The Venus Figurine

Pregnancy has always had a sacred place in mythology. From the Palaeolithic Venus figurines, to the various stories of deities born from virgins, pregnancy has been cloaked in mystery and draped in awe –the curious interregnum separating being from non-being. That special state when the woman is suddenly not alone in her body, and then, equally suddenly not just a person, but a mother –a transformation that is as miraculous now as it was in millennia past.

It is still a source of wonder for me, even after 40 years as an obstetrician. But I think one has to be particularly careful in its blanket ascription to every woman –To every thing there is a season, and a time to every purpose under the heaven. For many women, it has been a rite of passage, a validation of their gender, whereas for others…

I am always on the lookout for popular articles on pregnancy and its resulting motherhood –not so much for resolution of the pro-life/pro-choice conundrum, but mainly to understand the current societal prescriptions for acceptable attitudes and behaviours of mothers. How intrusive is social media in moulding conduct and beliefs? There were a few clues in an opinion piece in the Guardian newspaper: https://www.theguardian.com/commentisfree/2017/may/30/detach-myth-motherhood-from-reality-future-generations But, judging from the tenor of the piece, it would seem difficult to avoid dissenting views.

The author, Angela Saini, introduces the topic by saying, ‘It’s hard for any woman to escape the expectation to be a mother. The maternal myth suffuses every human culture, from Catholicism’s Virgin Mary to Hinduism’s goddess mother. It’s considered the most natural state of womanhood, leaving the childless woman the object of pity. Let’s not even mention the woman who doesn’t want or like children at all.’ And then she imputes an opinion to a famous restauranteuse who was criticizing the UK prime minister about something –that ‘motherhood somehow makes a person automatically care about not only her own children but everyone else’s as well; and that women who aren’t mothers don’t have the same caring sense towards future generations.’ Fighting words, as they say.

Saini goes on to write, ‘But maternal instinct is not a switch that exists in every woman, ready to be flipped as soon as she smells a baby. Relationships between mothers and their children are frequently far more fraught than the myth leads us to believe. It shocks us that mothers can be selfish. […] There is scientific evidence to suggest that the maternal instinct may even be contingent on a woman’s circumstances. […] maternal instinct may sometimes depend on whether a mother has the support she needs. We’re not a species designed to cope alone. Indeed, we’re at our most social when it comes to parenting, often recruiting many people around us to help. It really does take a village to raise a child.’

Her point, obviously, is that maternal instinct is not an all-or-none phenomenon –it can exist in degrees, and like a flower, it may take a while to fully bloom. ‘[…] motherhood is not always an against-all-odds epitome of selfless caring. Sometimes it can involve emotional calculation, weighing the needs of both parent and child. We all assume that a mother always wants the best for her child, above her own needs. What we seem to deliberately ignore is that a child’s welfare can also depend heavily on the mother’s own needs being met.’

And so, ‘For the sake of both mothers and children, we need to begin detaching the myth of motherhood from the reality. It’s unfair of any society to expect women to be the best mothers they can be without economic or emotional support, just because they should love their children. Not all women are happy to be mothers.’

She concludes by observing that ‘Many mothers will know that birth doesn’t always signal a rush of immediate love. The maternal bond may build slowly over time. For a small few, it may never appear. And some never experience the urge to have children. We think of all these as unnatural exceptions, bucking the normal trend of how a woman is supposed to feel. But the scientific and historical evidence shows that none of it is strange at all. […]The most unnatural thing of all is forcing a woman into motherhood in the anticipation that she will biologically fall into line when a baby arrives.’

As an obstetrician, my responsibilities ostensibly end with the birth of the baby, and yet how can a duty ever end? Delivery is seldom the last time I see the woman and her baby, and it is certainly not the last time I hear their stories. We are all stories.

Jennifer sat in my office crying inconsolably. It started out as most other visits start, as I remember. She was seeing me for her post-partum checkup, six weeks or so after the normal delivery of a healthy baby boy. It was her first pregnancy and everything had gone well in hospital. She had left smiling, if a little stunned at the rapidity of her labour.

When she came into the office she was the picture of contentment, although I did wonder why she hadn’t brought the baby. I don’t deal much with babies, but the mothers usually bring them to show them off. It’s always nice to see how they’ve changed since birth, and marvel at the almost constant eye contact between the two of them. Usually, I get the impression the mother is only half listening to my questions –she is completely involved in a world I cannot really enter.

