Are the Maesters responsible for the incredibly small Great Houses?

[Alyn Oakenfist]

6 minutes ago, Lady Dacey said:

"She died in childbed" is GRRM's go to phrase when it comes to killing woman off page. He abuses the trope, plain and simple. It's a gendered way to get rid of characters that could be dead for a myriad of reasons or not even be dead at all. That you don't remember the characters that faced such fate speaks to how lightly the issue is treated, the banality of death in childbed in this fictional world. It was never so in history, though obviously it was more prevalent than it is today. In the main series, besides Johanna Lannister and Lyanna Stark (about whom we cannot make any statement, actually) there are several others: Rhaella Targaryen, Minisa Tully, Mance Rayder's wife Dalla, Jon Arryn's first wife Jeyne Royce, his sister Alys Arryn, ser Jorah Mormont's first wife (an unnamed Glover), Victarion's unnamed first wife, Mors Crowfood Umber's unnamed wife, three Frey ladies (Ser Stevron's daughter Magelle, his third wife Marsella Waynwood, and Ser Aenys' wife Tyana Wylde). These are just women in the current story's time frame, no historical characters included. If I would add those, the list would feel never ending.

There a many misconceptions about labour and delivery in the realm of "common knowledge" about such events. I know a thinf or two about it, from the moment I became pregnant I contected activists in my country and became myself an activist for good practices in childbirth. I live in the country with highest c-section rate in the entire world, and a much higher maternal death rate than it ought to be with the (high) level of health assistance we have here, and that's due to iatrogenic reasons.

Childbirth is different for each woman that goes through it and each time the same woman goes through it. Yet, I feel entitled to speak about such an experience, having gone through 10 hours of labour and natural delivery without any medical intervention whatsoever (though inside a hospital). Think no IV infusion, no analgesia ou anesthesia, no episiotomy, no lithotomy. GRRM's work reads like that of someone who didn't bother to do the research, so it falls to us to criticize it where it's due. Maternal and infant death were on all accounts much lower in the middle ages than later in the renaissance and early moder era.

This is from the World Health Organization: the maternal mortality ratio in developing countries in 2013 is 230 per 100 000 live births versus 16 per 100 000 live births in developed countries. There are large disparities between countries, with few countries having extremely high maternal mortality ratios around 1000 per 100 000 live births

These very poor-performing countries have limited-if-any access to modern medicine, and yet they're still having a extremely high rate of 1% maternal mortality. That feels much lower than Westeros!! The only feasible explanation is 'GRRM doesn't know what he's talking about'. People (usually men) attempting to justify such scenario probably don't know either.

To be fair, died in battle is almost as worse for the men in the backstory, particularly in the Dance in F&B. Like I get GRRM wanted to make the conflict seem that much more devastating by murdering every noble in sight, but hot damn that's a lot of dead commanders. Like I think the only commanders that survive the Dance start to finish are Unwin Peake and Corlys Velaryon, because they're important for later

[Lady Dacey]

1 hour ago, Alyn Oakenfist said:

To be fair, died in battle is almost as worse for the men in the backstory, particularly in the Dance in F&B. Like I get GRRM wanted to make the conflict seem that much more devastating by murdering every noble in sight, but hot damn that's a lot of dead commanders. Like I think the only commanders that survive the Dance start to finish are Unwin Peake and Corlys Velaryon, because they're important for later

That seems fair, though I know nothing about the death rate of military commanders in history. 

[Alyn Oakenfist]

9 minutes ago, Lady Dacey said:

That seems fair, though I know nothing about the death rate of military commanders in history. 

Well given that they always had state of the art armor and equipment, not to mention proper training and a personal guard, I'm guessing it would have been far better then the fly swatting we see in the dance.

[Lord Varys]

@Lady Dacey

When we went through this issue after FaB made it very glaring yet again, I actually checked on the English and French queens from the middle ages from the era which mostly influenced George's work and even a cursory research reveals that not many royal women actually died in childbirth. Child mortality was much higher, especially if you think about the infections and what not which can kill you up until you reach your teens.

There are quite a few royal children which didn't live to adulthood (think of some of Eleanor of Aquitaine's children as well as Edward II's elder brothers) while very few queens and princesses died in childbirth.

For FaB the scenario of Alyssa Velaryon is somewhat believable, but that's basically the only one.

George's depiction of mothers suck for the following reasons:

1. Pointless deaths in far to great a number. The most glaring of those cases is Jeyne Marbrand, Tywin's mother, where George just can come up with any other manner of death but death in childbirth.

