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The definite guide to childbirth mortality in Westeros: the true numbers, and why they matter

Inspired by a few comments in another thread, here's a short essay I've been wanting to write for a while and finally managed to type out.
Enjoy.
Table of Contents:
  1. Childbirth mortality in the medieval and early modern era
  2. Childbirth mortality in Westeros
  3. Why does it matter?
  4. ASOIAF and deconstruction
0) Terminology
Childbirth/maternal mortality (MM) = the event of a woman dying because of childbirth-related causes, during childbirth or afterwards (e.g. puerperal fever) Childbirth/maternal mortality rate (MMR) = the probability of a woman dying in any single childbirth Lifetime childbirth/maternal mortality rate (LMMR) = the probability of a woman to die due to childbirth-related causes (instead of other causes of death)
1) Childbirth mortality in the medieval and early modern era
Westeros is inspired by the high & late medieval and early modern era of Europe. Think ~1200-1700. This post is concerned with the issue of childbirth and mortality of mothers going through this process. This is a fascinating field of study, as there are still many misconceptions about this in our mainstream understanding of the medieval era. According to the Encyclopedia of Children and Childhood in History:
Studies by Roger Schofield, B. M. Wilmott Dobbie, and Irvine Loudon estimate that maternal mortality rates between 1400 and 1800 were between 1 and 3 percent. Most often, women died in childbirth due to protracted labor caused by a narrow or deformed pelvis, fetal malpresentation, postpartum hemorrhage, or puerperal fevers. The health risk was renewed at each pregnancy. Since a woman averaged five pregnancies, 10 percent of these women died during or soon after childbirth.
Maternal mortality rate, mind, applies only to the women who actually are in childbirth. 1-3% is a very wide range, by the way. This is because 1400-1800 is a very wide timespan and Europe is quite the large and variable continent - in fact, both of this is true for Planetos and Westeros as well, but I am getting ahead of myself.
According to Daily Life in Medieval Europe, the medieval Florentine woman had a 1.44% chance of dying in each childbirth she had. (MMR) This number maps the 1-3% given above at the low end, which makes sense - medieval Florence was a highly developed, urbanized area with somewhat better infrastructure and medical care than other European regions.
Birth was a moment of heightened danger both for the mother and child, although complications were the exception rather than the rule. Statistics on maternal mortality are rare for the Middle Ages, but in fifteenth-century Florence there were 14.4 maternal deaths for every 1,000 births. Such a figure suggests that death in childbirth was an unusual event, but still extremely high by modern standards–about twice the rate of the poorest countries of the Third World today.
Compare: My home country of Germany has a bit of a high maternal mortality rate today compared to other industrialized countries, but not especially high. It's .07 in 1,000. That's a whole lot better than 14.4. Out of 100,000 childbirths, only 7 women die. Out of 100,000 births in medieval Florence, 1440 mothers died. In GRRM's words, that would be 'frighteningly high by modern standards'.
2) Childbirth mortality in Westeros
The medicine in Westeros is very highly developed compared to the rest of the technology and science. This should include maternal care. GRRM says:
Childbirth isn’t quite the killer in Westeros that it was in medieval Europe in the real world, since Westeros has the maesters, who are a considerable improvement over medieval barbesurgeons… but the levels of mortality for both infant and mother would still be frighteningly high by modern standards.
(Interestingly, he doesn't seem to mention midwives, who were an important source of medical care for pregnant women in this period.) Plus, ASOIAF is concerned with the nobility, whose level of medical care is exceptionally high - but we do have many examples of lowborn women giving birth as well. So the MMR in Westeros that we see should be roughly around the Florentine women we saw above and not on the upper end of the scale. Heck, let's even round it up to 1.5% to make it easier to calculate. You can even take 3%, the highest estimated MMR from the Encylopdia, if you want to assume, for whatever reason, that Westeros' MMR is more analogous to the places and times in medieval Europe with the highest MMR rather than the lower end. If you want to do that, just replace the 1.5 with 3 in the following calculations.
