Martha Ballard

Childbirth’s “Grinding Pirouette,” a Colonial Midwife, the Odon Device: Some Background to BUMP

In the spirit of the EST/Sloan Project’s commitment to “challenge and broaden the public’s understanding of science and technology and their impact in our lives,” we offer this essay on some of the scientific and historical background to BUMP by Chiara Atik, the current EST/Sloan mainstage production. BUMP begins previews on May 9 and runs through June 3. You can purchase tickets here.

Background essay by Rich Kelley

Apes and chimpanzees give birth in one to two hours. Human moms average ten to twenty. Why does our labor take so long?  

Blame our large brains. And our preference for walking upright. We are the only mammal to walk on two legs. That comes at some cost. In 1960, physical anthropologist Sherwood Washburn identified “the obstetrical dilemma.” Evolution, it seems, sometimes involves tradeoffs.  Some seven million years ago, walking upright offered our ancestors an advantage. Our arms could reach higher branches, our hands became free to carry food and to make tools. Walking on two legs uses less energy to cross long stretches of grassland. And we could run.

Diagram relates the size of the maternal pelvic inlet (outline) and the size of the neonatal head (dark circles) in selected primate species

Diagram relates the size of the maternal pelvic inlet (outline) and the size of the neonatal head (dark circles) in selected primate species

But to walk upright our pelvis needed to change its size, shape and positioning. And this changed how human females gave birth. Non-human primates have pelvises and birth canals that resemble a ring or a hoop.  The primate infant’s head is usually smaller than the birth canal, which is positioned forward on the body. This makes birthing simpler. Delivery can take one to two hours and the baby emerges face up, guided out by the hands of the mothers to immediately begin nursing. Primate mothers can manage this by themselves and usually give birth away from others, in seclusion.

Midwife's view of the birth canal in a chimpanzee ( P. troglodytes ),  A. afarensis  (A.L. 288–1, ‘Lucy’) and a modern human female. Note the necessary rotation of the head in the human female.

Midwife's view of the birth canal in a chimpanzee (P. troglodytes), A. afarensis (A.L. 288–1, ‘Lucy’) and a modern human female. Note the necessary rotation of the head in the human female.

Our human pelvis has to solve a tricky problem. For us to walk it needs to be narrow; but our brains are large and the female pelvis needs to be able to deliver the newborn’s head. As Tina Cassidy describes it in Birth: The Surprising History of How We Are Born:

“Today, the upper opening of the pelvis is wide from side to side . . . the lower pelvis, however, the baby’s exit, is widest from front to back. And therein lies the problem . . . human birth is, quite literally, a twisted process. In order to pass through the birth canal, the baby’s head—the largest part of its body—must rotate as it descends in a grinding pirouette. . . . Assuming the baby is not breech—being born feet or buttocks first—its head must enter the pelvis facing up toward the pubic bone, with the widest part of the head—ear to ear—lining up with the widest part of the pelvis—hip to hip. But that has to change quickly. The baby must begin to turn sideways, as much as forty-five to ninety degrees, in order to align its body with the widest pelvis outlet, its head emerging face down rather than face up.”

Sequential changes in the position of the child during labor.

Sequential changes in the position of the child during labor.

But why is labor so painful?  The chimpanzee brain is about one-third the size of the human brain. Because of the human infant’s large head, the cervix of the human female must dilate three times as much as other primates. Chimpanzee mothers dilate 3.3 centimeters before delivery. Human mothers must dilate 10 centimeters, which takes more time, and is significantly more painful. According to the Mayo Clinic, mothers describe the last three centimeters as being the most painful part of giving birth.

Because of the difficulties of human delivery—and the care the child needs during its second nine months—anthropologists Karen Rosenberg and Wenda Trevathan have argued that “assisted childbirth” is probably as old as bipedalism:

“Because the human fetus emerges from the birth canal facing in the opposite direction from its mother, it is difficult for the mother, whatever her position, to reach down, as non-human primate mothers often do, to clear a breathing passage for the infant or to remove the umbilical cord from around its neck. If a human mother tries to assist in delivery by guiding the infant from the birth canal, she risks pulling it against the body’s angle of flexion, possibly damaging the infant’s spinal cord, brachial nerves, and muscles.”   