But when I asked Jennifer how the baby was, her face changed. “Jonathan was marvelous for the first day or so…” she said, her voice trailing off. “But I was so amazed at him, so involved in his every move, of course he seemed perfect.”

The first tear slid down her cheek and she stared out the window behind me for a moment, as if she were afraid I’d ask her more. Then, she grabbed for a tissue from my desk and wiped her cheeks. “Doctor, he never sleeps! I feed him, I burp him, I change him, I rock him… And so does Tony, but it only works for a while, and then he starts again. We took him to the pediatrician, but she just smiled and reassured me. Some babies are like that, she said. It’s not colic, it’s not something Tony and I are doing wrong… And it will settle.

“But it hasn’t! Neither of us are getting any sleep and now Tony and I are fighting… I wish we’d never decided to have a baby…” She stopped talking and suddenly stared at me in terror as if she’d admitted to some unspeakable crime… And to the doctor who’d seen her excitement for her entire pregnancy…

She began to sob. “I don’t think I’m a very good mother, doctor. My friends seem able to manage with their babies… They don’t need any help!”

I waited to hear her out, but she just sat huddled in front of me weeping inconsolably. “Did your mother stay with you?” I said softly. “I remember she was with you in labour.”

She shook her head sadly. “Tony and I figured we could manage.” She wiped her cheeks again and grabbed another tissue. “She wanted to stay and help, but I’ve always been her independent child.” She sighed with a deep stertorous gulp of air. “I was kind of embarrassed to admit I might need some help, to tell the truth…” She stared at me with wide red eyes, like a doe peering out of the woods.

I smiled and sat back in my chair. “There’s an African proverb I’m sure you’ve heard, Jennifer: It takes a village to raise a child. I think it also takes a mother to help her child…That’s what mothers are for, isn’t it…?”

She stared at me for a second or two, a weak and wobbly smile fighting to control her lips. “You mean…?”

“Phone her,” I said.

And she did –right there in the office.

 

 

 

 

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Time Out, eh?

Time-outs to wring behavioural change from naughty children are all the rage nowadays. Everywhere you go there seem to be men sitting near their tantrum-laden little boys in the parking lots of stores, or women standing outside of cars fastidiously ignoring the screams of alternately pounding and pouting children confined within. Perhaps this has been going on for years, but only recently have I begun to notice the ritual. In fact, it seems so ubiquitous, that I am beginning to suspect a flaw in my own upbringing. I don’t remember being an easy child; maybe I just had easy parents. Or maybe the Encyclopedia Britannica of the age didn’t cover that aspect of childrearing.

It might be investigating the obvious, but I had to look it up at any rate. Time-outs are more acceptable attempts at behaviour modification than corporal punishment –spanking comes to mind- especially in public, where the difference between remonstration and child abuse is uncomfortably opaque. The idea of social exclusion was likely popularized in a paper by a Dr. Montrose Wolf at the University of Washington in the mid 60ies, drawing on the work by his mentor, Dr. Arthur Staats (who called it ‘time-out’).

But, unless you grew up in Winnipeg in the 1950ies, you might now regard time-outs as such an intuitively obvious way of treating both the child’s misbehaviour and the resultant parental frustration, that you would be forgiven for assuming it had been hard-wired in our DNA. Perhaps it was, but with variable penetrance, and probable mid-prairie epigenetic modification –anyway, there seem to be some issues with its application: http://www.cbc.ca/news/health/time-outs-study-parenting-1.3888166

By default, I suppose I’m an educationally impoverished repository of doctrinal wisdom when it comes to children. As an obstetrician, for years -until my own arrived, at least- my responsibilities ended with handing the freshly-liberated, and usually screaming newborn to the mother, tidying things up, and then congratulating the smiling, emotionally overcome parents before I left the room. I didn’t expect to be confronted with any of their subsequent behavioural peccadillos. But, as Shakespeare’s Cleopatra remarked, those were ‘my salad days, when I was green in judgment’.

Usually, I enjoy seeing children in the waiting room –they lend a kind of friendly family air to the office. Sometimes, however, there are things I need to discuss with the mother, procedures I need to perform, or even examinations that might alarm the child, so my enjoyment is often that of seeing the child stay in the waiting room. It’s not called that for nothing.

Clara was already a harried teenage mother of a two year old when I first met her several years ago, and I delivered three more for her in the following years. Now in her late twenties and recently divorced, she had been sent to see me for permanent birth control.

I heard the excited screaming even before I reached the front desk, and I have to admit that I hid behind a wall to assess the situation more fully before I ventured into the open. The first of the children I delivered -Edward, now around five- was stirring the pot by running around the room clutching a toy to his chest so the dauphin, despite the obvious entitlement of age, could not get it.

