Eve Ate the Apple and Gave us the Obstetrical Dilemma, Right?

Eve ate the apple, and birth became painful for humans ever afterward.

The obstetrical dilemma is a concept that is pervasive in our culture and in our medical system. The idea is that human birth is “difficult” and painful because of either Eve’s curiosity or, in scientific land, because of two specific evolutionary changes. The first change was from using four limbs to using two for locomotion.  Humans stand up on two legs (bipedalism), and the theory purports that this made the outlet of the human pelvis smaller. The second evolutionary change was the intense need for social interaction to teach our young how to survive. Other animals rely more on instinct and less on teaching/learning to know how to find food and shelter. This need for social interaction and the use of language required a bigger brain housed in a larger skull… thus humans had to start birthing large-brained babies from smaller pelvic outlets resulting in more difficult births.

In academic language, it sounds like this: “The hypothesis holds that antagonistic selection for a large neonatal brain and a narrow, bipedal-adapted birth canal poses a problem for childbirth” (Dunsworth, et al., 2012).

Here’s the thing.

This theory, very widely accepted, is based on a lot of assumptions that were never tested or clarified. 

It also arrived on the scene at a time when (mostly male) physicians were attempting to wrest control of birth away from (mostly female) midwives and move birth from homes to hospitals. The “obstetrical dilemma” fit the needs of the dominant group. Birth is difficult, perhaps they could go so far as to call it “dangerous!”, and therefore birthing people need expensive “experts” with access to the latest technology to save their lives.

If you want to know a LOT more about this history, I recommend reading a 2003 classic article by Dana Walrath called, “Rethinking Pelvic Typologies and the Human Birth Mechanism.”

In this post, I want to question just two of the assumptions that underpins the obstetrical dilemma theory. The first is the idea that labor and birth are longer, more difficult, and more painful for humans than for any other animal, including our primate relatives. But the fact is that at the time this theory was finding wide acceptance, scientists had extraordinarily few observations of primate birth to use for comparison. This was before the time of, say, Jane Goodall (who studied gorillas) or Dian Fossey (who studied chimpanzees) or Galdikas (who studied orangutans). We did not know until 1971 that orangutans were fruit eaters, so imagine what we knew of their reproductive experiences?

In Walrath’s article, she details some of what we have come to learn about primate birth experiences. Turns out that primate birth can be long and difficult, too. Their infants also need to rotate in order to emerge (something we thought was uniquely human because of the obstetrical dilemma). Some primates have had documented labors as long as 60 hours! Researchers do not usually get to observe primate birth up close, so we actually do not know much about the birth positions of primate infants (for example, do they face upwards or downwards? Occiput posterior or anterior?).

A second assumption is that humans give birth to young “earlier” in their gestation than other animals because of their large brains. We often say in the natural birth world that human babies are born about “three months too early” and we have the phrase “fourth trimester” to explain how helpless human infants are in the early months. But, again, guess what? We decided this was true before we really investigated it. As Dunsworth, et al. write, human gestation is longer than that of chimpanzees, gorillas, and orangutans. And not only is gestation absolutely longer, if we control for the relationship between the body mass of the birthing person/primate and the length of pregnancy, humans look like we have a LONGER pregnancy!

In academic language, that sounds like this: “At 38–40 wk, on average, human gestation is absolutely longer than that of Pan (32 wk) and Gorilla and Pongo (37–38 wk). Controlling for the positive relationship between maternal body mass and gestation length in primates (n = 21 species; r2 = 0.56; Fig. 1 and Fig. S2), humans are second only to Pongo in their gestation length. Human gestation length is 37 d longer than expected for a primate of similar body mass, relatively longer than either Gorilla or Pan. So not only is human gestation not truncated, as comparisons controlling for adult brain size might suggest, but the data indicate that gestation has increased in the hominin lineage.”

One takeaway I have is this: Birth works very well, evolutionarily speaking! Humans are successful at reproducing and producing live offspring. Our bodies have been designed through evolutionary pressures to give birth well and at the right time, just as other animals’ bodies are designed to give birth well and at the appropriate time. If we are going to take any lessons from our primate relatives, it is probably fair to take this lesson: We can do it!

