Do Women Really Need Help to Give Birth?
- Kicki Hansard
- 22 minutes ago
- 16 min read
What the evolution of human birth can teach us about support, safety and the role of the doula
A video from Mack Explains appeared in my Facebook feed recently, looking at a question that has fascinated anthropologists for a very long time: why does human childbirth appear to be so much more complicated than birth for many other mammals and primates?
The explanation he gives is based on a genuine and fascinating area of evolutionary anthropology. Human babies have relatively large heads, we walk upright and our pelvis has evolved under a number of competing pressures, while the baby has to make a remarkably complex journey through the pelvis, usually rotating as it descends. The comparison in the video is made with animals such as horses and chimpanzees, who appear able to give birth without another member of their species helping them, whereas human women, we are told, need assistance.
There is plenty of evidence to support the idea that human birth is anatomically unusual and often more mechanically complex than birth in other primates. What caught my attention was not really the anatomy, but the conclusion that seemed to follow from it, because when we say that women need help to give birth, what exactly do we mean by help?
There is an enormous difference between recognising that human beings appear to have evolved as social birthers, often labouring with other people nearby and believing that a woman’s body requires another person to make birth happen. There is also a difference between recognising that complications sometimes arise and skilled assistance can save the life of a woman or baby and beginning from the assumption that birth itself cannot happen without somebody helping it along.
Once I started thinking about that distinction, I realised that the question reaches much further than one video. It takes us into evolutionary anthropology, the physiology of labour, the history of maternity care and perhaps most importantly, the way we have come to understand what it means to support somebody who is giving birth.
Human birth really is different
We need to begin with the anatomy because there is no point responding to the medicalisation of childbirth by pretending that human birth is mechanically simple when the evidence tells us otherwise.
Compared with other primates, there is a relatively close relationship between the dimensions of the baby’s head and the maternal pelvis, while the changing dimensions of the human birth canal mean that the baby usually needs to rotate during descent. The shoulders then have their own journey to make, which is one reason human birth has attracted so much interest from evolutionary anthropologists.
For much of the twentieth century this was explained through what became known as the obstetric dilemma, the idea that two important developments in human evolution placed competing demands on the pelvis. Efficient walking on two legs was thought to favour one pelvic configuration while giving birth to increasingly large brained babies favoured another, leaving human beings with an evolutionary compromise in which babies are born through a particularly close fitting birth canal.
The traditional explanation has been challenged and refined considerably in recent years, although that does not mean the underlying anatomical complexity has disappeared. A major review published in the American Journal of Biological Anthropology in 2023 concluded that there is good evidence for an obstetric dilemma while emphasising that it is considerably more complicated than the old story of walking upright versus having a large brained baby. Pelvic anatomy, fetal dimensions, maternal body size, metabolism, nutrition, environment and many other factors interact, with considerable variation between individual women and babies.
What is important, though, is that anatomical complexity should not be confused with physiological incapability. For a healthy woman with a straightforward pregnancy, NICE describes giving birth as generally very safe for both the woman and her baby, while the large Birthplace in England study found serious adverse outcomes for babies of low risk women to be uncommon across birth settings.
Complications can, of course, arise during an apparently straightforward labour and there will always be occasions when skilled assistance becomes important or urgently necessary, which is precisely why access to good midwifery and obstetric care matters. The existence of those uncommon circumstances does not, however, establish that normal human birth routinely requires somebody else to make it happen.
That is the distinction I think gets lost when the evolutionary complexity of the human pelvis becomes evidence that women cannot give birth without help.
Did humans evolve to need a birth attendant?
Anthropologist Wenda Trevathan has spent decades studying childbirth from an evolutionary perspective and her work, alongside that of paleoanthropologist Karen Rosenberg, is particularly relevant to this discussion.
One of the unusual features they have explored is the rotational pattern of human birth and the fact that babies commonly emerge facing away from their mothers. In many non-human primates, the mother is able to reach towards her baby as it emerges and guide or lift it towards her own body, whereas the mechanics of human birth can make this considerably more difficult.