2. Him being too lazy to invent more children who died in childbirth for the various generations to equal out/complement the women who died in childbirth.

3. The discrepancy in the effectiveness of maester medicine apparently allowing them to bring up most/all noble/royal children (safe some weird cases like the many children of Aerys and Rhaella) while them being helpless to save women who die in childbirth like flies.

4. George's inability to allow wives to outlive husbands in almost any case. Olenna is the only noble widow in ASoIaF proper, and this kind of thing is very rare in history, too. It stands to reason that Daenaera Velaryon, Myriah Martell, Aelinor Penrose, Betha Blackwood, and Shaera Targaryen also do not outlive their husbands - which means most/all of them are very likely to die in childbirth (as Dyanna Dayne most likely also did). This is most glaring in the case of Alysanne Targaryen who could have easily outlived her husband for a couple of years considering she was younger than he was and neither of them died at a particular old age. A funny anecdote in this context is that George failed to realize that Visenya Targaryen was massively older than the so-called 'Old King' during the writing process of TWoIaF, trying to sell Jaehaerys I as the oldest Targaryen so far.

This is all especially vexing because historically various queens and royal women had multiple spouses.

In principle, George has a very weird obsession with women dying in childbirth, anyway, if you consider the ridiculous world-building of 'Fevre Dream' where all the female vampires are routinely killed by their children during birth. And we also have to consider it as very deliberately that Dany's, Jon's, and Tyrion's mothers all died in childbirth giving birth to them. That's not an accident but apparently an important 'mythological' plot point.

 

[Lady Dacey]

@Lord Varys thou art right. There is no really no room for arguing here. F&B was a real disappointment. 

In the main series, Dalla was the most glaring example to me. The whole scene before the battle bothered me - Dalla is described "lying on a pile of furs beside the brazier, pale and sweating" and a few moments later Val comes to Jon and says "the birth has started". That was bad enough as a depction of labour, but I became truly enraged when Jon offered us just as a side thought that she had died and he was sad for it. She was a young and healthy woman by all accounts, the chances of her dying during delivery are minimal. 

[Lord Varys]

4 hours ago, Alyn Oakenfist said:

To be fair, died in battle is almost as worse for the men in the backstory, particularly in the Dance in F&B. Like I get GRRM wanted to make the conflict seem that much more devastating by murdering every noble in sight, but hot damn that's a lot of dead commanders. Like I think the only commanders that survive the Dance start to finish are Unwin Peake and Corlys Velaryon, because they're important for later

In a history book it makes sense that only important people are mentioned, and casualties in war among important are noteworthy things.

And while many men die in battle as they should, not that many commanders die - and most of them are clearly morons or make crucial mistakes or are the victims of suicide attacks. With the dragonriders your point strikes closer to the truth since a lot of those battles seem to be designed to involve morons who do their best to get both parties killed.

In general, men do get a variety of deaths, e.g. various illnesses, accidents, murder. Women can die just as much as men from a pox, infected wounds, falls from horses, or attempts on their lives.

Which is why I actually do like the manner of Princess Viserra's death ... although pretty much nothing else about her story.

1 hour ago, Lady Dacey said:

@Lord Varys thou art right. There is no really no room for arguing here. F&B was a real disappointment. 

In the main series, Dalla was the most glaring example to me. The whole scene before the battle bothered me - Dalla is described "lying on a pile of furs beside the brazier, pale and sweating" and a few moments later Val comes to Jon and says "the birth has started". That was bad enough as a depction of labour, but I became truly enraged when Jon offered us just as a side thought that she had died and he was sad for it. She was a young and healthy woman by all accounts, the chances of her dying during delivery are minimal. 

Yes, that was very odd. I never thought much about that, but it could have been much better if Dalla hadn't died ... or if she had died then because of actual complications brought about by the battle. Say, because a horse or a mammoth had been charging into the tent.

[FictionIsntReal]

On 10/18/2020 at 3:57 PM, Manderly's Rat Cook said:

Maternal mortality doesn't stand out as particularly high to me to be honest. The only examples in recent history that I can think of are Lyanna and Joanna Lannister

You're forgetting the third head of the dragon: Dany's mother also died giving birth to her.

14 hours ago, TheLastWolf said:

It's the medieval ages. They don't have Apollo hospitals. 

How familiar are you with medieval maternal mortality? I included a couple links on that, including one directly comparing it to Westeros.