In a survey of 296 cultural groups, Rosenerg and Trevathan found that “assisted birth comes close to being universal.”

woodcut childbirth.jpg

For most of human history, those assisting at births were exclusively women. Until about a hundred years ago, delivery occurred in the home, in the bedroom or around the hearth. In Europe and early America, these attendants were called “God’s siblings,” later shortened to “gossip,” their chatter the basis for the word’s current meaning. After a successful birth, the gossips would organize “a groaning party,” a feast for midwife, mother and the assembled women, its name recalling the sounds of labor. Men penetrated the birthing sanctum at their peril. In 1522, a German physician, Dr. Wert, eager to learn more directly about the birthing process, disguised himself as a woman to try to enter a delivery room. He was discovered and reportedly burnt at the stake.

A Midwife’s Tale: Martha Ballard

Martha Ballard, a midwife in colonial Maine, kept a detailed daily account of her activities from 1785 until a few months before her death in 1812. Over those twenty-seven years she delivered 814 babies. Her mortality rate (excluding stillbirths) was 2.5 per 100—very impressive for that time. Being a midwife then involved canoeing down rivers and trudging through snow, sometimes delivering two or more babies within twenty-four hours in houses miles apart. 

A page from Martha Ballard's diary, February 3 - 12, 1800.

A page from Martha Ballard's diary, February 3 - 12, 1800.

Laura Ulrich Thacher notes, in her Pulitzer Prize-winning biography of Ballard, “In Martha’s diary, it is doctors, not midwives, who seem marginal.”  One poignant entry records Ballard’s reaction when a new young doctor does not defer to her years of experience but rather “chooses” to participate himself in the birthing. From ancient times, male physicians were usually called in only for emergencies, when the life of the child or the mother was at risk, hence the adage, “When a man comes, one or both must necessarily die.” In those instances, the life of the mother was paramount. From the Hippocratic Writings we learn that the earliest medical tools related to childbirth were not tools to ease delivery but rather tools for the extraction of the dead fetus. Caesarian sections in ancient times were mostly performed so that the child and mother could be buried separately. The first record of a mother surviving a C-section was not until the 1580s in Switzerland (her husband, a professional pig gelder, performed the operation).

Forceps: A Family Secret

Peter Chamberlen the Third

Peter Chamberlen the Third

When obstetrical forceps first appeared in seventeenth-century Europe, only members of the all-male barber-surgeon guild could legally use them. The invention is credited to Peter Chamberlen the elder, a French inventor and surgeon. He and his surgeon brother gained fame for delivering babies in difficult cases because of their use of a secret instrument. For 150 years, through several generations of man-midwives, the Chamberlen family kept secret exactly how that instrument worked. Due to etiquette, man-midwives had to operate within severe constraints. A large sheet covered the expectant mother, one end wrapped around her, the other tied around the man’s neck. Without looking beneath the sheet, the man-midwife was expected to deliver the baby by feel.

The Chamberlen forceps

The Chamberlen forceps

The Chamberlens had a knack for theater. Two men would lug a large elegantly carved lined box into the delivery room.  They then cleared the room and blindfolded the mother before slipping their device under the sheet. During its use, they would clang bells, hammers, and chains to cause further misdirection. It wasn’t until 1813 when some of Peter Chamberlen’s tools were discovered in an attic of a house that the ingenuity of his invention became clear. His forceps used hinged blades that allowed each to be positioned independently around the head of the infant, something not possible with tweezers.

In the 1950s, Swedish professor Tage Malmstrom developed the ventouse, or Malmstrom extractor. In its current version this device involves placing a suction cup onto the head of the baby. The doctor uses a handheld pump to gently apply suction and the suction draws the skin from the scalp into the cup. Handles on the device enable the doctor to pull the baby out.   Over the last few decades, caesarean section and vacuum extractors have replaced forceps as the preferred means of delivery. Since 1985, the World Health Organization has maintained that the ideal rate of caesarean sections is between 10% and 15% of live births. Beyond 10% there is no added improvement in the maternal or newborn mortality rate. Yet from 1996 to 2014, the rate of caesarean sections of all births in the U.S. has risen 55%, from 21% in 1996 to 32.5% in 2014. A recent study by the British Medical Journal found that “C-section rates were lower among poorer women and increased with rising economic status.” High caesarean rates can result in negative outcomes: infection, hemorrhages, and surgical complications.

