed an increase in neonatal respiratory distress and hypoglycemia in the CS groups, but a) how would a CS cause hypoglycemia?, and b) those are important risks, but largely transient. As a potential parent, I’d be much more interested in some measure of hypoxic brain damage. Also, this study looks at CS without medical indication, but I wonder if there isn’t some selection bias there with it being chosen by people expecting a difficult labor because of known factors like large fetal size (would have a bearing on the hypoglycemia certainly) or small stature in the mother.

        • Sue

          Becky05 – I can only see the abstracts of those two papers at the moment, but the first one says:
          “Neonatal complications were generally low in both the groups with no significant differences being observed (p > 0.05).”

          The second paper recorded infant adverse events as ” Infant outcomes showed a higher incidence of respiratory distress with an OR of 2.7 (95% CI 1.8–3.9) in the elective caesarean section group compared with infants born by emergency caesarean section. The risk of hypoglycaemia was at least twice as high for infants in the caesarean group.” (both temporary physiological measurements, not outcomes) but did not mention whether there was a lower rate of physical injury etc.

          I’m not seeing greater neonatal risks from cesarean section.

          • Becky05

            You’re right, only the second showed increased neonatal mortality from CS. I’m sorry about that, I’m not sure what I was thinking with my wording there.

            I’m not saying that CS doesn’t have some neonatal benefits, I’m saying that they’re rare enough that it is hard to get them to show up in research, and the (usually) short term harms are more frequent and tend to show up more.

            While respiratory distress is usually temporary it is still a very serious and potentially life threatening condition.

          • Becky05

            Maybe I’d meant to include this article? http://pediatrics.aappublications.org/content/123/6/e1064.long

  • GuestM

    Just downloaded the book and can’t wait to read it. Thanks for bringing it to our attention.

  • LukesCook

    “In other words, hunter gathers were never “perfectly evolved,” they represented the best adaptations to conditions as they existed at that time.”

    And not even the best possible adaptations – sufficient to survive and pass on genes relative to their competitors. To win a race you don’t necessarily need to be Usain Bolt – just fast enough to make it over the finish line faster than the other runners in that particular race.

    • The Computer Ate My Nym

      As the old joke goes, I don’t have to outrun the lion, I just have to outrun you.

    • Kerlyssa

      And there’s still a fair bit of randomness. Some women with perfect pelvises and milk that wouldn’t quit did get hit by meteors, etc. Can’t finish the race if a volcano explodes under your feet. Sometimes, the dice just ain’t with ya.

  • AmyM

    Oh that stupid gut flora thing…I guess there was a? more than 1? study that showed that gut flora was different in vaginally born babies vs. Csection babies. It didn’t say if that means anything—is there any evidence that the difference is bad? And which babies were in this study anyway? I would imagine that gut flora is different in adults than in babies, and probably different in a 1yr old vs a 6yr old, no? And wouldn’t it be influenced by where you live and what you eat? A baby nursing would be exposed to bacteria on the mother’s skin, that a bottle fed baby might not be. So what? I’m willing to believe that science might find correlations between a given type of gut flora and a condition…the finding that bacteria was largely responsible for ulcers was recent, I think?

    • http://profiles.google.com/beholditiswritten Dave Hale

      You’re referring to Helicobacter pilorii (sp?) Within the last decade or two, they discovered that it played a major role in gastric and duodenal ulcers. That’s why it is now (as far as I understand it) standard practice to include an antibiotic in the treatment regimen for ulcers.

      • AmyM

        Yep!

      • Sue

        H. pylori (the “pylorus” is the outlet of the stomach)

        • http://profiles.google.com/beholditiswritten Dave Hale

          thanks for the correction. If I had taken 20 seconds to google it, I would have gotten it right. :)

    • Captain Obvious

      Was it this study that only had 24 babies? Or am I confusing it with another study? If this true, then water births should not be allowed since the babies are rinsed off immediately after birth. No baby should be bathed for 24 hours. :-/

      • Iris

        My baby came out with a handkerchief over his mouth and nose and clutching a bottle of antiseptic spray; the little bugger was sabotaging my vag flora transmission project. I thought I’d given birth to Woody Allen..

        • Sue

          Iris – that is HILARIOUS!

