March 13, 2012

Childbirth and C-Sections in Bioarchaeology

Basically since we started walking upright, childbirth has been difficult for women.  Evolution selected for larger and larger brains in our hominin ancestors such that today our newborns have heads roughly 102% the size of the mother's pelvic inlet width (Rosenberg 1992).

Yes, you read that right. Our babies' heads are actually two percent larger than our skeletal anatomy.

Fetal head and mother's pelvic inlet width
Photo credit:
Obviously, we've also evolved ways to get those babies out.  Biologically, towards the end of pregnancy, a hormone is released that weakens the cartilage of the pelvic joints, allowing the bones to spread; and the fetus itself goes through a complicated movement to make its way down the pelvic canal, with its skull bones eventually sliding around and overlapping to get through the pelvis.  Culturally, we have another way to deliver these large babies: the so-called caesarean section.

Up until the 20th century, childbirth was dangerous.  Even today, in some less developed countries, roughly 1 maternal death occurs for every 100 live births, most of those related to obstructed labor or hemorrhage (WHO Fact Sheet 2010).  If we project these figures back into the past, millions of women must have died during or just after childbirth over the last several millennia.  You would think, then, that the discovery of childbirth-related burial - that is, of a woman with a fetal skeleton within her pelvis - would be common in the archaeological record.  It's not.

Archaeological Evidence of Death in Childbirth

Two recent articles in the International Journal of Osteoarchaeology start the exact same way, by explaining that "despite this general acceptance of the vulnerability of young females in the past, there are very few cases of pregnant woman (sic) reported from archaeological contexts" (Willis & Oxenham, In Press) and "archaeological evidence for such causes of death is scarce and therefore unlikely to reflect the high incidence of mortality during and after labour" (Cruz & Codinha 2010:491).

The examples of burials of pregnant women that tend to get cited include two from Britain (both published in the 1970s), four from Scandinavia (published in the 1970s and 1980s), three from North America (published in the 1980s), one from Australia (1980s), one from Israel (1990s), six from Spain (1990s and 2000s), one from Portugal (2010), and one from Vietnam (2011) (most of these are cited in Willis & Oxenham).  Additionally, I found some unpublished reports: a skeleton from Egypt, a body from the Yorkshire Wolds in England, and a skeleton from England.

The images of these burials are impressive: even more than child skeletons, these tableaux are pathos-triggering, they're snapshots of two lives cut short because of an evolutionary trade-off.

The wide range of dates and geographical areas illustrated in the slideshow demonstrates quite clearly that death of the mother-fetus dyad is a biological consequence of being human.  But what we have from archaeological excavations is still fewer than two dozen examples of possible childbirth-related deaths from all of human history.

Where are all the mother-fetus burials?

As with any bioarchaeological question, there are a number of reasons that we may or may not find evidence of practices we know to have existed in the past.  Some key issues at play in recovering evidence of death in childbirth include:
  • Archaeological Theory and Methodology.  From the dates of discovery of maternal-fetal death cited above, it's obvious that these examples weren't discovered until the 1970s.  Why the 70s?  It could be that the rise of feminist archaeology focused new attention on the graves of females, with archaeologists realizing the possibility that they would find maternal-fetal burials.  Or it could be that the methods employed got better around this time: archaeologists began to sift dirt with smaller mesh screens and float it for small particles like seeds and fetal bones.
  • Death at Different Times.  Although some women surely perished in the middle of childbirth, along with a fetus that was obstructed, in many cases delivery likely occurred, after which the mother, fetus, or both died.  In modern medical literature, there are direct maternal deaths (complications of pregnancy, delivery, or recovery) and indirect maternal deaths (pregnancy-related death of a woman with preexisting or newly arisen health problems) recorded up to about 42 days postpartum.  An infection related to delivery or severe postpartum hemorraging could easily have killed a woman in antiquity, leaving a viable newborn.  Similarly, newborns can develop infections and other conditions once outside the womb, and infant mortality was high in preindustrial societies.  With a difference between the time of death of the mother and child, a bioarchaeologist can't say for sure that these deaths were related to childbirth.  Even finding a female skeleton with a fetal skeleton inside it is not always a clear example, as there are forensic cases of coffin birth or postmortem fetal extrusion, when the non-viable fetus is spontaneously delivered after the death of the mother.
  • Cultural Practices.  Another condition of being human is the ability to modify and mediate our biology through culture.  So the final possibility for the lack of mother-fetus burials is a specific society's cultural practices in terms of childbirth and burial.  In the case of complicated childbirth (called dystocia in the medical literature), this is done through caesarean section (or C-section), a surgical procedure that dates back at least to the origins of ancient Rome.
Cultural Interventions in Childbirth