From observations such as these came the hypothesis sometimes described as obligate midwifery, the suggestion that assistance during childbirth may have offered such an evolutionary advantage that seeking company during labour became part of human reproductive behaviour.
I find this idea entirely plausible. If having another person nearby meant that a woman was more likely to survive an unexpectedly difficult birth, less vulnerable to threats, better able to care for herself immediately afterwards or more likely to have somebody available to respond if the baby needed assistance, then giving birth socially could clearly have offered an evolutionary advantage.
Where I think we need to be more careful is in what we conclude from that, because evidence that human beings evolved towards social birth does not necessarily tell us that the physiological process of birth itself requires another person to perform it. It may instead tell us that childbirth was safer, emotionally and practically easier and in evolutionary terms, more successful when trusted people were nearby.
The distinction between humans and other primates is not as absolute as it once appeared either. Researchers have observed birth related attendance and supportive behaviour among several primate species, including bonobos, which raises interesting questions about whether social behaviour around birth may have evolutionary roots that predate humans.
Perhaps, then, the more useful question is not whether women evolved to need somebody to help them give birth, but whether human beings evolved to give birth socially and if they did, what the presence of another person actually provided.
What was the other person there for?
Women have gathered around other women during childbirth throughout recorded history and across many cultures, although we should be cautious about romanticising what birth looked like in the past. Before modern obstetric medicine there were women who died from haemorrhage, infection and other complications that we can now often recognise and treat, while babies died from circumstances that modern maternity and neonatal care can sometimes prevent.
It is entirely possible to be grateful for those developments while still being curious about the broader role of the people who historically attended women during labour, because responding to emergencies was only one part of what birth attendants and other women around the labouring mother did.
Their presence could provide warmth, food, water, familiarity and reassurance, while somebody else could tend the fire, look after children, protect the woman’s privacy, rub her back, help her move, listen to her, recognise when something had changed and remain alongside her during what might be many hours of labour. The value of another person may therefore have existed long before the point at which anybody physically needed to intervene in the birth.
This is where I think our understanding of the word help becomes particularly important, because being present because a woman is incapable of giving birth without you is fundamentally different from being present because your presence contributes to the conditions in which she can give birth.
Modern research into continuous labour support gives us an interesting way of exploring that distinction.
What happens when a woman is continuously supported?
A major Cochrane systematic review by Bohren and colleagues examined 26 trials involving more than 15,000 women and found that those receiving continuous support during childbirth were more likely to have a spontaneous vaginal birth and less likely to have a caesarean or instrumental vaginal birth. Their labours were slightly shorter on average, they were less likely to use some forms of pain relief and they were less likely to describe their birth experience negatively, with the review finding no evidence that continuous support caused harm.
What interests me about these findings is not simply that support appears to make a difference, but what the person providing that support is actually doing.
The World Health Organization describes continuous companionship as including reassurance, emotional support, touch, massage, assistance with movement and positioning, practical comfort and help with communication.
These are not activities that force the cervix to dilate or mechanically move the baby through the pelvis, yet collectively the presence of another person appears to be associated with measurable differences in how labour unfolds.
The Cochrane researchers also explored whether outcomes differed according to who provided the support and found indications that some benefits may be particularly pronounced when the person is neither a member of hospital staff nor part of the woman’s own social network and is present specifically to provide continuous support, which is essentially the role occupied by a doula. These subgroup findings need to be treated cautiously and should not be used to claim that doulas themselves prevent caesarean births, although they do raise an intriguing question about why the presence of somebody who carries no clinical responsibility for the birth of the baby might influence the experience and outcome of labour.
Part of the answer may lie in understanding that birth does not happen separately from the brain and nervous system.
