For months after the birth of my fourth child thoughts of death and dying haunted me.
As I nursed my newborn and herded my older children, my mind preyed on what it felt like in the moment of dying. My thoughts constantly returned to how it felt when you knew there were only minutes left to live, or if, indeed, you would realise. Was there pain, clarity, realisation, or merely a cessation of being?
I had, by that time, skirted dying twice, and memories assailed me.
Each encounter had been accompanied by the rushing warmth of my own blood, and being too engrossed in a newborn and agony to realise that this was when, in past times or a different country, I would have died.
The first of my excruciating flashbacks was from the birth of my firstborn, a decade prior.
Twelve exciting hours of labor at home, twenty-four increasingly desperate hours at the hospital and suddenly, after hours of pushing, kneeling on the bed and clutching to the bedhead, I was on my back, surrounded by a multitude of people.
A young doctor - presumably a student- had a vacuum on my baby’s head, her foot up on the bed beside me for leverage as, panicked, she yanked with all her strength.
This was the moment muscle tore from bone.
This was the moment that led to my pelvic floor collapsing, my bladder, bowel, uterus, descending into my vagina — a common process known as prolapse.
The moment that led to ten years of my innards falling painfully out and my eventual hysterectomy and surgical repair.
Back then, I had no idea.
I had expected peaceful ‘surges’ to ease my baby into the world. Despite reading dozens of birth books, I paid little attention to anything I read about ‘vacuums’.
As I bled out, I looked across at my husband’s grey face and discovered what a man looks like when he believes his wife and child are dying. The student was pushed away, a more experienced doctor took over, one who didn’t use his foot as leverage.
My son was born - I reached for his purple, elongated, frog-like body as he emerged from me, but he was hurried away. Soon he was screaming and I was desperate to hold him.
My exhausted uterus couldn’t stop bleeding — there was little time and as I haemorrhaged they began sewing — well before the anaesthetics hit.
I tried to breath through it with the slow and careful breathing my ‘calmbirth’ course had taught me — and realised it is more difficult to breathe mindfully when needle and thread are stitching the torn and battered flesh of your birth canal before any kind of numbness has hit.
Those moments became my second most common flashback — my already bruised, torn and exhausted vagina stitched without anaesthetics while my baby screamed.
There are places needles should not go.
The vulnerable flesh of the vagina tops my list, although the stitches probably saved my life, and I am grateful.
They gave me a strangers blood and my baby nursed eagerly and easily and I was happy.
But still, there was blood everywhere. Attached to many cords, I couldn’t shower for two days, and I found blood under my fingernails, smeared down my thighs, on my flaccid, now empty stomach, in my hair. Each time I shifted, even slightly, more blood pulsed from me — the nurses couldn’t keep up with it and I constantly lay on bloody sheets.
When I was dis-attached from the cords I stumbled to the bathroom and in the mirror beheld a monster: bloody, pallid, swollen, bruised. It felt as if my baby had taken all the goodness and life from me and left a husk.
My baby was with me and he was beautiful and all that is perfect.
But I can’t forget.
My next meeting with death happened eight years later.
Again, it occured around midnight.
My fourth — last — baby nursed lustily, her umbilical cord newly cut, and I was dazed, besotted and adoring.
It had been a beautiful birthing.
I stayed at home until I knew I needed to travel the few minutes to the hospital. As soon as I had been checked I lurched into the triangular bath, and stayed there, on my knees, in the darkened bathroom, listening to beloved music.
I quickly realised my waters needed to be broken — none of my babies had been born until the amniotic sac had been manually broken, and then they had arrived within half an hour.
The midwife sounded doubtful when I insisted upon this. When she left the room I expounded on the necessity of this to my husband, probably louder than I thought, as I was wearing headphones. I was demanding that he do it, or I do it, when she returned, and agreed.
After my waters were broken I returned to the bath and within minutes stood up, needing the toilet, then realised it was my baby crowning. My husband eased our baby into the world as I stood in the water.
Her birth had been perfect.
The slow realisation that I recognised the steady, warm flood beneath me was not perfect.
“Ah, I think I’m bleeding to much,” I told the midwife. She checked, and quickly agreed. She started pounding on my tender belly. I breathed through it, curious to see the technique was such a primal, ancient one.
The doctor was called, who decided she’d need to explore my womb.
There was pain.
The pain of a full human hand ascending my battered birth canal, pushing through my loosened cervix, systematically peeling the inside of my uterus as she searched for remaining fragments of placenta.
Eventually she brought out a blood clot the size of a lemon. It was all done without anaesthetics.
This sharpened my ideas on pain.
My newborn, velvet soft and smelling like heaven, was warm and right in my arms and I concentrated on not tightening my hold on her with the searing hurt. But breathing steadily, slowly, was hard. My breaths were shuddering. One. Two. Three. Four.