It's often assumed that the term caesarean/cesarean section comes from the manner of birth of Julius Caesar, but it seems that the Roman author Pliny may have just made this up. The written record of the surgical practice originated as the Lex Regia (royal law) with the second king of Rome, Numa Pompilius (c. 700 BC), and was renamed the Lex Caesarea (imperial law) during the Empire.  The law is passed down through Justinian's Digest (11.8.2) and reads:
Negat lex regia mulierem, quae praegnas mortua sit, humari, antequam partus ei excidatur: qui contra fecerit, spem animantis cum gravida peremisse videtur.
The royal law forbids burying a woman who died pregnant until her offspring has been excised from her; anyone who does otherwise is seen to have killed the hope of the offspring with the pregnant woman. [Translation mine]
Example of Roman gynaecological equipment: speculum
From the House of the Surgeon, Pompeii (1st c AD)
Photo credit: UVa Health Sciences Library
There's discussion as to whether this law was instituted for religious reasons or for the more practical reason of increasing the population of tax-paying citizens.  In spite of this law, though, there isn't much historical evidence of people being born by C-section.  Many articles claim the earliest attested C-section as having produced Gorgias, an orator from Sicily, in 508 BC (e.g., Boley 1991), but Gorgias wasn't actually born until 485 BC and I couldn't find a confirmatory source for this claim.  Pliny, however, noted that Scipio Africanus, a celebrated Roman general in the Second Punic War, was born by C-section (Historia Naturalis VII.7); if this fact is correct, the earliest confirmation that the surgery could produce viable offspring dates to 236 BC.

This practice in the Roman world is not the same as our contemporary idea of C-section.  That is, the mother was not expected to survive and, in fact, most of the C-sections in Roman times were likely carried out following the death of the mother.  Until about the 1500s, when the French physician Fran├žois Rousset broke with tradition and advocated performing C-sections on living women, the procedure was performed only as a last-ditch effort to save the neonate.  Some women definitely survived C-sections from the 16th to 19th centuries, but it was still a risky procedure that could easily lead to complications like endometritis or other infection.  Following advances in antibiotics around 1940, though, C-sections became more common because, most importantly, they were much more survivable.

Caesarean Sections and Roman Burials

Roman relief showing a birthing scene
Tomb of a Midwife (Tomb 100), Isola Sacra
Photo credit: magistrahf on Flickr
In spite of the Romans' passion for recordkeeping, there's very little evidence of C-sections.  It's unclear how religiously the Lex Regia/Caesarea was followed in Roman times, which means it's unclear how often the practice of C-section occurred.  Would all women have been subject to these laws?  Just the elite or just citizens?  How often did the section result in a viable newborn?  Who performed the surgery?  It probably wasn't a physician (since men didn't generally attend births), but a midwife wouldn't have been trained to do it either (Turfa 1994).

Whereas we can supplement the historical record with bioarchaeological evidence to understand Romans' knowledge of anatomy, their consumption of lead sugar, or the practice of crucifixion, this isn't possible with C-sections - the surgery is done in soft tissue only, meaning we'd have to find a mummy to get conclusive evidence of an ancient C-section.

We can make the hypothesis, though, that because of the Lex Regia/Caesarea, we should find no evidence in the Roman world of a woman buried with a fetus still inside her.  This hypothesis, though, is quickly negated by two reported cases - one from Kent in the Romano-British period and one from Jerusalem in the 4th century AD. The burial from Kent hasn't been published, although there is a photograph in the slide show above.