The physiology of birth is affected by more than the uterus and pelvis
It is tempting to imagine labour as a mechanical process in which the uterus provides the force and the pelvis provides the passage, with successful birth depending largely upon whether the contractions are strong enough and whether the baby fits. Human physiology is considerably more complex, with labour coordinated through an intricate relationship between the uterus, brain, nervous system, hormones, baby and the physical and emotional environment surrounding the woman.
Oxytocin is central to this process and research measuring maternal oxytocin during physiological childbirth has found that its secretion becomes increasingly pulsatile as labour progresses, with changes in both the frequency and strength of those pulses towards birth. Oxytocin is also doing more than stimulating uterine contractions because it has actions within the brain and forms part of a wider neuroendocrine system involved in stress regulation, social connection and maternal behaviour.
This is also where some of the familiar explanations about fear and labour need more care than they are sometimes given. The idea that adrenaline simply stops oxytocin is an appealing way of explaining the relationship between safety and birth, but human physiology does not operate through such a simple switch.
Catecholamines such as adrenaline and noradrenaline have normal physiological functions during childbirth and stress hormones naturally rise as labour progresses, with changes towards the end of labour thought to play important adaptive roles for both mother and baby. Birth itself is an intense physiological event, so the aim cannot be to remove stress from it entirely.
What appears to matter is the interaction between normal physiological stress and the perception of threat. Research suggests that psychological stress and sympathetic nervous system activation can interact with labour physiology, while observational studies have also found associations between fear of childbirth and longer labour. Those studies cannot prove that fear itself caused labour to be longer, although they add to a wider body of evidence suggesting that a woman’s psychological and physical environment cannot simply be separated from what her body is doing.
This gives us a much more grounded way of talking about safety in childbirth without claiming that a frightened woman cannot produce oxytocin or that an interruption will automatically stop labour.
What do we mean when we say a woman feels safe?
Within modern maternity care, safety understandably tends to be discussed in clinical terms, including blood pressure, foetal heart rate, blood loss, temperature, labour progress and the many other observations that allow midwives and doctors to identify when something may be changing.
There is another aspect of safety, however, which is continually being assessed by the nervous system and which relates to whether the environment itself feels threatening or secure.
A woman in labour may be surrounded by unfamiliar people, unable to control who enters the room, asked repeated questions, exposed physically, interrupted during contractions or uncertain about what is happening next. Another woman may be in exactly the same clinical environment yet feel completely secure because she knows the people around her, understands what is happening and feels listened to and protected.
Neither woman has consciously instructed her nervous system how to respond to the room.
Human beings continually take information from our surroundings and assess whether we are safe enough to lower our vigilance, which is one reason privacy, respectful communication, companionship and freedom of movement feature so strongly in the World Health Organization’s recommendations for good intrapartum care.
WHO describes childbirth as a physiological process that can occur without complications for the majority of women and babies while also warning that increasing medicalisation can undermine women’s own capability to give birth and negatively affect their experience. This is not an argument against maternity care, but an invitation to think more carefully about what good maternity care is there to protect as well as what it is there to prevent.
What changed when birth moved into hospital?
At the beginning of the twentieth century, most women in Britain gave birth at home, whereas by the end of the century hospital birth had become overwhelmingly the norm. This transformation happened gradually through the professionalisation of maternity services, enormous developments in medical knowledge, changing understandings of risk and government policies that increasingly favoured hospital birth.
By 1970, the Peel Report was recommending sufficient facilities for 100 per cent hospital delivery and home birth rates subsequently fell dramatically. The development of antibiotics, blood transfusion, safer surgical techniques, anaesthesia, neonatal care and increasingly sophisticated ways of recognising complications transformed what could be done when a woman or baby genuinely needed medical assistance.
I would never want to return to a time when those things were unavailable, although I do think it is worth asking whether something else changed as birth moved from the woman’s home into an institution.
The people surrounding her changed, responsibility shifted and the language itself began to tell a different story about who was doing what. We still routinely talk about a doctor or midwife delivering a baby or record that a baby was delivered at a particular time, even though it was the woman who laboured and gave birth.