    • DiomedesV

      Also, if babies really do acquire important gut flora in the process of vaginal birth, why not obtain some of that vaginal fluid in the mother and smear it all over the baby who is born by C-section? Is there some reason why we can’t do that?

      • auntbea

        Yes. The reason is because that’s gross.

        • DiomedesV

          Why? Most babies are exposed to it in the vaginal canal. Then they eat something excreted by the mother for several months.

          • auntbea

            This is true. True, and also gross.

          • Hannah

            To be fair, most of the things that need to have happened to get to that point are pretty gross, when you think about it.

          • Kerlyssa

            Sex in a nutshell.

            ‘That was disgusting. Let’s do it again!’

          • Hannah

            To be equally fair, “gross” is just a manifestation of our species’ inbuilt (and evolutionarily advantage) aversion to other people’s bodily fluids. Naturally, their are exceptions.

          • Hannah

            That should read “advantageous” of course.

          • LukesCook

            In which case, why stop there?

          • Amy

            Last week I had my daughter with me at my annual pelvic exam, and she got a hold of the doc’s used glove. The poor doctor was horrified and so embarrassed that she had been able to get it, but I was like “oh it’s OK, she came out through there, so I’m sure there’s no harm done. And I have Purell in my purse.” lol gross.

          • araikwao

            Secreted, not excreted.

      • LukesCook

        How exactly do you envisage that the obtaining of vaginal fluid would work? And what if the reason for the c-section was GBS or herpes or HIV? Could one not just culture those bacteria that are actually shown to be beneficial (and if one can’t work out which, if any, are, then surely one isn’t going to go about smearing babies with vaginal fluid) and administer it in some slightly less rustic fashion?

        • DiomedesV

          And what if the reason for the c-section was GBS or herpes or HIV?

          Then don’t do it. That’s obvious. But there’s no reason to think that you need a lot of vaginal fluid.

          My point is that the notion that a vaginal birth must always give babies something vital that they simply cannot get from a C-section in the form of gut flora need not be true. Of course, all the studies on vaginal birth and gut flora are purely association, so there’s no reason to worry about it as of yet. But if it is important, there’s no reason to think such an issue can’t be easily circumvented for many C-section babies.

      • antigone23

        That’s what I thought when I read that article about gut flora. If it really makes that much of a difference, do it.

      • Captain Obvious

        Straight from MDC today…
        “I was a breech baby born via c-section, because I was breech. Now, I don’t know that it’s possible for someone to say they wish they’d died instead, but I do wish that I had not been born via c-section. C section birth results in different gut bacteria. My gut has never been right & my children have suffered for it (because even though they were all born vaginally & breastfed, I passed on my bad stuff to them). I believe that the c-section birth resulted in a lack of connection between my mother & I that has been the downfall for our relationship. It doesn’t matter what you do to someone you aren’t connected to, or so she seems to believe. Perhaps I would have been nursed had I not been born that way. Who knows? But again, since c-section makes breastfeeding more difficult & less likely to happen, it was likely a factor.

        In addition to a decision as to whether a baby should be delivered via c-section or vaginally because of presentation, the potential effects on future pregnancies & deliveries need to be considered, as a part of the informed consent. In an environment of few if any VBACs, I think the future ramifications should be weighed more heavily. If/when VBACs are more the norm, then I think it could be considered less heavily. My brother, my mother’s 2nd & last child, was born via c-section, because her first baby was born that way. He too has a messed up gut & also has mental illness as a result of his unhealthy gut. (I realize my ideas about gut health are not mainstream. I’m okay w/ it & it comes from years of research so I am completely comfortable w/ what I am stating here.)

        I’m responding because you asked about things from the baby’s perspective. I do not intend to minimize the experience of the mothers you are speaking of. I can not imagine what it must be like to be in their shoes. I should also say that I do not believe that all babies were meant to be born & live. Animals just don’t work that way. I’m not one for saving every baby & person regardless of the cost to the individual & those around then. I have never experienced a loss so saying this is easier for me than someone who has. ”
        Just wow

        • DiomedesV

          Oh, I agree, this is an absurd perspective, and personally I find the jumping on the gut-flora bandwagon to be silly. But my point was that there’s no reason to think that vaginal birth necessarily provides some aspect of gut flora that can’t be done to C-section babies.

        • Mrs. W

          ….wtf.

        • Renee Martin

          OH.MY.GOD
          “I do not believe that all babies were meant to be born&live.”