Clara’s long auburn hair, now partially liberated from whatever restraints she’d attempted at home, was hanging forlornly around her shoulders, while her eyes followed the action around the room like a hockey game. A large lady now, she sat uncomfortably on the edge of her seat, no doubt hoping to catch Edward and the toy if he was so unwise as to come anywhere near grabbing range. The youngest, still breast feeding, was the only one over whom she exercised even temporary dominion.

I glanced nervously around the room from the shelter of the alcove, hoping she had brought a friend or older family member with her, but Clara was the last patient of the day and the room was otherwise empty.

“Clara,” I said, face prepared, and hoping she hadn’t noticed me behind the wall. “Nice to see you again.”

The children immediately stopped running and flocked to my side to tug on my clothes. Jamie, the oldest, grabbed the toy from Edward, who was now too busy trying to reach my stethoscope to notice.

“I… I saw you… watching from the alcove, doctor,” Clara said, blushing a deep crimson because she almost said ‘hiding’. “I tried to get my sister to take care of the kids, but she had to work today…” She shrugged and reached out with lightning speed to grab Jamie’s arm before he could swat his brother. “You behave yourself, Jamie, or you’re gonna do a Time-out, eh?”

Jamie immediately akimboed his arms and made a face at his brother. “He grabbed my car…!”

Clara glared at him and frowned, but from the defiant face with which Jamie greeted the threat, I could see the battle lines hardening.

I glanced at my secretary sitting behind the front desk, but she was on the phone and I realized that I was on my own. “Let’s go into my office,” I said, with a worried look at the boys, and the little girl, Janice, who by now had decided that the way to recapture some attention was to stick her tongue out at Jamie. Only the baby seemed compliant, but that was probably because Clara was still nursing her.

My office, unfortunately, was not designed for children –there are simply too many things that could tip over or break if handled indelicately. On the way down the hall to the office, I even thought of getting my secretary to fake a call from the hospital requiring my immediate assistance, but she was still on the phone and merely winked at me as I passed. I got the impression she was just holding the receiver for show.

As soon as the troupe entered the office they began to explore, and Jamie, who had probably never seen pennies before, made a quick exploratory lunge for the penny bowl that sat in front of a terra cotta statue of a begging lady precariously balanced on a little oak table. Edward, on the other hand, was reaching for the carved wooden statue of a woman holding a child that I had put behind a plant on my desk, and Janice was trying to extract the contents of the shelf where I keep my medical journals. It was a multi-pronged attack worthy of an Alexander.

“I’m not sure this is going to work, doctor,” Clara said, trying unsuccessfully to reposition the baby onto a breast while glaring at all three of her children now crawling along the floor scooping pennies into their pockets.

I called my receptionist to come in with us. “Laura,” I said as she opened the door a crack and peeked in. “Please put the phone on hold, or something…  I need your help.” Actually, I needed a time-out.

I could feel Laura’s eyes rolling behind the door. She was the mother of three young children, so she knew what I was going to ask.

“I want you to take the kids and… occupy them for a few minutes while I talk to Clara.”

She shrugged, but I could tell from her face that she thought it might be an interesting challenge as she gathered the tribe -minus the now sleeping baby- and led it out of the door. The office felt so peaceful suddenly that Clara and I just looked at each other for a moment. I managed to gather a more complete history and when I opened the door to lead her across the hall to the examining room I could only hear quiet giggles.

Finally, after Clara and I had discussed her needs, we both tiptoed down the corridor to the waiting room. But it, too, was quiet except for Laura’s voice telling a story as the children sat around her in a little circle on the floor.

Each of them had a plastic speculum with a sticker face stuck on the top and when Laura asked a question, one of the children would make the speculum talk. They were loving it and didn’t even look up when we crossed the rug. But Laura did, her eyes glistening from quiet laughter.

Clara just stared at them, unable to speak.

Laura chuckled and then shrugged. “I gave each of them a choice of those little funny face stickers we always give to the kids and showed them how to attach them to the top of the speculum.” A contented sigh escaped as she watched them all talking quietly to each other through the specula. “From then on, it was just role playing…”

“How did you ever think of that, Laura?” I asked when they’d all left.

She shrugged again. “The specula have always reminded me of quidnuncs… you know, snoops -those who insist on sticking their noses in other people’s business.”

I had to sigh in admiration -Laura has a name for everything. I just hope she doesn’t expect me to name the specula now… But I looked up quidnunc just in case.