Language matters because it often reveals where we have placed agency. Describing the professional as the person who delivers the baby subtly positions birth as something performed for the woman rather than something she is doing with skilled people available to support and assist her when needed.
This shift also took place alongside an understandable increase in professional responsibility. Midwives, obstetricians and hospitals are accountable for the care they provide and for recognising complications, which inevitably means observation, documentation, assessment and decisions about when intervention may be appropriate.
None of those things is inherently wrong, although together they create a very different environment from one in which a woman labours within her own territory surrounded by familiar people.
What happens when everybody in the room feels responsible for making birth happen?
This is the question that stayed with me after watching the Mack Explains video because perhaps the cultural belief that women need help to give birth affects more than women themselves.
A woman may enter labour already wondering whether her body will know what to do, while her partner may look towards the professionals for reassurance that everything is all right. The midwife carries professional responsibility for monitoring both woman and baby and recognising any deviation from normal progress, while the obstetric team carries responsibility for responding when complications arise and the institution itself operates within policies, protocols and thresholds designed to manage risk.
Everyone wants a healthy woman and a healthy baby, yet within that entirely understandable desire for safety there is the possibility that normal physiological birth gradually becomes something everybody feels responsible for managing.
I am not suggesting that observation causes complications or that medical intervention creates difficult births through some simple sequence in which women become frightened, adrenaline rises and oxytocin disappears. The evidence does not allow us to make that claim and the physiology of childbirth is far too complex for such a straightforward explanation.
What I do think we can reasonably ask is whether our underlying belief that women require help to give birth can sometimes create environments in which physiological birth becomes harder to protect, particularly when observation gradually becomes direction and support gradually becomes management.
Being available to help when help is needed is not the same as beginning with the assumption that help is required for birth to happen.
Women sometimes need help in childbirth without necessarily needing help to give birth
For me, this is the distinction at the centre of the whole discussion.
A woman can have confidence in her body’s capacity for physiological birth while choosing to give birth somewhere that provides rapid access to emergency obstetric care. A midwife can trust birth while remaining alert to the possibility that physiology may move into pathology and a doula can believe wholeheartedly in a woman’s capability while understanding that births sometimes take unexpected turns.
Trusting women does not require us to pretend that birth is always straightforward and recognising risk does not require us to begin from the belief that women’s bodies are incapable.
Perhaps this is also a more useful way to understand why human beings appear to have given birth socially for such a long time. If another trusted person could provide protection, familiarity, warmth, food, water, reassurance and practical care while also recognising the occasions when genuine assistance was required, there would be an obvious evolutionary advantage to giving birth in company without needing to conclude that women themselves had somehow lost the ability to give birth.
A woman who feels secure enough to become absorbed in labour does not also have to remain responsible for everything happening around her. Somebody else can notice who is entering the room, find water, communicate with other people, support her partner, protect periods of silence and remain steady when labour becomes intense.
None of this physically pushes a baby through the pelvis, yet the research on continuous support tells us that these things matter, which perhaps means we should be paying considerably more attention to what support actually is.
What this means for the doula
This question goes to the heart of how we teach doulas at The BirthBliss Doula Academy because, over many years of supporting women and training doulas, I have become increasingly interested in what happens when we stop thinking first about what the doula can do and begin instead with how she can be.
People understandably arrive at doula training wanting practical knowledge. They want to know which positions might help, what they can suggest when somebody has back pain, what belongs in a doula bag and what techniques they can offer when labour becomes difficult. There is value in knowing those things, although there is also a danger that the doula enters the room carrying her own version of the same assumption we have been exploring throughout this article, that if she is there to help, she must therefore be doing something.
This is why our approach at BirthBliss begins with BEING, then NOTICING, then RESPONDING and finally DOING.