12 hours ago, Manderly's Rat Cook said:

Nobody thought anything of it, so it must have been a very normal thing

GRRM has been very inconsistent on this. He's said that marrying off (or consumating) young girls is uncommon for that reason, but has numerous examples of it happening. Sansa is admittedly an unusual example because the Lannister are trying to beat the Tyrells to the punch and get her claim to Winterfell.

Quote

Giving birth is dangerous in itself, going through many pregnancies is a repetition of that danger

In one of the links above, someone does an explicit calculation of how dangerous it would be to repeat it the average number of times a medieval woman would give birth. It should still be atypical.

Quote

I'm not saying that "death in childbed" wasn't more common than it is in our world

GRRM has stated that due to maesters it's LESS common, but he doesn't seem to know what the actual rate in the medieval era was.

7 hours ago, Alyn Oakenfist said:

Like I get GRRM wanted to make the conflict seem that much more devastating by murdering every noble in sight, but hot damn that's a lot of dead commanders

Greg Clark in "A Farewell to Alms" noted that it was relatively prosperous farmers who were able to reproduce themselves in medieval England. Poor people couldn't afford to marry & support children, while the nobles kept killing each other off. I don't think it was all in civil wars though.

[The Grey Wolf]

I agree with everything said here about women dying in childbirth. As for commanders dying in the Dance I feel that 1) way more Green commanders die than Black commanders and 2) the Dance is poorly-written.

[Ran]

Comparison to medieval maternal mortality isn't really correct (and I've remarked on this to George in the past). 

Medieval midwives did not rummage around in corpses to study anatomy. Maternal mortality rose sharply in Europe after the Middle Ages precisely because the increasing attendance of doctors in a pre-germ theory setting led to unsafe practices such as treating people and studying corpses, and then going right ahead without significant disinfection efforts to delivering babies. By the mid-19th century, there were places where the rate of maternal mortality was approaching 10%(!). It took Ignaz Semmelweis to recognize a need for antiseptic procedure in specific relation to childbirth, at a time when germ theory was gaining great support. Westeros does not have germ theory, and indeed the various works have maesters mentioning things like humors and miasmas, references to pre-germ theory theories of bodily health and disease.

So while George, nearly 20 years ago, made an off-hand remark that he viewed childbirth as being a little less dangerous than the Middle Ages thanks to the maesters, the reality is that the actual evidence is that the maesters are probably making childbirth more, not less, dangerous due to overconfidence in their knowledge while in fact being sorely lacking in a particular area.

It's absolutely true that GRRM does not, or did not, have the correct view of maternal mortality in the Middle Ages, but in this area you need to look later than the Middle Ages to find similar conditions in any case.

What would be most useful is if we had information on births among commoners. How often does a commoner refer to their mother having died in childbirth? I know off-hand that we have Dalla's death, which I'm guessing was a breach birth or something, but otherwise I can't remember any references to smallfolk women dying in childbirth to a similar degree as Westerosi noblewomen. The only real difference between them would be access to maesters.

[Manderly's Rat Cook]

16 hours ago, Lady Dacey said:

 

"She died in childbed" is GRRM's go to phrase when it comes to killing women off page. He abuses the trope, plain and simple. It's a gendered way to get rid of characters that could be dead for a myriad of reasons or not even be dead at all. That you don't remember the characters that faced such fate speaks to how lightly the issue is treated, the banality of death in childbed in this fictional world. It was never so in history, though obviously it was more prevalent than it is today. In the main series, besides Johanna Lannister and Lyanna Stark (about whom we cannot make any statement, actually) there are several others: Rhaella Targaryen, Minisa Tully, Mance Rayder's wife Dalla, Jon Arryn's first wife Jeyne Royce, his sister Alys Arryn, ser Jorah Mormont's first wife (an unnamed Glover), Victarion's unnamed first wife, Mors Crowfood Umber's unnamed wife, three Frey ladies (Ser Stevron's daughter Magelle, his third wife Marsella Waynwood, and Ser Aenys' wife Tyana Wylde). These are just women in the current story's time frame, no historical characters included. If I would add those, the list would feel never ending.

There are many misconceptions about labour and delivery in the realm of "common knowledge" about such events. I know a thing or two about it, since from the moment I became pregnant I contacted activists in my country and became myself an activist for good practices in childbirth. I live in the country with highest c-section rate in the entire world, and a much higher maternal death rate than it ought to be with the (high) level of health assistance we have here, and that's due to iatrogenic reasons.