          Wow,someone actually SAID this!

      • Ceridwen

        Apparently (I work with folks who study the vaginal microbiome so we have lots of discussions about this sort of stuff) that exact thing is being studied.

        • Iris

          Ew, you have gross friends!

      • Iris

        What, as in dipping your finger in whipped cream and licking it clean? That kind of low tech approach? Only not with ice cream?

      • LukesCook

        Just thinking off the top of my head – if it’s _gut_ flora that are being acquired during vaginal birth then presumably it’s the mother’s _gut_flora that are required, rather than her vaginal flora? Are vaginal flora different or are they just the same flora that have migrated from the, ahem, gut, to the vagina? Also, presumably the flora need to find their way into the baby’s actual gut, rather than just be smeared around on the skin. In which case, why pussyfoot around smearing vaginal fluid on a baby? The right method would seem to be a spoonful of maternal feces. Or would that interfere with breastfeeding?

    • PoopDoc

      Helicobacter pylori is a bacteria that causes gastritis and can cause gastric ulcers. It’s a tough bug to kill. It’s also considered a pathogen, so not really “flora”.

      There has been some really interesting stuff about how gut flora is associated with different health conditions – including things like obesity, allergies, and autoimmune disease. Is it is a chicken and egg issue though. Is your gut flora different and contributing to the problem, or is your gut flora different because of the problem?

      • AmyM

        Thank you, yes this is what I was referring to (the current ignorance of the role of gut flora wrt conditons, etc).

      • Captain Obvious

        Vaginal discharge can be loaded with bacterial vaginosis or yeast strains commonly with pregnancy. Worse it may have gonorrhea, clamydia, trich, herpes, HPV, MRSA, GBBS, E coli, pseudomonas, or other no so great stuff present. And the intestines right next door has a whole host of great stuff too. Makes me wonder who wants to eat raw placenta after passing it through the vagina near the anus?

        • Not My Normal Nym

          Neil Degrasse Tyson, regarding the intelligent design of the human body:

          And what comedian designer configured the region between our legs—an entertainment complex built around a sewage system?

          • Something From Nothing

            I looove Neil degrasse Tyson…

          • Victoria

            Leon Uris has a similar line in his book Mila 18, “a playground between two sewers.”

          • The Computer Ate My Nym

            I’ve always heard that as a joke about god being a chemical engineer because who else would put an amusement park right in the middle of two toxic waste dumps?

      • Eddie

        There is also some evidence that H Pylori mediates the human immune system (to help it survive) and that getting rid of it can increase autoimmune disease. I don’t know how compelling the evidence is in favor of this.

        • Dr Kitty

          But people aren’t dying in large numbers from perforated stomach ulcers any more, so, you know- that’s a bonus.

          Ulcers were a leading cause of hospital admission and surgery until fairly recently, and kill(ed) a lot of people.

          • Eddie

            I’m not going to argue that one speculative risk means you don’t treat for a known immediate problem! If this turns out to be true, it just means maybe we mediate how we treat.

          • Dr Kitty

            The only people who are getting H Pylori eradiction therapy from me are those who have been tested for H Pylori, which means they already have symptoms of dyspepsia which prompted the test in the first place.

            Personally, I don’t test and treat asymptomatic people for H Pylori.

            Are there doctors doing that? It seems like overkill.

          • Eddie

            Again, I am *not* saying that this *speculative* risk (later higher risk of autoimmune disease) means we change how we treat anything today. I was only pointing out the interesting fact of this theory I’ve read about in the lay scientific literature. My prediction is that with 10 – 15 years we’ll have a clearer picture about risk factors for autoimmune diseases. If H Pylori truly turns out to be a risk factor, there are choices beyond “don’t treat ulcers with the best possible treatment”!

            Your two posts in this thread come across as if you think I’m saying medicine is doing the wrong thing today. I am not saying that. I had no intention of challenging any current treatment methods or saying anything doctors were doing today was “wrong.”

        • PoopDoc

          And untreated H.pylori is associated / “causes” MALT lymphoma. So pick your poison.