The Odon Device: Inspired by YouTube

In 2005, Jorge Odon, an Argentinian garage mechanic, bet a friend he could extract a cork from an empty wine bottle without breaking it. He won the bet thanks to a YouTube video he had seen that showed how to do this by inflating a plastic bag inside the bottle until it gripped the cork and then pulling both out. Odon then had the inspiration that this same technique could be used to deliver babies in distress. Having already patented several auto-related inventions, he set to work to realize his idea using a glass jar for the womb, one of his daughter’s dolls for the baby, and a fabric bag and sleeve sewn by his wife as the extraction device. Successful demonstrations to local obstetricians (always starting with the cork and bottle trick) led to consultations with doctors at CEMIC, the Center for Medical Education and Clinical Research in Buenos Aires. At first they thought he was pranking them, but eventually they responded positively and even recommended changes: doing away with the bag that surrounded the baby’s body and just having one bag to surround the baby’s head.

Jorge Odon demonstrating his device

Jorge Odon demonstrating his device

Odon’s big breakthrough came in 2008 when he was granted ten minutes at a conference in Argentina to present his device to Dr. Mario Merialdi, director of Reproductive Health at the World Health Organization. Merialdi deemed the device “fantastic.” Their ten minute meeting stretched to two hours and led to both traveling that December to the birth simulation center at Des Moines University in Iowa for a successful series of tests. The WHO then agreed to conduct a series of hospital-based tests of the device in three phases in Argentina and South Africa. In 2013, Becton Dickinson and Company (BD) licensed the development rights of the Odon device and developed a new prototype based on their pre-clinical studies. The Odon Device now consists of two main components: a plastic sleeve and an inserter. The sleeve contains an air chamber that is inflated around the fetal head by a manually operated bulb pump. Once the sleeve has surrounded the baby’s head, air is hand pumped into the inner surface of the sleeve until the sleeve has a secure grasp of head. The inserter is then removed and the baby is pulled out. The simplicity and low cost of the device make it potentially revolutionary in reducing mortality in instances of prolonged labor in low-resource settings. Caesarean sections, by contrast, require expensive surgical theaters.

The sequences of an Odon Device extraction

The sequences of an Odon Device extraction

In 2017, the WHO and BD conducted the third phase of testing. They prioritized three criteria: safe for mothers and babies, easy for different cadres of skilled birth attendants to use, cost-effective, and affordable in low resource settings. In March 2018, they announced the results of the latest round of tests. The Odon device was inserted successfully in 46 of 49 women (93%), and successful delivery with expulsion of the fetal head after one-time application of the Odon device was achieved in 35 women (71%). The report concludes: “Delivery using the Odon device is therefore considered to be feasible.” BD will next pursue a randomized pivotal clinical trial before potential introduction in clinical practice.

Gadding online

In her diary Martha Ballard identifies herself as a “gadder,” that is, someone who frequently visits neighbors to chat and exchange news, recipes, plant medicines, and stories. Today, what gadding goes on among mothers is more likely to happen online via message boards, forums, parenting networks, blogs, and Facebook, Yahoo, Google and Meetup groups. Many of these groups are centered around a physical community so that they can help a new mom find local resources, whether a Nanny, a doula, an OB/GYN or a great deal on strollers. The Bump, one of the largest and oldest (now ten years) online communities for new and expecting mothers, reports that 80% of working mothers use message boards or forums, with 75% naming them as one of the top two most valued resources for information, second only to talking to mothers face to face.    

You can read more about BUMP and the brilliant playwright who wrote it in our interview with Chiara Atik

The views expressed in this essay are solely those of the author. The Alfred P. Sloan Foundation funded BUMP in part because of the compelling nature of one of the stories that inspired it: Jorge Odon's invention of the Odon Device. Its support for the play should not be construed as endorsing the device or any of the products or services mentioned in the play or in this essay.

Chiara Atik on new mom message boards, ALT lines, science stories, and BUMP

Chiara Atik

Chiara Atik

This year’s EST/Sloan Mainstage Production is the world premiere of BUMP, written by Chiara Atik and directed by Claudia Weill. Previews start May 9 and the show runs through June 4 at EST. BUMP is the exuberant exploration of the evolution of women's understanding about and control over the childbirth process through the  stories of three separate quests for knowledge: a young expectant mother in colonial New England getting coached through her first pregnancy by a peppery midwife (inspired by the diary of Martha Ballard); a contemporary message board where new pregnant moms swap gripes, quips, and observations; and a grandfather/mechanic's invention of a device that could revolutionize how babies in distress could be safely delivered (the last inspired by the story of Argentinian mechanic and inventor Jorge Odon).  We interviewed Chiara a year ago when, as Midwife/Mechanic, her play received a workshop production as part of the 2017 First Light Festival. This year we have even more questions.  