Childbirth is different for each woman that goes through it and each time the same woman goes through it. Yet, I feel entitled to speak about such an experience, having gone through 10 hours of labour and natural delivery without any medical intervention whatsoever (though inside a hospital). Think no IV infusion, no analgesia or anesthesia, no episiotomy, no lithotomy. GRRM's work reads like that of someone who didn't bother to do the research, so it falls to us to criticize it where it's due. Maternal and infant death were on all accounts much lower in the middle ages than later in the renaissance and early modern era.

This is from the World Health Organization: the maternal mortality ratio in developing countries in 2013 is 230 per 100 000 live births versus 16 per 100 000 live births in developed countries. There are large disparities between countries, with few countries having extremely high maternal mortality ratios around 1000 per 100 000 live births

These very poor-performing countries have limited-if-any access to modern medicine, and yet they're still having a extremely high rate of 1% maternal mortality. That feels much lower than Westeros!! The only feasible explanation is 'GRRM doesn't know what he's talking about'. People (usually men) attempting to justify such scenario probably don't know either.
 

The reason why I didn't think of them is mostly because it's been a few years since my last re-read. I did realise I didn't mention Rhaella though after I wrote my reply. I'll get back to her later.

At the start of the 20th century maternal mortality was about 1 in 100, which is similar to low income countries that have the worst mortality rates. The worst has 1 in 75, so I think 1 in 100 might be a good estimate what the maternal death rate could be. What you didn't take into account I think it's the lifetime maternal death risk is though, which increases with the number of pregnancies a woman goes through. So the number of women dying doesn't equal the number of births. One woman would generally have multiple children, and often lots of them. And the numbers you state are only applicable to live births. The number would be significantly higher if it included stillbirths and miscarriages. Stillborn births, van be very dangerous, since it increases the chance of the child being in the wrong position, and the child also doesn't give a hormonal response to the mother's hormones, which can prevent her from properly going into labour. So if you have 10 women, and all those women give birth 10 times to either live or dead children, they will have 100 children between them. If one dies during the tenth birth, then you have a maternal mortality of 1 in 100, or 1%. And that would be INCLUDING stillbirths, so it would STILL be LOWER than the current maternal death rate in low income countries, cause that number only includes live births.

I'm not entirely certain but I believe that haemorrhaging also occurs more often after miscarriages and stillbirths, which in turn would be more common when children couldn't be delivered through C-section (if necessary), and labor couldn't be induced. After 41 weeks of pregnancy, the risk of mother and/or child dying in childbirth significantly increases.

Even today in low income countries childbirth is the most common cause of death amongst women, and the more pregnancies a woman goes through, the more it increases. So I actually believe that the maternal death rate in Westeros might be even lower than in contemporary low income countries.

I do agree that we could do with more interesting female deaths though, especially in the world book. It almost seems as if the only women in the world book who would go on adventures sometimes and die in the process, were Targaryens. Where are the Aryas and the Briennes? I don't think we have too many childbirth deaths, I think we don't have enough fascinating female deaths.

For the main series I think the childbirth deaths are not that bothersome when it comes to the women who we aren't supposed to focus our attention on. Imagine if Jorah's Glover wife fell off a cliff? The first thing that would happen was forums full of people who are convinced that she didn't fall, no, Jorah pushed her, since he'd somehow foreseen that he'd fall madly in love with Lynesse. And the Glover wife didn't really die anyway, no she swam to the Iron Islands, joined Euron Greyjoy's crew and somehow ended up being Patchface. I don't think it's beneficial to the story if she had more backstory, and I think she was only written into the story, because GRRM wanted Jeor Mormont at the wall, and Jeor needed his son married before giving up his seat. Although it would've been cool if Jorah's first wife had had an actual name, and would've eaten herself to death or something. I definitely agree that it's lazy to not even give them names and a little more variety to their deaths. Still it's not the death rate itself that is the problem, more how casually it is treated. Which is a different subject altogether, and I totally agree with you on that. I get that they are very minor characters (if you can even call them that), and that maternal mortality would be a likely cause of death, they just could've been presented more as.. actual persons, with at least some specifics about them.

I think the point of the Grey wives is more about Walder, and the fact that he outlives all his wives, and he himself doesn't see them as people, so I can kinda forgive that. Some of them were bound to die in childbirth, cause not all 1000 of them could possibly die an interesting death.

I won't go into all of these women, because this post is already very long, but I do think that the deaths of the more important characters are treated with respect, and do serve a purpose.

Starting with Lyanna: her death is interesting, BECAUSE she dies giving birth. It is important because we need to find out that she has a child, and that she may have run off with Rhaegar on her own account. The death itself might be a cliché one, the reasons why she died that specific death, make it interesting. 