    • AllieFoyle

      I only know of one study that actually found differences in bacterial flora, and it had a grand total of 24 babies, only 6 of whom had been born by c-section. And the hygiene hypothesis is really still only a hypothesis, despite a fair amount of activity to prove it has merit. So, maybe it’s a little soon to be sincerely worried about dire consequences from lack of bacterial colonization…

      And *if* there were some demonstrable benefit to being colonized with certain bacteria, wouldn’t it be better to culture the beneficial organisms in an environment that was free of GBS, herpes, etc. and apply afterward?

      • Sue

        There is also evidence that a baby and infant’s gut flora is constantly changing, can doesn’t become stable until about age 3.

    • Sue

      Gut flora is 21st century woo. People are extrapolating the temporary changes post-antibiotics and the therapy for things like Pseudomembranous Colitis (C Difficile) with everybody and every situation. The woo industry typically takes a bit of science and misapplies it widely.

    • Ceridwen

      As far as I’m aware, there is currently no evidence that the difference is bad. And yes, there are differences in gut microbiomes between breastfed and formula fed babies (again, not linked to anything bad that I’m aware of). And there are large differences between adults and babies. But not so much between a 1 year old and a 6 year old. Basically once exclusive breast or formula feeding ends and solid foods enter the diet the gut microbiome of a baby converges rapidly on the gut microbiome of adults eating similar diets.

      We do have some evidence that differences in the gut microbiome can be linked to disease processes. Most compellingly so far, that C. diff can be treated with fecal transplantation. So the idea that there could be good or bad effects from differences in the gut microbiome is pretty reasonable. But that doesn’t mean we can skip the part where we demonstrate that differences in microbiome are linked to differences in health. Particularly given how much variation exists in the microbiome.

      • Sue

        An excerpt from an article on cesareans and gut flora, on the site The Converation:

        “Although birth is when we first encounter microbes, the process of acquiring a stable gut microbiota takes time. As any parent knows, an infant’s poo will change dramatically in texture, smell and even colour over the first year and introducing anything new to the diet often precedes an interesting experience. A stable microbial community isn’t formed until we have a fully developed immune system and an adult diet pattern – well after age three.”

  • The Computer Ate My Nym

    Hmm…

    Things I have that I wouldn’t have at my current age if I’d lived in prehistoric times:

    Teeth.

    A live child.

    All my fingers and toes. Not one gone to frostbite, infection, trauma, etc.

    Things I don’t have that I would have had if I’d been alive in prehistoric times:
    Multiple badly healed fractures.

    A dead baby being pulled from my uterus in pieces (in the best case scenario.)

    Things that would have been there either way:

    Cholesterol plaques in my arteries. Sigh. (Cholesterol plaques have been found in mummies from prehistoric times and in Otzi the “ice man”.)

    • quadrophenic

      For the life of me I can’t understand the obsession with “natural” or “ancient” remedies when it is so clear that our life expectancies and quality of life are so much better now.

      In 2012 I’m a 30 year old woman who is able to have a career and family while also having rheumatoid arthritis which is extremely well controlled with awesome medication. I can’t even fathom my chances of surviving in prehistoric times. But in say the Middle Ages, I would have been a nearly blind (my eyesight is correctable with glasses) cripple by the age of 22. My career prospects would probably be limited to beggar and/or prostitute. I’d be too disabled to even be a peasant.

      • The Bofa on the Sofa

        I commented the other day how the life expectancy in rural China in 1920 was less than 25 years.

        Men actually lived about a year longer than women (24.5 vs 23.5), but I’m figuring that was because of the dangers of childbirth.

        Those were the good old days…

        • Iris

          When Mozart was my age, he’d been dead six years..

        • The Computer Ate My Nym

          IIRC, men live longer than women in modern day Afghanistan. Pregnancy is not and never has been “inherently safe”.

        • Eddie

          Before World War I in America, men lived longer than women, I believe.

          • Dr Kitty

            Also remember that in turn of the century USA a leading cause of cardiac death was ruptured syphilitic aneurysm.

          • The Bofa on the Sofa

            Just to say that “syphilitic aneurysm” is a great phrase.

          • http://www.facebook.com/jennifer.delaney.90 Jennifer Delaney

            gross

        • LukesCook

          I suspect that before the advent of modern obstetrics women may have had shorter lifespans than men generally, other than in specific situations such as a major war or period of significant civil unrest. The stories all have wicked stepmothers, not much mention of stepfathers.

        • Sue

          Yes – Bofa – and yet so many people promote CHinese Traditional Medicine because “It’s worked for thousands of years”.