A maternal mortality rate of 1.5% means that there's a 98.5% chance to survive per childbirth. Let's take Catelyn as an example of how this works. She has born 5 children and no miscarriages that we are aware of. The probability to survive all 5 births is 0.985*0.985*0.985*0.985*0.985. That comes out at about .927 (rounded), so a probability of surviving all 5 of her childbirths of 92.7%. So around a 7% lifetime chance of dying in childbirth. (LMMR) So her death in the childbed would be an exception, but still really, really high compared to modern sensibilities.
Compare: In modern Germany, Cat's probability of surviving her 5 births is 99.96%, and thus a 0.04% lifetime chance of dying in childbirth.
What would be the realistic LMMR of all women in Westeros, now? The Encylopedia of children... claims medieval women had 5 children at average; let's take this as the Westerosi noblewomen average too. (This average includes women without any children, which means that the median number of actual children per mother we'd expect to see would be lower than 5, especially considering the high infant mortality rate. This seems to broadly map with the actual number of children we are given in the books.) So Cat, our example, is actually our average example of how high lifetime maternal mortality should be. Therefore, we expect to see 7% of women in Westeros dying from childbirth, and 93% from other causes: accidents (extremely lethal in medieval Europe), diseases (flu, ...), plagues (great spring sickness, ...), "old age/natural causes" (heart diseases, cancers, dementia, ...), famines (especially in Westeros with its out-of-whack seasons!), violence (war, spousal violence, ...), suicide, ...
Compare this, now, to what's actually on page, the known causes of death we see with our Westerosi women. For example, three of the most prominent female deaths are Lyanna, Rhaella, and Joanna, all in childbirth to three of our protagonists, for example. But wait, BelFarRod, you really cannot compare these three cases to actual scientific data! We do not have the cause of death for most characters in the books! Fret not, dear Mr. Strawman, someone has actually done the work and compiled all stated causes of death for Westerosi women. What a mad lad, what a mad fandom. This statistic includes only known causes of death and excludes all unknown causes of death, which might or might not be childbirth-related. It is furthermore concerned with individual women - this means it is broader than only counting named characters, like e.g. Catelyn, but also characters who are not named but are known to us as individuals, e.g. Barra's mother. It does not include non-individual women, e.g. "all women in Braavos born 200 or earlier", which, though all dead, would rather make the calculation entirely useless. But since it is characters we are concerned with, leaving out 'masses' is valid. From this, we can arrive at the LMMR by looking at the percentage of women dying in childbirth vs other causes.
Childbirth deaths are 31; non-childbirth deaths are 148. So, for 179 women, 31 died in childbirth.
Doing the math here, we arrive at a whopping 17.32% lifetime maternal mortality rate. Insert Too Damn High meme. Remember that our expected average noblewoman's lifetime maternal mortality rate, based on both actual medieval numbers and GRRM's own (!) goals, was 7%. This is more than double that number, when it should be that number or even lower. Even the extreme end of medieval LMMR, 14%, is still lower than that.
3) Why does it matter?
Very well, BelFarRod, you have shown that you can do history research and use a calculator, and I commend you for it. Your 6th grade high school maths teacher would surely be impressed if she could see you now. But why does this even matter? We have known for a long time that GRRM Can't Math (tm). Look at the Wall, and the size of the castles! He just doesn't really know about realistic numbers, and this is just another example of his writing going against his stated goals. Well, Mr. Strawman, thanks again for bringing this up. For one, now you can state some cool facts about medieval (lifetime) maternal mortality rates at your next party, and I can assure you that this will make you the hit at any party. Nothing cooler than knowing exact numbers of medieval maternal mortality rates.