Now Rhaella... Poor Rhaella... I think her death is the most poetic (if you can call it that) ending to her arch of miscarriage misery. I think she was bound to die in childbed. You may agree or disagree, but her death also makes sense. All the circumstances contributed to it, and it would almost have been surprising if she survived.

* First off: she was close to 40. The risk of maternal mortality more then doubles for the ages 35-40, compared to 30-35. 40-45 it almost doubles again compared to 35-40. And those are today's numbers. So her age wasn't in her favour to begin with.

* This was her 11th (!!) pregnancy (and obviously the only one that killed her. She already had 5 miscarriages and stillbirths, and lost three babies in the crib, which must have caused an immense amount of grief, and also fear for each new birth, and so much pressure. The physical and emotional strain of going through all that by itself must've crushed her.

* Her oldest son was recently killed in battle. Her husband was killed as well, although that must've been a relief. But she was obviously grieving during her pregnancy, and grief can result in malnutrition, and obviously causes a lot of stress and anguish. Not a good thing for mother or child.

* Her daughter in law was violently raped and murdered, her grandchildren were brutally murdered as well.

* She herself just barely escaped the same fate with her only surviving child.

* She was in the middle of a war, that her side had already lost, and she and her only surviving child were at the top of the most wanted list.

* She had suffered severe and prolonged physical, emotional and sexual abuse by the hands of her husband.

* The child she was bearing was the result of a violent rape.

* Her husband had been the most powerful man in Westeros, and also a paranoid schizophrenic, and she had had to live with him, abiding his will at any time.

* There was a violent storm going on, that must've sounded like the castle was under siege.

What could possibly go wrong? Under circumstances that stressful, more stressful than I can possibly imagine, it's at the very least unsurprising that the birth didn't go well. She probably barely had any strength left to give birth at all, and it's a wonder that Dany even survived. With this in mind I think any other death for Rhaella would've felt hollow and off. This is how she was supposed to die; her entire arch builds up to it.

Dalla gave birth in the middle of a battle as well, so I suppose GRRM's reasoning was that it was caused by stress as well, but I suppose she could've been stabbed to death as well, or the tent caught fire, and Val could only get the baby out our something. There were other possibilities, but the circumstances at least make her death in this manner plausible for reasons other than that she's woman, and she's giving birth, and I think that that's the point you were trying to make, that women shouldn't just die all the time because they're women and are having babies.

The last one I'm going into is Jeyne Royce; Jon Arryn's wife, since I believe the way she dies serves as important purpose as well. We are meant to think about whether Jon Arryn was the one who had fertility issues, rather than Lysa. This can only happen if we know that he had problems producing offspring with other women than Lysa. His previous wife had to die as well for him to be able to marry Lysa as well. Now the point of her dying in childbed, was not that she was a woman giving birth, but that she died because she was giving birth to a stillborn child. Probably a child that didn't die because of a lack of oxygen during birth, but one that was already dead in the womb, and thereby making the birth harder and more dangerous. The way she dies is intended to make us think that there is a genetic defect on Jon's side, rather than Lysa's. Luckily his second wife just died of a chill, otherwise it would be overkill.

The last thing I'd like to mention is that in the current timeline in the books, we only see Dalla dying in childbed. Lysa dies an interesting death, as does Cat. Ygritte is killed by an arrow, that Jon was afraid was his. We hear of Barra, Robert's bastard daughter being murdered, and Dany walks into a pyre and doesn't even die. We see Brienne almost being killed by face-eating.. if any of the main female characters die, I can't imagine any of them dying in childbirth. Maergery will die an unusual death, and so will Myrcella. Cercei won't go that way either, nor would Brienne, or Arya. The only one I could possibly imagine dying that way would be Sansa, but I don't think she will. 

Jeyne Westerling perhaps, or Roslyn Frey.. maybe Jeyne Poole.. probably one of those three, I can see that happen, but not all of them, although I do think that at least both Jeynes will die. Because Jeyne rhymes with pain :-( 

Sorry for giving you an entire book to read. I think we're basically on the same page, except on whether the amount of maternal deaths is realistic.

[Manderly's Rat Cook]

13 hours ago, Lady Dacey said:

@Lord Varys thou art right. There is no really no room for arguing here. F&B was a real disappointment. 

In the main series, Dalla was the most glaring example to me. The whole scene before the battle bothered me - Dalla is described "lying on a pile of furs beside the brazier, pale and sweating" and a few moments later Val comes to Jon and says "the birth has started". That was bad enough as a depction of labour, but I became truly enraged when Jon offered us just as a side thought that she had died and he was sad for it. She was a young and healthy woman by all accounts, the chances of her dying during delivery are minimal. 