Being comes first because a doula needs to be able to stay alongside a woman without immediately looking for something to change, solve or improve, while noticing asks her to pay attention to what is actually happening rather than what she expected to happen. From there she can begin to respond to this particular woman in this particular moment, which may mean reassurance, touch, silence, supporting her partner, finding food, changing something in the environment or recognising that the woman does not need anything from her at all.
There will also be occasions when doing something practical is exactly what is needed, although doing becomes a response to what has been noticed rather than the starting point.
This way of working requires a certain humility because a doula can attend hundreds of births without ever being the person who gives birth to one of those babies. Her knowledge and presence may matter enormously, yet the birth does not belong to her and she does not need to prove her usefulness by constantly intervening in it.
The same principle can sit comfortably alongside excellent midwifery and obstetric care. A skilled professional can recognise the moment when assistance is genuinely needed without approaching every physiological process as though it needs to be corrected and a doula can support a woman’s trust in herself without stepping outside her role or encouraging distrust of medical care.
Perhaps what we need is not less help in childbirth, but a more thoughtful understanding of what helping actually means.
Perhaps women never needed us to take birth over
When I think about women gathering around another woman in labour across generations and cultures, I wonder whether we have sometimes interpreted that gathering through our modern understanding of childbirth.
Perhaps women did not gather because the labouring woman was incapable of giving birth, but because childbirth makes us vulnerable and there is enormous value in knowing that somebody trustworthy is nearby while we turn our attention inward and allow ourselves to become absorbed in what our body is doing.
Somebody could keep watch so that the woman did not have to, maintain warmth and privacy, bring food and water, care for other children, offer reassurance when she became frightened and recognise the uncommon but important moment when something genuinely was wrong.
Human beings tend to seek one another during intense experiences and childbirth may be one of the oldest examples of that instinct.
This allows us to hold two truths comfortably together. Modern maternity care gives women and babies access to assistance that previous generations could not have imagined and there will always be circumstances in which that assistance is essential, while the existence of that help does not require us to begin with a story that women’s bodies are fundamentally incapable of birth.
We can begin instead with respect for physiology alongside access to excellent midwifery and obstetric care, with environments that protect dignity and privacy, with continuous support and with people around women who understand the difference between being ready to help and believing that birth cannot happen without their help.
For me, that distinction sits at the heart of doula work and at the heart of what we teach at The BirthBliss Doula Academy. We are not training another person to enter the birth room looking for something to do, but someone who can remain curious enough to notice what this particular woman needs, steady enough not to intervene simply because she feels she should be useful and knowledgeable enough to recognise when responding and doing really are called for.
Perhaps that is closer to what women have needed from one another all along.
References
Watch the Mack Explains video on Facebook
Bohren MA, Hofmeyr GJ, Sakala C, Fukuzawa RK and Cuthbert A. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews. 2017;7:CD003766.
Birthplace in England Collaborative Group. Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ. 2011;343:d7400.
Grunstra NDS, Betti L, Fischer B, Haeusler M, Pavlicev M, Stansfield E, Trevathan W, Webb NM, Wells JCK, Rosenberg KR and Mitteroecker P. There is an obstetrical dilemma: Misconceptions about the evolution of human childbirth and pelvic form. American Journal of Biological Anthropology. 2023;181(4):535–544.
National Institute for Health and Care Excellence. Intrapartum care, NG235. NICE.
Rosenberg K and Trevathan W. Birth, obstetrics and human evolution. BJOG. 2002;109(11):1199–1206.
Trevathan WR. The evolutionary history of childbirth: Biology and cultural practices. Human Nature. 1993;4(4):337–350.
Uvnäs-Moberg K, Ekström-Bergström A, Berg M et al. Maternal plasma levels of oxytocin during physiological childbirth: a systematic review with implications for uterine contractions and central actions of oxytocin. BMC Pregnancy and Childbirth. 2019;19:285.
World Health Organization. WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: World Health Organization; 2018.
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