          • The Bofa on the Sofa

            Yeah, Sue, that was the context of my original comment. Why would anyone want to use TCM? Has anyone actually LOOKED to see how well it “has worked for thousands of years”?

            Oh, I’m sure the apologists would have every excuse in the world as to why the horrible outcomes that the Chinese faced for thousands of years was not due to TCM, and to be fair, it probably isn’t, but then again, there is no indication that TCM did any good, either.

            I mean, do they think that without TCM the lifespan would have been 22 years instead? That’s the type of argument that would need to be made.

        • anonymous

          OT (but on-topic to Bofa’s comment): I think you may have posted your original comment re. 1920s rural lifespan in China and TCM in connection with my query re. fertility acupuncture last week. I talked with the nurses at the clinic about the acupuncturist’s fees, and asked for clarification on the reason for acupuncture. The nurses were shocked at the fees and insisted that I talk again with my doctor. No one there had had any idea how expensive the acupuncturist was. They clarified that they were recommending it as a way of relaxing (similar to massage, eating ice cream in bed, exercise, etc.), and not for fertility enhancing purposes. The doctor told me that he was changing his recommendation for me and that I should do anything but acupuncture, even if it’s less expensive acupuncture. He also said they would re-evaluate their relationship with that acupuncturist. I also pointed out the acupuncturist’s involvement in moxibustion and fad diets. Anyway, thanks again to everyone for the words of scientific wisdom and support.

        • http://www.facebook.com/jennifer.delaney.90 Jennifer Delaney

          Ah yes… the good ole’ days of childbed fever, if you managed to make it through labor. Puerperal fever, if you will. And let’s not forget that women often had 5, 6, oh heck, let’s call it 15 kids, because many of those children were not expected to make it to adulthood due to cholera, measles, mumps, typhoid, polio, or heck, just a really bad flu. So, if you happened to be really good at birthin’ babies, you would expect to lose several between birth and age 5 or 6. So, you survived, only to live with the tradegy of the loss of one or more of your children. It was virtually guarenteed.

      • theadequatemother

        I think one of the two of you would have died in the first year of life…wasn’t infant mortality something like 50% back then?

        • LibrarianSarah

          Croup almost did me in during the 1980s. I couldn’t imagine what my chances would have been in the 1980s BCE

      • Iris

        Quadrophenic, I’m sorry to harsh your mellow, but have you not noticed it’s 2013?

        • quadrophenic

          Jeez, it’s only March. I can’t be expected to remember a new year that happened just 3.5 months ago!! I’ll start writing 2013 sometime in May.

          • The Computer Ate My Nym

            Someone today pointed out to me that 6 months from now it would be September and I nearly fainted in horror. Shouldn’t 6 months from now be July?

          • The Computer Ate My Nym

            Someone today pointed out to me that 6 months from now it would be September and I nearly fainted in horror. Shouldn’t 6 months from now be July?

        • Felicitasz

          ” I’m sorry to harsh your mellow,”

          One of the greatest thing about this site is how I add more and more expressions to my English by reading.
          Thank you all who have ever contributed.
          Thank you very much.

          • Sue

            “No worries!”, Felicitasz

    • Cellist

      “Things I have that I wouldn’t have at my current age if I’d lived in prehistoric times:”
      My husband.
      God bless Western Medicine.

      • Charlotte

        Same here. Congenital heart defect that was hard to treat even in the 1970s.

    • ccccat

      Are you telling me I’ve been avoiding bread for NOTHING? Curse you paleo diet!!

      • The Computer Ate My Nym

        IIRC, there is a fair amount of evidence that paleo-humans ate grain. Wild grain, sure, until they learned to cultivate it, but grain. So it wasn’t even a paleo diet that you were eating…

      • http://www.facebook.com/people/Tara-Dukaczewicz/100000875276196 Tara Dukaczewicz

        The paleo recipes really crack me up, paleo pizza for instance. I’ve read Clan of the Cave Bears and they made no mention of having a pizza night.

        • Amy M

          Ha! I bet Ayla invented pizza though, just like she invented spear-throwers, maxi pads, the bra, flint firestarters, and she is also responsible for the domestication of wolves and horses. I’d say lions, but no one else tried that after Ayla, so I guess it didn’t catch on.