It was intense. Soon over. I am grateful the doctor stopped my bleeding, saved my life, without surgery.
Later, as I stumbled to the shower, someone commented ‘It looks like a murder scene.’
I lost three litres of blood before the doctor staunched it.
After a time, the flashbacks became less vivid, I clawed back a little more sleep, and realised that humans aren’t designed to think too much about their own mortality. Our minds shy from it, or even the realisation that it applies to us.
But those first weeks and months - weeping with exhaustion and sleeplessness as I held my nursing baby with one arm, did the dishes with the other, settled squabbling children, cleaned the house, carted kids to school, kindergarten, appointments - made me consider, deeply, birth and trauma in our society, and in the past.
I was milk-stained, vomit stained, occasionally blood-stained as I mis-judged my lochia — the six week discharge of bloody fluid after a child’s birth.
My womb dragged and ached and tried to fall out due to the lasting trauma from my first birth.
My hands and feet were swollen and arthritic. Rheumatoid arthritis appeared with my body’s shock after my first birth, stayed for a year, and then appeared again after the fourth.
Amongst all this, I pondered.
I have all the advantages in this world. I am white, middle class, educated, straight, healthy, with a devoted partner and extended family, and yet still my body felt broken and memories assualted me.
How do women without my advantages survive? How do women in different societies, how did women in the past, survive, without being able to choose the number and spacing of their children, without hospitals to staunch bleeding, stitch up tears, cut out and wrench out over-large and misaligned infants?
My brain was hazy with sleep deprivation. I found it hard to shape the questions I needed.
What is a normal birth? Is it normal to find birth so hard and recovery so slow?
How did humans as a species survive, when our births are so dangerous, and so many of us suffer from permanent damage in our birthings?
According to the WHO, worldwide, at the moment, for every 500 births, one woman will die. In some countries maternal mortality is massively higher. In South Sudan for every 86 births one woman dies.
For every death, countless others will experience lifelong injuries and trauma.
Within the 'developed' world a little over one in every 10,000 woman will die in childbirth. This varies wildly depending on which 'developed' country is looked at. Even within countries, maternal mortality fluctuates wildly depending on race, socioeconomic group and location.
In 2001 a study estimated the death rate during ‘natural’ birth, without intervention, at 1 in 66.
Let us not forget that death, and permanent injury, are entirely natural.
Presently, half of all woman in Australia who have a vaginal birth will experience prolapse while overall one in five woman in Australia will have symptoms severe enough to need surgery.
For what is, essentially, ones insides becoming ones outsides, this seems an overlooked statistic.
We are lucky in Australia: a recent study in Pakistan found that 75% of woman who had four children or more experienced prolapse and 25% of woman between 36 and 40 years old had symptoms of prolapse. Over 60% of those woman with prolapse said it affected their lives to a severe or moderate degree. Nearly ninety percent of these woman had never talked about it with a doctor.
Difficult childbirth is not unique to humans. Spotted hyenas have a 15% mortality rate for first time mothers, while 60% of their infants suffocate during birth.
Death and permanent disability are very natural side effects of birth throughout the mammal kingdom. However, it seems that among primates, human births are particularly difficult, and human babies are particularly cost intensive.
But are our rates of damage unique to us now? What are our rates of trauma now? What ‘should’ they be?
I found it difficult to find a control group to compare. Each culture is so unique, each time so different. There are so many factors to take into account — nutrition, sanitation, disease, parasites, health, culture.
How could I compare a hunter-gatherer birth to a medicalised western birth when there are so many variables? I became fascinated, obsessed, with birth, birthing, the dependency of infants and what it means to us as a species.
When we were still becoming ‘us’, before agriculture, when we were still indistinguishable from the other primates, how did we as a species survive when our births are so fraught, our infants so dependant, and needing help for so long?
My fourth baby weaned — a percentage of my brain returned and I undertook an online university course on human evolution.
I was only interested in one topic — how birth and babies impacted human evolution. It made immense sense to me that one of the main factors making humans ‘us’ is the uniqueness of our infants.
I wondered how humans managed before — how did the primates who evolved into us cope with the unique reproductive difficulties humans are heir to?
How did those ancient primate mothers stay alive when the scent of their birth-blood would attract predators, and they had uniquely helpless and cost-intensive infants to nurture?
Was it the agricultural revolution that made childbirth so inherently dangerous and difficult? Our change of diet and increased carbs? Our lack of exercise? Am I to blame for my difficult births? Was I too lazy, should I have eaten fewer vanilla slices?
My (somewhat obsessive) research on human origins led me to understand that our young are uniquely costly.
I truly believe that we are us — intelligent, curious, creative, thoughtful, playful, manupulative, talkative, inventive — because of the uniquely dependent babies we birth and their extensive period of dependency.