I recently visited Portugal (yay for travel in the New Covid-Is-With-Us Times!) and I was, like many Americans, blown away by how ancient artifacts and buildings exist side-by-side with modern architecture. I was also in love with the many places I saw historic, artistic depictions of women breastfeeding infants. Here is one from 1519 that I found just turning a corner down an alley on the exterior of the Cathedral of Braga. In Portuguese it is called Nossa Senhora do Leite (Our Lady of Milk!)

Nossa Senhora do Leite 1519 by Nicolas Chantereine on Cathedral of Braga

In Porto, in the beautiful train station downtown, there are blue and white murals (azulejos) that look ancient but are “only” about 120 years old. They were created by artist Jorge Colaço starting in 1905. Many of the murals depict “important” events in Portuguese history, but some of the murals show more everyday life scenes, such as this one, in which a woman is breastfeeding in the bottom corner while the everyday work of subsistence agriculture goes on:

Porto Train Station

It isn’t just ancient depictions that I ran into on my trip. In the window of shop selling local art, I found this charming depiction of the Holy Family co-sleeping. No crib in sight! 🙂

Contemporary art for sale in Braga

And, just because it’s amazing!, my photos of remnants of Roman aqueducts from about 2,000 years ago !!!! in Ponte de Lima. We are such a young country over here across the Pond!

Ponte de Lima Roman Aqueduct

So, this was inspiring! BOTH my books made this list. There are a few more here I am interested in checking out now, too. Great gift list for anyone pregnant in your life! Click here for the full list: motherrisingbirth 2017 Best Books!Fourth Trimester Companion cover


Mamademics photoSo, I ran across this birth story today.

It make me smile and laugh out loud.

I have to say that I am always wondering why the fathers of our planet do not write more poetry, more prose, more essays about the wonder of the women they have witnessed give birth to new humans. I witness this as a doula, and I am in awe every single time. Cesarean birth. Vaginal birth in a squat. Vaginal birth with doctor’s hands all over the place. Doesn’t matter. I’m in complete awe. How did she DO that?

But doulas write about it and talk about it all the time. Why don’t dads? Well, here’s a dad who appreciates the woman in his life. Love it!

Awesome Birth Story by a Dad!

Fourth Trimester Companion coverMy second book-child is about to be born!

I am so excited! I was inspired by all the women of Mom-Baby Groups with whom I have laughed and cried and shared life-saving tips. This book is my attempt to share our collective wisdom for all the new mamas who think they are alone.

You can pre-order the book directly from me

BOOK LAUNCH price of $13

or 2 for $25! (List price: $22.99). Plus $1 shipping for each book you order. (One book = $14 total). I will sign your book and send to you on January 9th. Get one for yourself and for all the mamas and mamas-to-be in your life!

You can preorder through this link:


Make sure to leave your address so I know where to send your copy. (You can also send your address to my e-mail fourthtrimestercompanion@gmail.com.)

Doulas and birth professionals: Stock up! This price is a great deal!

Peace, Sleep, and Baby Smiles,



Birth – like Life — is full of choices!

I am all for choice and accessibility to good drugs, but it seems strange to me that “natural childbirth” is considered a radical movement by so many people. People wonder if they “can do it” without the epidural, as if unmedicated birth is the “alternative” only for special unicorns, the epidural being the expectation and default. There are absolutely people who need an epidural for a safe and/or trauma reducing birth, so thank goodness we have them. I think it would be terrible to not have access to them.

What concerns me is the language we tend to use around epidurals chosen in normal birth, phrases like “I couldn’t have given birth without one,” Most often epidural use is about the privilege of choice and accessibility when the level of sensation or tiredness involved with birth is not desired . That isn’t a bad thing. But It isn’t literally that we couldn’t “do it” (barring special circumstances, remember), because if accessibility were removed, most folks WOULD “just do it”.

A truer statement for many people is “I didn’t WANT to do it without the epidural when I felt how tough the pain was to work through.” And that is okay! We don’t need to apologize for our choices in birth. Ever. People are awesome birth givers with or without epidural. But it is powerful to own a choice rather than relegate our reason for pain relief to an assumed organic failure of our collective birth giving body/mind.

My concern is that “I couldn’t do it” feeds the cultural norm of birth being generally undo-able, a legacy passed down to the next generations of physiologic birth “impossibility”. It is powerful to say “Given the epidural’s accessibility, I chose not to ‘do it’ because I preferred the idea of reduced pain” There is nothing shameful about exercising that choice. The power to own choice seems to be a stronger legacy to leave than a belief that phyiologic birth is virtually impossible.