Interestingly, the Jerusalem find was studied and reported by Joe Zias, who also analyzed the only known case of crucifixion to date.  Zias and colleagues report on the find in Nature (1993) and in an edited volume (1995), but their primary goal was to disseminate information about the presence of cannabis in the tomb (and its supposed role in facilitating childbirth), so there's no picture and the information about the skeletons is severely lacking:
We found the skeletal remains of a girl (sic) aged about 14 at death in an undisturbed family burial tomb in Beit Shemesh, near Jerusalem.  Three bronze coins found in the tomb dating to AD 315-392 indicate that the tomb was in use during the fourth century AD.  We found the skeletal remains of a full-term (40-week) fetus in the pelvic area of the girl, who was lying on her back in an extended position, apparently in the last stages of pregnancy or giving birth at the time of her death... It seems likely that the immature pelvic structure through which the full-term fetus was required to pass was the cause of death in this case, due to rupture of the cervix and eventual haemorrhage (Zias et al. 1993:215).
Both Roman-era examples involve young women, and it is quite interesting that they were already fertile.  Age at menarche in the Roman world depended on health, which in turn depended on status, but it's generally accepted that menarche happened around 14-15 years old and that fertility lagged behind until 16-17, meaning for the majority of the Roman female population, first birth would not occur until at least 17-19 years of age (Hopkins 1965, Amundsen & Diers 1969).  These numbers have led demographers like Tim Parkin (1992:104-5) to note that pregnancy was likely not a major contributor to premature death among Roman women.  But the female pelvis doesn't reach skeletal maturity until the late teens or early 20s, so complications from the incompatibility in pelvis size versus fetal head size are not uncommon in teen pregnancies, even today (Gilbert et al. 2004).

More interesting than the young age at parturition is the fact that both of these young women were likely buried with their fetuses still inside them, in direct violation of the Lex Caesarea.  So it remains unclear whether this law was ever prosecuted, or if the application of the law varied based on location (these young women were both from the provinces), social status (both young women were likely higher status), or time period.  Why wasn't medical intervention, namely C-section, attempted on these young women?  It's possible that further context clues from the cemeteries and associated settlements could give us more information about medical practices in these specific locales, but neither the Zias articles nor the Kent report make this information available.

Childbirth - Biological or Cultural?

Childbirth is both a biological and a cultural process.  While biological variation is consistent across all human populations, the cultural processes that can facilitate childbirth are quite varied.  The evidence that bioarchaeologists use to reconstruct childbirth in the past includes skeletons of mothers and their fetuses; historical records of births, deaths, and interventions; artifacts that facilitate delivery; and context clues from burials.  The brief case study of death in childbirth in the Roman world further shows that history alone is insufficient to understand the process of childbirth, the complications inherent in it, and the form of burial that results.  In order to develop a better understanding of childbirth through time, it's imperative that archaeologists pay close attention when excavating graves, meticulously document their findings, and publish any evidence of death in childbirth.

Further Reading:

This post was chosen as an Editor's Selection for ResearchBlogging.orgD.W. Amundsen, & C.J. Diers (1969). The age of menarche in Classical Greece and Rome. Human Biology, 41 (1), 125-132. PMID: 4891546.

J.P. Boley (1991). The history of caesarean section. Canadian Medical Association Journal, 145 (4), 319-322. [PDF]

S. Crawford (2007). Companions, co-incidences or chattels? Children in the early Anglo-Saxon multiple burial ritual.  In Children, Childhood & Society, S. Crawford and G. Shepherd, eds.  BAR International Series 1696, Chapter 8. [PDF]

C. Cruz, & S. Codinha (2010). Death of mother and child due to dystocia in 19th century Portugal. International Journal of Osteoarchaeology, 20, 491-496. DOI: 10.1002/oa.1069.

W. Gilbert, D. Jandial, N. Field, P. Bigelow, & B. Danielsen (2004). Birth outcomes in teenage pregnancies. Journal of Maternal-Fetal and Neonatal Medicine, 16 (5), 265-270. DOI: 10.1080/14767050400018064.

K. Hopkins (1965). The age of Roman girls at marriage. Population Studies, 18 (3), 309-327. DOI: 10.2307/2173291.

E. Lasso, M. Santos, A. Rico, J.V. Pachar, & J. Lucena (2009). Postmortem fetal extrusion. Cuadernos de Medicina Forense, 15 (55), 77-81. [HTML - Warning: Graphic images!]

T. Parkin (1992).  Demography and Roman society.  Baltimore: Johns Hopkins University Press.

K. Rosenberg (1992). The evolution of modern human childbirth. American Journal of Physical Anthropology, 35 (S15), 89-124. DOI: 10.1002/ajpa.1330350605.
J.M. Turfa (1994). Anatomical votives and Italian medical traditions. In: Murlo and the Etruscans, edited by R.D. DePuma and J.P. Small. University of Wisconsin Press.