 (Interview by Rich Kelley)

 BUMP consists of three distinct and compelling story lines, all about the childbirth process. How did you decide that these were the three story lines you liked the most and wanted to pursue? Were there other story lines you tried and abandoned?

It’s been these three stories since the beginning! The Sloan Commission came from the story of a car mechanic who happened to invent a birthing device – though my account of it is largely fictionalized. The next part was inspired by some old obstetrics tools I saw in a museum. I started thinking about midwives, and what birth was like before modern medicine. And then the third came from my friend Rachel, who had recently had a baby and regaled me with all the stories from her “Birth month message board.” So these became the three stories!

how to remove a cork from inside a bottle

The YouTube video (or one like it) that inspired the Odon Device

It was just about a year ago that BUMP received a workshop production as part of the 2017 EST/Sloan First Light Festival. How has the play changed since those workshops?

A lot. It’s still changing! I’d say the midwife storyline is largely untouched but the story of the mechanic and his family has hopefully developed considerably since last year.

How many different pregnancy message boards did you sample as part of your research for BUMP? Did you find much difference in the community or the comments from board to board?  Which was the most informative? The most fun?

Hundreds. I love them. I’m obsessed with them. They’re such a peek into other people’s lives. Pregnancy message boards are especially tight-knit: here are other women who are going through exactly what you’re going through, at the exact same time, and unlike your friends, coworkers, family, they will never get tired of discussing symptoms, or test results, or maternity clothes, or ultrasound pictures.

I’ve read so many boards over the two years I’ve worked on this play, and what’s kind of fun/crazy is that every month...there’s a new one! Every month a new group of women gets pregnant, a new board is created, and people start to post.

A page from Martha Ballard's diary, February 3 - 12, 1800.

A page from Martha Ballard's diary, February 3 - 12, 1800.

The wildest thing I came across in my research (though honestly, it’s beyond research now. The play is written. I’m just addicted!) is a month board that somehow – I think through just the detective work of some of the suspicious members – discovered that someone who had been regularly posting to the board was not actually pregnant. This was months into the pregnancies, when people had been posting to the board every day for so long, and had really gotten to know each other. So people were shocked and scandalized, and even women on the other boards were gossiping about what happened on the NOVEMBER board (or whatever it was).

You have now spent more than a year immersed in the world of pregnant mothers, both contemporary and colonial. What new things have you learned? How has this changed your perspective on childbirth?

Oh, honestly, I wish the Odon device were already available! It’s not quite yet, they’re still doing clinical trials, though very confident it will be on the market soon. I would so happily offer to test it. It’s impressed me so much, I absolutely believe in it, and if something so uninvasive can effectively get a baby out in so few pushes, I’d almost hate to give birth without it.

I know that the producers at EST emphatically insist that EST/Sloan plays have to work as a play and yet have substantive science content. What have you found is trickiest about writing a play about science?

Well, there’s a lot of information you have to impart to the audience when you’re doing a science play. In real life, when you get information, you’re probably reading something, or watching something, or noticing something – none of these things are active or dramatic! They’re all quiet and internal.

So figuring out how to impart information in a way that feels natural and true to the characters and in the dramatic arc of the play, AND making those moments entertaining, is very difficult!

Jorge Odon demonstrating the Odon Device.

Jorge Odon demonstrating the Odon Device.

I find it very very hard to dramatize a moment of scientific or creative discovery – the actual Eureka! Moment – so I just skipped it in this play, focusing instead on the inspiration, and then the aftermath.

You mentioned once that you get impatient with theater that doesn’t take into account the audience experience. How does BUMP deal with the audience experience? What do you want the audience to take away from BUMP?

It’s funny, it’s very easy to have lots of opinions on this when you’re in the writing process (or in the audience of another play) but it feels so vulnerable to talk about when you’re in production, because you’re so aware of the possibility of falling short!!! But what we hope is that the play is entertaining, and funny, and warm, and that the audience enjoys spending the time with these characters as much as we do. And we’ve been pretty strict about pacing, and when the play needs to race to the finish line.

I love being at home. I think most people love being at home! Most people enjoy not having to trek to midtown. So I guess, when it comes to the audience, I hope that the experience of watching the play is ultimately worth not being at home.