Second, I argue that just like with the Wall and the castle sizes, we should be aware of this wrong math, lest we take it as fact - and we do have this preconception of women dying in childbirth that makes it easy to take this incorrect statement as fact. And "medieval childbirth" is even more relevant to our lives today than "building a wall of ice" or "building a medieval castle" - while giant ice walls are not really part of our daily lives, childbirth still is and probably will always be an important part of our lives. We are people who undergo childbirth, we are people whose loved ones undergo childbirth, and finally, we are people who exist due to childbirth. Ain't nobody out there existing due to giant ice walls. So someone has to do the research.
Third, the death of women matters. ASOIAF, as a work, is very much concerned with gender and gender roles, from Cersei to Sam to Sansa to Arya to Theon, and the rigidity especially of pre-modern European societies' gender roles. And one major part of Westeros' gender role for women is pregnancy, and for noblewomen, "being a broodmare". This is an important character motivator, part of the society, and criticized throughout the text. Rape is another recurring event, and does lead to pregnancy and therefore a chance of death. Keeping in mind that Westerosi women apparently have a 17% chance of dying from childbirth during their lifetime, thus, gives us the instrument of analyzing this aspect of the text, and the characters and their arcs, more precisely. It makes a difference, finally, to a young woman's attitude towards sexuality if the chance of ending her life in total is 7 or 17%. Obviously, these characters have not done the math, but they see the women around them, and they hear the stories of their deaths. In a society with a LMMR of more than double that of medieval Europe, this difference is noticeable to every member of society.
Fourth, and most importantly... Take a step back from text, and look at our society, and look at the author. Here we have a book written by an author who claims he wants the (lifetime) maternal mortality rate to be lower than in actuality, and still his LMMR is more than double the actual LMMR of his historical inspiration. We know GRRM writes women very well, we know there are many, many feminist themes in GRRM's writing, and we know that GRRM certainly didn't try to write such high maternal mortality rates - rather the opposite. But then how did this happen? How could this happen? GRRM can't math is one explanation, and it's certainly part of it. GRRM's research is not a historian's research, and this is also part of it. But here's the other thing. Dying in childbirth is an inherently and by definition gendered death. Why did GRRM's mind go to "oh, they all died in childbirth"? Why didn't Rhaella die of starvation half a year after Dany's birth? Why didn't Joanna die of a flu two years after Tyrion's birth? Why didn't Lyanna die falling down the stairs of the ToJ? Their deaths in childbirth are necessary for the plot, necessary for the character arcs of many of the protagonists. Their gendered deaths are necessary for the story to work. And it's a damn good story, don't get me wrong - Joanna's death specifically in the childbirth of Tyrion makes Tyrion's and Jaime's and Cersei's arcs and relationships with each other that much more compelling. Apparently, GRRM seems to think that gendered deaths make for good storytelling, or else we would see much less of them, and not nearly such an unrealistically high number.
But why do these gendered deaths make for a good story? Are drowning, plagues, violence, or famines less suited, as causes of death, to tell a good story? Why did GRRM apparently decide these gendered deaths specifically make for a good story? Why must so many mothers of the protagonists die in childbirth?
Why do women die in the birthing bed, and men die on the battlefield?
4) ASOIAF and deconstruction
Stories are not written in a vacuum. ASOIAF looks at the romanticized view we have of our medieval-inspired fantasy worlds, and deconstructs it, tears it down to reconstruct the elements that matter, the elements that we care about, so we can leave the trash behind. Look at how bad feudalism is. Look at how much classism sucks. Look at how destructive war truly is. Look at the violence inherent in slavery. Look at how rigid gender roles suck. Look at the difficulty of being good in a bad world, look at the difficulty of making decisions as a ruler. "What's Aragorn's tax policy?" goes hand-in-hand with "How does Rosie feel about giving birth to 13 children?", two questions traditional fantasy ignores. And it's fascinating to see the author who goes out to ask such questions return to these old, flat tropes of women dying in childbirth - without, apparently, even noticing it!
When do our minds return to old tropes without us even noticing?
Oh, that's a good question, BelFarRod. Why thank you, Mr. Strawman, let's think about it together.
submitted by BelFarRod to pureasoiaf

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