C. Wells (1975). Ancient obstetric hazards and female mortality. Bulletin of the New York Academy of Medicine, 51 (11), 1235-49. PMID: 1101997.

A. Willis, & M. Oxenham (In press). A Case of Maternal and Perinatal Death in Neolithic Southern Vietnam, c. 2100-1050 BCE. International Journal of Osteoarchaeology, 1-9. DOI: 10.1002/oa.1296.

J. Zias, H. Stark, J. Seligman, R. Levy, E. Werker, A. Breuer & R. Mechoulam (1993). Early medical use of cannabis. Nature, 363 (6426), 215-215. DOI: 10.1038/363215a0.

J. Zias (1995). Cannabis sativa (hashish) as an effective medication in antiquity: the anthropological evidence. In: S. Campbell & A. Green, eds., The Archaeology of Death in the Ancient Near East, pp. 232-234.

Note: Thanks to Marta Sobur for helping me gain access to the Zias 1995 article, and thanks to Sarah Bond for helping me track down the Justinian reference.


Rui Sousa said...

I liked your post very much.

I was surprised by two different things. I had no idea the specullum was used in the Roman Period, and that it was that late in time that survivable c-sections were performed.


Kristina Killgrove said...

Thanks, Rui! Do an image search for Roman medical implements. It's amazing the sheer number of different kinds of implements they had - vaginal and rectal specula, catheters, scalpels, forceps, etc.

I might go back and clarify my statement on survivable C-sections - the first historically attested evidence doesn't come until the 16th century AD. It was practiced as a last-ditch effort, since it had a high rate of death, until the middle of the 20th century. Now, of course, it's quite routine.

Anonymous said...

I'm surprised (but also kind of not) that not all of these skeletons have been published - something so rare and interesting should have been published by now, but then it's just 'women's interest', after all. You should work this into an article!

Kristina Killgrove said...

Thanks, Stephanie! I'm considering the article angle - it would have to be just the Roman world, though (since I know that best). Trying to tackle all the burials in the world would require at least a master's thesis if not a dissertation! (Calling all grad students... :)

Anonymous said...

Why wasn't medical intervention, namely C-section, attempted on these young women?"

Perhaps it simply that it was obvious to those attending the birth that the child was no long viable?

Nick Thorpe said...

Dear Kristina,

One thing to note from your blog - the Garton Slack burial is not from a bog, but from the Yorkshire Wolds.

The forthcoming note by Simon Mays et al in International Journal of Osteoarchaeology about cut-marks on a baby from Hambleden villa is presumably relevant as well,

Nick T

Kristina Killgrove said...

Thanks for your comment, Nick. I'll fix the bog confusion. And although I'd seen the title of the Mays paper, I didn't read the abstract since a cut mark on a femur didn't seem all that interesting. Maybe the title should have included a clue to the content. Can't wait to read it!

Full reference for those who also might want to look it up:

Mays, S., Robson-Brown, K., Vincent, S., Eyers, J., King, H. and Roberts, A. (2012), An Infant Femur Bearing Cut Marks from Roman Hambleden, England. International Journal of Osteoarchaeology (Early View). DOI: 10.1002/oa.2232

Chris Chinnock said...

Loved the article, I was just wondering if there have been any studies on the effects of decomposition (autolysis, putrefaction etc)on an unborn fetus. My thought is that the delicate immature bones may not survive these processes which in turn may account for the lack of evidence available to us.


Kristina Killgrove said...

Chris - the forensic literature I found was primarily for fetal extrusion, which is when the fetus is ejected from the mother's body due to decomposition. (See the Lasso article in the reference section; but it's pretty graphic!)

Taphonomy of course would account for our finding fewer mother-child dyads in the archaeological record than we should. It is entirely likely that the mother's decomposing body would cause the fetus's body to decompose faster. So that may mean we should look for examples of fetal extrusion in the archaeological record.

Still, as the slideshow demonstrates, archaeologists have found a number of examples of mother-fetus burials through time and space.

Chavi said...

Amazing article! I'm a high-risk obstetrician (I blog here, among other places:, and I just taught a very non-archeologic lecture about Biblical narratives of childbirth and how they can be viewed by modern clinical eyes.

Thanks for this eye-opening post. There are some language changes I would make (it's unlikely that a cervix would rupture, for example) but overall absolutely mind-blowing for me.