–My friend and birth heroine, Lesley Everest, founder of Motherwit (Montreal and beyond!) wrote this reflection. — Cynthia

Ceridwen Morris summarizes my book for Babble. So, here is the VERY QUICK version of my book in case you don’t have time to read the whole thing or just went into labor and need a condensed version ASAP. 🙂 https://www.babble.com/pregnancy/7-tips-for-having-a-natural-hospital-birth/

Morris writes: I just finished reading  “Natural Hospital Birth: The Best of Both Worlds” and I loved it! It’s written by medical anthropologist and doula, Cynthia Gabriel and it’s solidly helpful for women hoping for this kind of birth.

Home birth is not for everyone for a whole host of reasons, but some women feel they’d like to have something close to it in a hospital setting. And for those women there are strategies. This book is dedicated to that concept.

Here are seven really smart tips I got from the book:

1. Plan it. Absolutely have a dream birth and write it all out if you want to. While so many well-meaning friends, docs, and childbirth educators tell women to “stay open” she says there’s still a place for being very clear about what you want.”To the call for flexibility I say, ‘Let the hospital be flexible!’” Her most important advice: “Make a birth plan, and get attached to it!” She says you don’t have to hand this long document over to everyone you encounter– the headlines will suffice– but for your own process, writing it down can help you.

2. Get a great birth team together. Think about who will be with you to support you in labor. You really want to have a midwife or doctor who supports your wishes. This might mean you need to switch care providers mid-pregnancy (don’t worry, they’ll have plenty of other patients), hiring a labor support doula and taking a childbirth class “Taking charge of creating a positive birth team is a vital step in preparation for a natural birth.”

3. Learn about what happens in labor and what it feels like. Her sections on this topic are outstanding. She describes different kinds of labor but throws in amazingly accurate descriptions of what a woman looks like and acts like (for the partners) and feels like (for the moms who’ve never given birth before).  She writes about particularly challenging moments: the car to the hospital, triage, mid-active labor (at around 5-6 centimeters dilation) and transition.


4. Learn lots of coping strategies. Investigate all the ways you can cope without pain medication and practice a bunch of them with a partner beforehand. Gabriel gives a list of ways to help cope (she is a very big fan of getting in the water– a tub or shower) but also describes in detail how these things play out and help at various stages.

5. Wait an hour. When a medication or a medical procedure is proposed ask, “what if we wait an hour?” How this is answered will give you a lot of information. Sometimes you say, “What if we wait an hour” and the doctor says, “Oh, OK.” Now you know this is not an emergency but a suggestion.

6. Stay home in early labor. And while you’re at it? Ignore it! Ignore it until you can’t ignore it anymore.

7. Eat, cry or move. Often if a woman reaches a plateau in labor and it seems to slow down– often eating (for energy), crying (to release stress) or moving (to enable better positioning for the opening of pelvis/descent of baby and/or reducing pain) will likely help!

Gabriel also offers so much great, easy-to-follow advice for partners I can’t sum it up in a bullet point. But I will say, if you’re hoping for a non-medical birth in a medical setting, this book has a ton of good advice and info you can use.



Not everyone who is having their first baby had a wedding first. If you did, though, you have a natural window through which to peek at your relatives’ likely behavior — and your likely feelings about their behavior — at the birth of your baby. If you did not have a wedding, you may be able to think of another emotionally-heightened event at which family play a big role that will act as this window.

Mothers, mother-in-laws, sisters, and close friends are all likely to want to play a role at the time you give birth. I will focus mostly on mothers here, although for any mom-to-be it may be a sister or friend who lives nearby who is the focus of your attention. The question that pregnant women often ask their doulas is, “Should I invite her to the birth?”

If the woman had a wedding, this is where I usually start my questioning. Because it’s not about whether the relationship itself is good or bad. If you are considering inviting this person to your birth, I will assume the relationship is at least pretty positive. It’s about how the woman feels when she is doing something meaningful, stressful, and full of rapid decision-making in the presence of this other person.