It's the way Dalla's death is treated, as an afterthought, that is bothersome, not the fact she dies in childbed imo. It's true that she could've died any kind of death there, but there is enough context in the stress of giving birth in the middle of a battle, to make it a plausible death. The problem lies in that it's treated as an "oh that's too bad, but happens all the time" kind of way.

I don't think it's that important that the numbers add up. If one in 2 women would die in childbed it could still be fine, as long as it wasn't treated like ".... aaaand there goes another one... Yup.. yup.. we've lost her, neeeext!" And yes, GRRM definitely does that to his minor female characters.

[broken one]

18 hours ago, Lady Dacey said:

 

It was never so in history,

Ive just done quick research on wifes of polish kings and dukes from X to XV century (just briefly for feudal defragmentation period - too many of them) and found only 1 case of death connected with child birth! It was Hedwig D'Anjou, most popular one - probably this is why I had expected different outcome.

[FictionIsntReal]

17 hours ago, Manderly's Rat Cook said:

Even today in low income countries childbirth is the most common cause of death amongst women

Do you have a citation for that?

[Manderly's Rat Cook]

On 10/21/2020 at 2:21 AM, FictionIsntReal said:

Do you have a citation for that?

I can't find it any more, but I meant to say amongst young women in low income countries, not most common in general, that wouldn't make sense. I typed too quickly, and it was a long post. I'll see if I can find it again. I thought I read it here but I don't see it, so I either read it somewhere else, or misremembered.

 

EDIT: I really can't find it. Perhaps I misinterpreted something out misremembered. I got more information Here and Here. I did read other articles as well, however I wrote my post in one go the day after I read them, cause I had to chew on it for a while. I noticed on rereading then that I did misquote some numbers. 35-40 is less than double the number of deaths compared to 30-35. Sorry about that.

[TheLastWolf]

On 10/19/2020 at 8:13 PM, Lady Dacey said:

 

"She died in childbed" is GRRM's go to phrase when it comes to killing women off page. He abuses the trope, plain and simple. It's a gendered way to get rid of characters that could be dead for a myriad of reasons or not even be dead at all. That you don't remember the characters that faced such fate speaks to how lightly the issue is treated, the banality of death in childbed in this fictional world. It was never so in history, though obviously it was more prevalent than it is today. In the main series, besides Johanna Lannister and Lyanna Stark (about whom we cannot make any statement, actually) there are several others: Rhaella Targaryen, Minisa Tully, Mance Rayder's wife Dalla, Jon Arryn's first wife Jeyne Royce, his sister Alys Arryn, ser Jorah Mormont's first wife (an unnamed Glover), Victarion's unnamed first wife, Mors Crowfood Umber's unnamed wife, three Frey ladies (Ser Stevron's daughter Magelle, his third wife Marsella Waynwood, and Ser Aenys' wife Tyana Wylde). These are just women in the current story's time frame, no historical characters included. If I would add those, the list would feel never ending.

There are many misconceptions about labour and delivery in the realm of "common knowledge" about such events. I know a thing or two about it, since from the moment I became pregnant I contacted activists in my country and became myself an activist for good practices in childbirth. I live in the country with highest c-section rate in the entire world, and a much higher maternal death rate than it ought to be with the (high) level of health assistance we have here, and that's due to iatrogenic reasons.

Childbirth is different for each woman that goes through it and each time the same woman goes through it. Yet, I feel entitled to speak about such an experience, having gone through 10 hours of labour and natural delivery without any medical intervention whatsoever (though inside a hospital). Think no IV infusion, no analgesia or anesthesia, no episiotomy, no lithotomy. GRRM's work reads like that of someone who didn't bother to do the research, so it falls to us to criticize it where it's due. Maternal and infant death were on all accounts much lower in the middle ages than later in the renaissance and early modern era.

This is from the World Health Organization: the maternal mortality ratio in developing countries in 2013 is 230 per 100 000 live births versus 16 per 100 000 live births in developed countries. There are large disparities between countries, with few countries having extremely high maternal mortality ratios around 1000 per 100 000 live births

These very poor-performing countries have limited-if-any access to modern medicine, and yet they're still having a extremely high rate of 1% maternal mortality. That feels much lower than Westeros!! The only feasible explanation is 'GRRM doesn't know what he's talking about'. People (usually men) attempting to justify such scenario probably don't know either.
 