Jillian Bean said...

I really enjoyed the article; I am currently writing a dissertation on archaeological evidence of Roman infanticide, and it has some really useful information, and a few facets I had not considered.

Kristina Killgrove said...

@Chavi - Thanks for your comments! I'm not an obstetrician (obviously), so it's nice to get a reaction from someone who knows more about childbirth than I do.

@Jillian - Oooh, looking forward to your dissertation. There's some stuff in the bioarch record on infanticide, but the interpretations are always problematic.

Anonymous said...

A very interesting article. I was unaware that C-Sections were being performed during the period of Roman rule.

Anonymous said...

The most common cause of death in childbirth is post-partum hemorrhage (and its consequences). It was true then, and it is still true now in developing countries. So for me, it is very understandable not to see many burial dyads then and now, because it's usually the mother who only dies but the baby lives. Sad but true.

Antonio Ragusa said...

I apologize for my english very poor, but I wanted to congratulate you for your work and add some comments
In humans, birth involves other people. Unlike nonhuman primates, which at the time of childbirth seek solitude, human mothers actively seek assistance at birth.Today, virtually all women in all societies seek assistance at delivery from relatives, doctors or midwives. The most important problem in modern obstetrics is the absolute fact that most of the world shares will take place without any assistance. “Skilled birth attendance: What does it mean and how can it be Measured? A clinical skills assessment of maternal and child health workers in Nepal: Averting maternal death and disruption CARLOUGH M. (1); MCCALL M. (2); International journal of obstetrics and gynecology (j Int. Gynaecol. Obstet.) ISSN 0020-7292.”
Howell reported that, despite giving birth alone is a cultural ideal at! Kung (a tribe of hunter from south africa), most of the women near the time of their birth mothers, their sisters or other women. A woman who gives birth alone arouses interest.So, although there may be rare exceptions, the attendance at birth is a phenomenon that has become universal in our species. At some point in the evolutionary scale of the human, the benefits of care at birth exceeded the disadvantages (such as infection or stress resulting from contact with other people), which has emerged as one of the characteristics of the human species: the 'obligate midwifery. "International journal of gynecology and obstetrics (Int. j. gynaecol. Obstet.).
The human birth can therefore be considered a social event. When it began, so this radical change? Anthropologists trace the civilization from the cult of the dead.The origins of human feeling and sentiment of brotherhood and belonging derived from it, so would be sourced from the recognition of the sacredness of death. This concept comes to us by the interest aroused by the discovery of numerous archaeological burial sites, mainly occurred in the last 100 years, however, the views of anthropologists is vitiated by the continued history of stones, because the attendance at birth does not leave virtually any trace, but I am absolutely convinced that the first sign of civilization was to assist our women in this difficult job that is giving birth to a newborn. From all this comes a sense of awe and wonder that still catches me, despite my not very young age, every time I witness a new birth (I am obstetrician). I am therefore convinced that we must restore sacredness to this gesture and not reduce it to mere mechanistic production of a healthy baby and a healthy mom. Of course, this remains a “sine qua non”, who protects the child and maternal health can not but wish for a successful event auspicious birth, but if the assistance is reduced to this, if that is mechanized, it loses the foundation of sacredness that configure it. To this day we must fight it with the board, with the availability of money, with the judges, with other colleagues who are experts in name only and the Midia, which tend to reduce everything that is bad news.In practice I think the chilbirth have contributed most of the cultures of death to make us what we are. As I said before the birth assistance leaves no traces on the contrary, the death builds tombs, this concept comes from the misunderstandingThe first historical data on this as you showed in your intersting work are from the Roman world.

Antonio Ragusa MD

Kristina Killgrove said...

Thanks for your comment, Antonio. Human birth definitely involves other people in a way that birth in the rest of the animal kingdom doesn't. Because our babies heads are so big, there is a rather complicated rotation the baby undergoes in order to get out of the birth canal - and this rotation ends with the baby's face pointed down (towards the mother's back) rather than up, making it difficult for the mother to deliver the baby herself (as she can't lift the baby up until it's all the way out or risk bending the spine the wrong way).

In a way, then, the traces of help with childbirth (doulas, etc.) are everywhere - every successful birth likely had assistance from an attendant!

MK said...

Thanks for the beautifully written blog. Enjoyed the whole post.

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