 

 

 

 

 

Pregnancy Stress

Curiosity is a curse sometimes. It strikes in the most unusual circumstances and often with little warning. Some little thing will set it off and bang, you’re hooked. I’m an obstetrician, so procreative issues are constantly surfacing in my life. Environmental stressors and reproductive failure also seem to be de rigeur in the social media nowadays so there’s no escaping it. The worry may have started with animal data -animals are the easiest to study so we often look at what evidence they provide and then extrapolate. I’m thinking of those dark mysterious star-filled nights at summer camp when there is howling in the distance, and everybody huddles together with questions.

And worst of all are those important things that don’t have ready answers, or the answers have different explanations each time you look for them. Different causes. The secondary sex ratio has always been that type of enigma for me: why isn’t the ratio exactly 1:1 in humans? Well, first of all, some definitions. The primary sex ratio is the ratio between the sexes at fertilization, and the secondary sex ratio is their ratio at birth. There’s even a tertiary ratio -the sex difference in mature organisms.

In the past, the gender ratio at conception was unknowable, so the only useful ratio was the one at birth -and that seemed to favour males (1.1 males for every 1.0 female). So did that mean that male sperm somehow outswam the female ones or damaged them on the way to the egg? Did it speak to the quality of the gametes or merely suggest that to balance tertiary sex ratios (the ratio in sexually mature organisms, remember) more males were needed because, unlike females, they were less able to make it through childhood..? Until recently, as I mentioned, there was no way to measure the primary sex ratio, so it remained a mystery. Now it seems there is, and, surprise surprise, there would appear to be an equality of sexes -at conception at least: http://www.pnas.org/content/112/16/E2102.full.pdf  This fascinating study tracks gendered mortality during development in the uterus. There is a theory (the Trivers-Willard hypothesis) which posits that more males are born in a favourable environment and more females in an unfavourable one because just one sex will be better at ultimate reproduction under those differing conditions.

So what conditions might effect the secondary sex ratio? Well, amongst other things, there is some evidence that major stressors may influence it. Large disasters have certainly been implicated -earthquakes, for example: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3881738/  And then, of course, there were the changes in secondary sex ratio immediately after the 9/11 World Trade Center attack in 2001… One explanation that has been offered to explain how this could occur is that males typically attain a critical fetal weight earlier than do females (the average weight of newborn males, for example, is ∼100 g greater than females) and this might exert a higher metabolic demand on mothers. So, depending on the gestational age and the extent of the stress, the mothers may be able to abort the male fetuses, but maintain the less physiologically demanding female ones. In other words, evolution would seem to have selected for those females that can regulate the sex of their offspring… Really?

That explanation seems rather contrived to me. Exactly how would the mother accomplish this feticide? And avoiding direct maternal involvement by referring it back to changes in placental function merely pushes the question back another layer. Of course, some have tried other approaches -for example citing the epigenetic environment (factors influencing the functionality of genes): http://humrep.oxfordjournals.org/content/20/9/2662.full But even when I force myself through the commentator’s words, the explanation still seems a little strained.

And yet, statistically, there does seem to be reason to believe that something is happening that relates to stress.

Of course pregnancy itself is a stress -levels of stress hormones increase as pregnancy unfolds: (http://www.jogc.ca/abstracts/full/201505_Editorial_1.pdf) -although, as the editorialist explains, ‘as a pregnant woman approaches term, environmental stress has less effect in triggering the usual response in the hypothalamic-pituitary-adrenal axis, and she becomes less responsive to the effects of stress’. Uhmm… So, pick your answer from a hat?

Well, in the rubble of destroyed answers and ever blossoming questions, what are we left with? Is there something special about violence that triggers it? Or does any stress threaten the ratio? And what constitutes a stress anyway? All imponderables, I suppose, but at least a recent article in the JOGC (Journal of Obstetrics and Gynaecology of Canada) brings it closer to home: http://www.jogc.ca/abstracts/full/201505_WomensHealth_1.pdf  And in an ‘Only in Canada, eh?’ fashion it demonstrates that we, too, can participate in the secondary sex ratio debate -on our own terms, of course. I mean, who would have thought that our two referenda on Quebec secession from Canada could provoke such a response? I’m almost proud that it did –it shows how involved we are in our country. How much it matters. And how we don’t need earthquakes, either.

And maybe the slight increase in female births that the worries about the referenda caused says something about our growing appreciation of women in Canadian society as well… I live in hope. But you gotta love this stuff, eh?