AL those woman and more died during childbirth. But if you take them as a percentage of total female characters in GRRM's world, very less. Considering that all didn't die in the same age. Over years. Lots of diseases, war's, grief etc. 

And not all those childbirth deaths are from childbirth. Like how Domeric Bolton didn't die from a stomach ache. Fir example, I have a personal crackpot that Joanna was finished off by Cersei to hide her relationship with Jaime or by Tywin after he found out that she had Aerys's child (Tyrion). Lot of circumstantial evidence for both. Just ask @Lord Lannister

[Loose Bolt]

3 hours ago, TheLastWolf said:

Joanna was finished off by Cersei to hide her relationship with Jaime

Joanna died 273 and Cersei was born 266 so she started her career as a serial killer very young

[Lord Varys]

On 10/20/2020 at 8:33 AM, Ran said:

Comparison to medieval maternal mortality isn't really correct (and I've remarked on this to George in the past). 

Medieval midwives did not rummage around in corpses to study anatomy. Maternal mortality rose sharply in Europe after the Middle Ages precisely because the increasing attendance of doctors in a pre-germ theory setting led to unsafe practices such as treating people and studying corpses, and then going right ahead without significant disinfection efforts to delivering babies. By the mid-19th century, there were places where the rate of maternal mortality was approaching 10%(!). It took Ignaz Semmelweis to recognize a need for antiseptic procedure in specific relation to childbirth, at a time when germ theory was gaining great support. Westeros does not have germ theory, and indeed the various works have maesters mentioning things like humors and miasmas, references to pre-germ theory theories of bodily health and disease.

So while George, nearly 20 years ago, made an off-hand remark that he viewed childbirth as being a little less dangerous than the Middle Ages thanks to the maesters, the reality is that the actual evidence is that the maesters are probably making childbirth more, not less, dangerous due to overconfidence in their knowledge while in fact being sorely lacking in a particular area.

It's absolutely true that GRRM does not, or did not, have the correct view of maternal mortality in the Middle Ages, but in this area you need to look later than the Middle Ages to find similar conditions in any case.

What would be most useful is if we had information on births among commoners. How often does a commoner refer to their mother having died in childbirth? I know off-hand that we have Dalla's death, which I'm guessing was a breach birth or something, but otherwise I can't remember any references to smallfolk women dying in childbirth to a similar degree as Westerosi noblewomen. The only real difference between them would be access to maesters.

I don't think this is a workable in-universe theory to explain away this issue.

While it is true that maesters do have problems correctly figuring out the mechanism of infectious diseases (and we should also keep in mind that Martinworld is a place where magical diseases are a thing, too), the way in which they deal with all the infected wounds of male characters - I'm speaking of Ned's crushed leg, Sandor's face, Jaime's infected stump, Jon's arrow wound, Lancel's Blackwater wounds, Viserys I's infected hand, etc.

If we were to pretend that the collective of mothers which died in childbirth - which is a literal army of women if we consider FaB - died because the maesters involved in their treatment basically arrived at their beds after their latest autopsy then it just doesn't fit with the fact that the same maesters are very competent in dealing with infected wounds.

And we are led to believe that proper maester medicine could have saved Drogo's life, for instance, and it seems Victarion issues with his hand have more to do with him searching help too late (and perhaps also with the dusky woman not being all that interested in administering proper care) than Maester Kerwin's incompetence.

All this indicates that maesters do know to wash their hands before they treat bleeding tissue, and that should include women giving birth. Even more so considering that the general impression we get from Westeros is that the nobility do wash themselves more often than clichéd depiction of the real world European middle ages. We hear constantly about people changing clothes to make them representable.

Bottom line is, there is a discrepancy in what kind of injuries manly warriors can survive (the most ridiculous example would be Sandor's infected wounds ... if the deus ex machina there is an elder brother with 'healing hands' then why don't such miracles never occur when privileged women do give birth?) and how many woman die in childbirth.

Add to that the ridiculously low child mortality and the entire thing makes even less sense. After all, if maesters sucked and treating women in childbirth, they should suck even more in treating young children suffering from various infectious diseases, burns, infected wounds, etc. That is unintentional/unconscious misogyny ... and intentional misogyny in the cases where 'death in childbirth' is a crucial part in a character's backstory as is arguably the case for Jon, Dany, and Tyrion.

It would be great to contrast health conditions and life expectancy of commoners and nobles ... but little we hear is that access to a maester can and often does mean the difference between life and death. And if we look at Dalla and imagine Lya as giving birth without a maester then there doesn't seem to be much difference in that department.