Did you feel like your mother (sister/aunt/friend) understood exactly what you needed in the moment and was acting like an extension of yourself at all the wedding events? Or did you feel like she kept bringing you problems and issues to solve? Did she love your ideas and offer to help out anywhere? Or did she disapprove of your decisions (subtly or not so subtly)? Did she try to talk you out of ideas that meant a lot to you? Did you feel like her feelings enhanced and deepened the meaningfulness of your wedding for you? Or did her feelings about your wedding interfere with your own enjoyment?


Mothers can be just like us or very different from us and still be capable of offering genuine support. But not all mothers can offer genuine support. Their own needs get in the way of that.

Take a good look at how you felt about your mother (sister/aunt/friend)’s role at your wedding. If you have any lingering feelings of resentment or disappointment, I would strongly urge you to find a way to keep your laboring space free of their presence. Give her an important job to do away from your birthing space (making a birthday cake for the baby is a great job, for example). You do not get a re-do on your birth experience, so, like a wedding, it’s important to plan carefully. Don’t discount this treasure trove of information about how people are likely to act. Together with your gut instinct, this information about the past can usually tell you what you need to know about, “Should I invite her to the birth?”


POST-PARTUM SEX By Cynthia Gabriel, Ph.D.

No one talks about the sex life of new parents. I could make a joke here about how that’s because there is none, but that is not true at all. We would just rather gossip about a celebrity’s sex life than talk about real and challenging issues in an open, accepting way. Here in this land of individual freedom, we just let people figure things out (I mean struggle) by themselves. But it doesn’t have to be this way!

I, myself, have struggled with my sexuality in the wake of becoming a mother and I could have used some advice and reality checks. I feel lucky and privileged to have talked about this intimate subject with hundreds of women in interviews and in mother-baby groups. So, from the get-go, let me acknowledge that this is a one-sided piece. I have only heard from a handful of new fathers and even fewer lesbian mothers about this issue. But from these new mothers, I want to share some observations.

Friends, family, and medical professionals may assume you haven’t had sex in a LONG time – as if pregnancy and sex were incompatible.

Although pregnancy does slow down a sex life for some couples, for many couples pregnancy is a time of great sexual exploration. Still, birth has a way of changing the sexual dynamic, even if you were enjoying yourselves fully just a few days or weeks ago.

It takes longer to have sex after the baby is born for many couples than you think. Many people assume that the six-week mark is some magic date because there is usually a check-up at six weeks with a doctor or midwife. Yes, one of the topics of conversation at this check up is supposed to be birth control and, yes, the medical professional will examine the perineal area and the abdomen for healing. But this does not mean that a magic date has arrived. Do not think for a moment that MOST people have sex sometime around the six-week mark. Some do. But many, many, many do not.

The first time you have sex after having a baby is more of a “check in” than an act of passion. This may continue for a while.

A woman often wonders what sex will feel like after having a baby, even if she gave birth by cesarean. “Things” feel different in her body and it’s not clear ahead of time how these new sensations will affect sex. Lactating women are probably experiencing leaking and spraying as part of their everyday lives and they usually worry about how this will affect the sexual experience. She may have relied on nipple stimulation in the past to help get to arousal. What if her nipples are too sore from a baby’s mouth to be played with like they were in the past?

If you go into the first time – and, realistically, the first five or six times – as experiments, you will be less disappointed. These are occasions to figure out what is going to work for you, not occasions to measure something about your sexual success.

Women are often deeply worried about how their partner will “see” them now. They NEED reassurance, but part of that need is not wanting to ask for it.

The partner probably needs and wants reassurance, too. The partner wants reassurance that s/he is still desirable and that the new birth mother is not so wrapped up in the infant that there is no room for their “couple-ness.” The bad news is that the new birth mother is in NO POSITION to offer this reassurance. She will be able to do this better when the baby is one year old and she is feeling more confident herself. But right now, these first MONTHS (that’s right. Months. Not weeks) she is the one who needs reassurance. It’s part of the trade-off about growing the baby and giving birth to the baby. So, no matter how much you wish she would tear your clothes off and tell you how sexy you are, now is the time for you to tenderly reassure her that you find her attractive AS SHE IS.

Getting annoyed at the baby is a TURN-OFF. Being understanding of her attunement to the baby is a TURN-ON.