You’ve been part of the writing team for the hit TV show Superstore (IMDB says you’ve written eight episodes so far!). Congrats on that. How is writing for a sitcom different from writing for the theater? I know that soap opera writers have to write to beats. Do you need to get a laugh every three minutes? Do you find that writing for Superstore has informed or changed your playwriting?

The cast of Superstore

The cast of Superstore

First of all, to say that I wrote eight episodes of Superstore is a very very flattering misapprehension courtesy of IMDB. I was in the writer’s room of Superstore, but it was a BIG writers room, where everyone sort of pitched ideas and jokes. The writers on that show are genius comedians. Everything that comes out of their mouths is funny! I was in awe. SO fast and SO funny.

This is sooooo hugely different from playwriting, or screenwriting, for that matter, where you sort of get to sloooowly construct things.  I am NOT funny out loud. I am ONLY funny like, by myself on my computer.

But one thing I learned from Superstore – that I actually used on Bump! – is about ALTs. Having ALT jokes or ALT lines in a script. You can have the actor read them both and see which you like. In television, I believe they would film all the alts, and you then choose the best one when you’re editing later. For BUMP, I just have the actor try a few and choose right there, but adding ALTs to a theater script is, I think, unusual, and straight out of my time at Superstore.

Do you remember when you first got turned on to science?

Well, tellingly, my interest in science is strongly tied to narrative! I took an incredible Microbiology class in high school which stood out from all the other science classes I’d ever taken because there was such a focus on the stories and scientists themselves – how Louis Pasteur discovered vaccinations by inoculating chickens with weak strains of bacteria; how John Snow traced the cholera epidemic in London back to a single water pump; how Ignaz Semmelweiss realized women were dying after childbirth because doctors weren’t washing their hands. I guess I like unusual discoveries and the logic behind them. It’s no wonder I was so inspired by the real-life story of Jorge Odon and his cork-trick discovery!

 When did you first discover you were funny?

I think there were a good few years of trying very hard to be funny without ever managing to do it. Then, when I was a freshman in high school, I wrote a funny short story (??why) that my friends really liked and passed around, AND I’VE BEEN CHASING THAT HIGH EVER SINCE.

In an interview in 2014 you raved about how great Twitter was for new playwrights. In an interview in early 2017 you scaled down your enthusiasm but admitted that you met your husband through Twitter. Then in November, 2017, just after the presidential election, you left Twitter completely. What happened? Do you blame Twitter for Trump’s election?

Chiara's retired Twitter page

Chiara's retired Twitter page

I loved Twitter when it felt like a fun and a low-key way to engage with people about art, writing, and current events. There was a time when it was really effective. Writers that I had long admired were suddenly just a tweet away, and I could interact with them! I could post a tweet, an article, a link, a recommendation to a play, and people would really engage back, read the link, go see the play, talk to me about it.

But now it’s just din. Everyone shouting over one another. I don’t feel like it’s an effective way to promote content or ideas anymore, and I don’t know why, only that I also am so much less likely to take a Twitter recommendation seriously.

That’s enough for me to become disenchanted with it, but the reason I quit altogether is that I vehemently disapprove of Twitter as a conduit for political discourse. 140 characters – or whatever it is now – is not sufficient for the kind of conversations I feel are necessary now. Retweeting something does not make you politically engaged – that’s something I learned the hard way in 2016. An unguarded, unthoughtful, unedited screed quickly typed and published on Twitter is absolutely not something I can stand for in a president. I literally find it insulting as a citizen. And I felt that to despise when Trump does it yet continue to use the medium myself would be hypocritical.

Twitter was fun for a long time. I am so indebted to it. But I can’t support it anymore. And I’m ready for longer, more thoughtful conversations.

What else are you working on now?

A screenplay and a play! I’m reading The Odyssey with my dad right now, and I’m hoping to write a play – a comedy! – that picks up where that leaves off – Penelope and Odysseus back to domesticity after a twenty-year break from it.

BUMP is being produced as this year’s Mainstage Production of The EST/Sloan Project, a twenty-year-old initiative between The Ensemble Studio Theater and The Sloan Foundation. BUMP starts previews on May 9 and continues performances through June 4 at The Ensemble Studio Theatre. You can purchase tickets here

Chiara Atik on getting a cork out of a bottle, dating, tweeting, delivering babies, and MIDWIFE/MECHANIC

Twice this week — on Tuesday, March 21 at 8 pm and on Wednesday, March 22 at 3 pm — this year’s EST/Sloan First Light Festival will feature a Roughcut Workshop of MIDWIFE/MECHANIC by Chiara Atik.