No other primate is born so helpless, and no other primate has young that needs care for so long. Studies of hunter-gatherer societies have determined that humans are at least eighteen before they can independently support themselves.
Among primates human newborns have uniquely large brains and are uniquely fat. Both of these factors affect our births and who we are in multiple ways.
Recently, it has become more accepted that humans are birthed at such an early stage in our development as that is the point mothers can no longer support the energy needs of growing such large brains.
While breastfeeding is also energy expensive - in the first six months of breastfeeding a mother expends the same amount of energy in supporting her infant as in the last trimester of pregnancy - the energetic costs of breastfeeding can be more controlled by the mother.
When the infant is in the womb the ongoing battle between the foetus and the mother for energy can leave both the (dead) loser.
Human newborns are helpless, unable to even hold to their mothers. Our infants are seven months before they reach the development stage of newborn chimpanzees.
It is this extended childhood that encourages learning and language.
Our babies are so helpless and high cost that human mothers cannot raise their infants alone. To successfully raise our young, humans need help. We need help in the difficult months of pregnancy and we need help when raising our draining, but rewarding, children.
Alone amongst primates, humans will abandon our newborns if we do not have support structures in place, aware that it is impossible to raise a human infant alone. We have evolved to be social creatures in part, and probably in large part, in order to raise our exceptional young.
Anthropologists suggest our babies are born uniquely fat in an effort to persuade their mothers, and those around them, that they are worth raising.
With their layer of blubber a human baby is telling its mother that it is a great investment.
Human infants evolved to be immensely cute. Studies show that their own baby’s smile affects a human mother in a similar way to cocaine.
It is a shame that this cuddly layer of fat makes the birth process more difficult; however, as our species still exists, it has been a successful strategy in the long term.
Our fat, large-brained, energy-expensive babies have always been difficult to birth.
The time of birth balances on the jagged point of what is best for the mother and what is best for the infant. Our difficult births are the price we pay for our intelligence.
Pregnancy is a time when the mother’s body and the infant’s body are locked in warfare. The foetus attempts to take as much energy as it can and the mother’s body attempts to conserve that energy for itself.
The resulting battle leads to frequent miscarriages (up to one in four pregnancies), morning sickness, gestational diabetes, pre-eclampsia. All of these can lead to the mother’s death.
Those of us that have been damaged in our birthings are part of the cost of us being human.
There are many of us leaking, aching, living with chronic pain. But we are part of the invisible, of the damaged, and less than perfect.
My births left me with permanent damage. My surgical repair means I am not supposed to lift more than fifteen kilos. Recently, something tore in my repair, my organs returned to their descent, and pain returned.
My experiences are as nothing compared to those who suffer from fistulas - tears between the vagina and the anus, which cause long term incontinence, pain, infection, infertility and social isolation. Often the horrifically long births - some lasting four or five days, also result in the stillbirth of the child.
My experiences are mild compared to many others, particularly of others who live in parts of the world where there are child brides, female genital mutilation and widespread malnutrition.
My experiences are mild compared to indigenous Australians who have a far greater rate of death and injury in birth, and often have long standing trauma associated with the health system.
I have three daughters — the thought of them experiencing even this level of pain and trauma, of having their bodies shattered in a similar way, affects me on a visceral level. I don’t want this for them. And yet, I know I would go through the pain again without a seconds reflection, for my children. The idea of a world without them is inconceivable.
There is not a day that goes by when I am not deeply grateful for my children.
There is not a day that goes by when I am not deeply grateful for reliable contraception.
There is not a day that goes by I am not afraid of governments changing, and taking away the present rights woman have over our bodies.
If my study has taught me nothing else it has taught me that woman are held captive by our reproductive system.
While our children are, or should be, our joy and delight, our reproductive system also leaves us deeply vulnerable.
For many years and in many places, our deaths in pregnancy and childbirth have been unavoidable.
Now, as medicine makes great advances and, for most of us, our health and sanitation has improved markedly as well, far fewer of us die and are injured in childbirth.
As parts of the world become safer places, as births take place in hospitals rather than at home, many of us forget that pregnancy and birth are inherently dangerous.
Woman are expected to make instantaneous recoveries, and birth is expected to be beautiful.
And sometimes woman do make instantaneous recoveries and sometimes birth is beautiful.
But there is an inherent danger and risk that will never be truly alleviated.
For those of us with long term damage, to be seen and acknowledged seems like a first step towards a more reflective society that is more inclusive of those deemed broken or imperfect.
For a society that does not turn away from pain but acknowledges that nature is as unforgiving as it is beautiful. That acknowledges that we have evolved to care about and depend upon each other, and respects and acknowledges the price mothers pay for our humanity.