If you manage to get all the things in order to have a sexual encounter (you are rested enough, had a shower, the baby is asleep, the bed is not full of baby poop or throw up, you are not mad at each other about who got up in the middle of the night for burping, etc.) and the baby wakes up and interrupts you…

If you can be understanding and caring toward your partner if she needs to take care of the baby (or if she asks you to do so) you are more likely to get another shot at this the next time the opportunity arises. It might be in five minutes, when the baby is calm or it may be another day.

If you groan and complain, you are less likely to get that second shot.

The choice is yours.

Figuring out WHEN and WHERE is more complicated than you think.

Some babies sleep enough that it’s possible to have a good sex life in your own bed. But many babies do not sleep enough and couples have to figure out where to go to have sex. The problem is that most babysitters come to YOUR house. If you can afford it, think of a hotel room for an afternoon as the same price as dinner and a movie. Once a month, this may be worth it.

Sex can hurt more after having a baby.

Although this is not true for all women, for a certain percentage of women sex after giving birth is more painful than it was before. Generally, the first thing to try is more lubrication. If that does not fix the issue, an estrogen cream can be helpful. This is a topical cream, not an estrogen pill that you take internally, so it does not have the same effects on your body that hormone pills do. In studies of “women’s sexual health after childbirth” about half of women report vaginal dryness as an issue. You are not alone!

Feeling “Touched Out” is a real problem for new mothers.

 Many new mothers who spend their days and nights caring for needy newborns want to spend their non-baby time not being touched. It’s a serious mismatch for new mothers and their partners who, likely, are feeling less touched than they were before the baby arrived.

There is not an easy answer to this problem; however, if you are the partner reading this essay, I would take away that providing down time without the baby is likely to be helpful to the new mother’s receptiveness to touch. Otherwise, this is an issue that just requires patience and understanding.

For you science geeks out there I am going to copy some information from a 2000 British Journal of Obstetrics and Gynecology about this issue. What I find fascinating is that the medical professionals write it this way “Sexual morbidity increased significantly after the birth: in the first three months after delivery 83% of women experienced sexual problems, declining to 64% at six months, although not reaching pre-pregnancy levels of 38%.”

I would reframe it this way:

Most of us hope that we will return to our pre-pregnancy sex life by about six weeks after our babies are born because this is what we are led to believe by birth books and doctors. The reality is that this expectation is not realistic, but no one talks about it openly. The truth: 38% of us have sexual difficulties even before we have babies and 83% of us are not having the same kind of sex life we used to have for THREE MONTHS and 64% for SIX MONTHS after our babies are born.

In other words, it is NORMAL to have a very different kind of sex life for a LONG TIME after our babies are born. It is UNUSUAL to return to an easy-peasy sex life within six months post-partum.


BJOG. 2000 Feb;107(2):186-95.

Women’s sexual health after childbirth.

Barrett G1, Pendry E, Peacock J, Victor C, Thakar R, Manyonda I.

Author information



To investigate the impact of childbirth on the sexual health of primiparous women and identify factors associated with dyspareunia.


Cross-sectional study using obstetric records, and postal survey six months after delivery.


Department of Obstetrics and Gynaecology, St George’s Hospital, London.


All primiparous women (n = 796) delivered of a live birth in a six month period.


Quantitative analysis of obstetric and survey data.


Self reported sexual behaviour and sexual problems (e.g. vaginal dryness, painful penetration, pain during sexual intercourse, pain on orgasm, vaginal tightness, vaginal looseness, bleeding/irritation after sex, and loss of sexual desire); consultation for postnatal sexual problems.


Of the 484 respondents (61% response rate), 89% had resumed sexual activity within six months of the birth. Sexual morbidity increased significantly after the birth: in the first three months after delivery 83% of women experienced sexual problems, declining to 64% at six months, although not reaching pre-pregnancy levels of 38% . Dyspareunia in the first three months after delivery was, after adjustment, significantly associated with vaginal deliveries (P = 0 x 01) and previous experience of dyspareunia (P = 0 x 03). At six months the association with type of delivery was not significant (P = 0 x 4); only experience of dyspareunia before pregnancy (P < 0 x 0001) and current breastfeeding were significant (P = 0 x 0006). Only 15% of women who had a postnatal sexual problem reported discussing it with a health professional.

Book Review

Just found this on the web. Thank you, Sarah Luk!