There Is No "Obstetrical Dilemma": Towards a Braver Medicine with Fewer Childbirth Interventions.

Abstract

Humans give birth to big-brained babies through a bony birth canal that metamorphosed during the evolution of bipedalism; they have a tighter fit at birth between baby and bony birth canal than do our closest relatives the chimpanzees; and they are incapable of grasping onto caregivers as early as infant chimpanzees develop the skill. Since the mid-20th century, these observations and more have been linked together into the "obstetrical dilemma" (OD): human babies are helpless because they are born early to escape before they outgrow the mother's pelvis, the expansion of which is prevented by natural selection for bipedalism. The OD continues to be a popular idea, often expressed as incontrovertible fact, but it no longer deserves its popularity. There are better explanations for gestation length, childbirth difficulty, and the developmental biology of newborns than mainly or only because of natural selection's constraints on women's hips. And humans are not born early either, as is widely assumed. This all-too-powerful human evolutionary narrative deserves our skeptical consideration. Bias from OD thinking is likely amplifying the perceived risk of cephalopelvic and fetopelvic disproportion during labor-contributing, even if slightly, to medicine's underestimation of women's bodies and over-implementation of childbirth interventions.