[Ran]

1 hour ago, Lord Varys said:

If we were to pretend that the collective of mothers which died in childbirth - which is a literal army of women if we consider FaB - died because the maesters involved in their treatment basically arrived at their beds after their latest autopsy then it just doesn't fit with the fact that the same maesters are very competent in dealing with infected wounds.

Not at all. Every example you provide are of obviously infected wounds. But maesters do not understand that they themselves are carrying invisible diseases when they are attending childbirth, and that these diseases are capable of entering women who are not suffering from any obvious wounds. It's not like post-birth they go, "And now we'll pour in the boiling wine:"

Think of all the examples of maesters treating people, and you'll notice a curious thing: not once are they described washing their own hands! Aemon, Qyburn, Kerwin, Pycelle -- all of them just go right in. They may wash out infected wounds after, but they don't actually have antiseptic routines for themselves or their instruments.

[Lord Varys]

42 minutes ago, Ran said:

Not at all. Every example you provide are of obviously infected wounds. But maesters do not understand that they themselves are carrying invisible diseases when they are attending childbirth, and that these diseases are capable of entering women who are not suffering from any obvious wounds. It's not like post-birth they go, "And now we'll pour in the boiling wine:"

Think of all the examples of maesters treating people, and you'll notice a curious thing: not once are they described washing their own hands! Aemon, Qyburn, Kerwin, Pycelle -- all of them just go right in. They may wash out infected wounds after, but they don't actually have antiseptic routines for themselves.

If this were so they would likely also reinfect said wounds when administering later treatment, most notably Jaime's stump which Qyburn had to treat multiple times. Also one would imagine that said maesters should then also treat bleeding women after childbirth the same way they would treat other wounds, i.e. wash them out with boiling wine and the other sterilizations methods they use.

Also, I'm not sure how a maester with dirty hands would not just reinfect the wound he is treating immediately after washing it out when he binds up the wound. If we assume they have no concept of infection via dirty hands then the idea would be that you can touch a wound with dirty hands even after you have washed out the wound without doing any harm.

In addition, we don't really know whether maesters are even attending childbirths routinely - we do have midwives as well (think of Rhaenya's and Alyssa's last pregnancy - especially during the latter the midwife present is seen as great an authority on Alyssa's condition as Maester Kyrie). While maesters might attending it is somewhat of a stretch to assume they are at the forefront of putting their dirty hands into the women giving birth and not the midwives - who are likely to do the heavy lifting, with maesters only taking a hand when things are getting dire and even then they might just direct the women, not actually do much.

And while maesters are not seen washing their hands prior to administering treatment, it is a stretch to assume that maesters do not wash their hands after doing autopsies or performing other filthy tasks. And the hands of midwives and other people assisting births - both with the nobility and the smallfolk - would not be cleaner than those of the maesters.

I'd agree that they would not be particularly sterile - and we would expect that the childbed fever cases we have would come from something like that - but I don't think we can make a case that maesters can play the role of early modern doctors compared to things in the middle ages.

And, again, this does nothing to explain away the core problem of there simply being too many cases of women dying in childbirth. That is a deliberate choice on part of the author which he reserves for women specifically while men tend to survive (hideous) wounds (and, to be fair, female warriors, too, if you think of Brienne in AFfC and Queen Visenya after the Field of Fire) not to mention their causes of death show a much greater variety.

George's world is very weird in the sense that marriage is usually a death sentence for a woman. We have lots of men with a succession of wives while we get very few women who remarry after their husbands are dead. But lots of queens and noblewomen in the real middle ages had multiple husbands.

[Ran]

3 hours ago, Lord Varys said:

If this were so they would likely also reinfect said wounds when administering later treatment, most notably Jaime's stump which Qyburn had to treat multiple times.

You do realize that washing hands is something that doctors, surgeons, and healers did not do until the 19th century?  Or even sterilizing equipment? People survived such treatment for centuries, but not as well as they could have. And in the very specific case of childbirth, early modern medicine -- with its lack of germ theory and antiseptic routines -- actually increased, not decreased, mortality. And it did it for centuries before someone pulled their head out of their rear and realized that it was the doctors themselves, and their direct interventions, that were the cause in the increase.

Maesters, as described, should increase childbirth mortality for women, not decrease it, compared to more traditional  midwives.

3 hours ago, Lord Varys said:

 

Also one would imagine

One would have to imagine it, since there is no such reference made in the books, that I can think of. Until there is, the idea that they're pouring heated wine into bodily orifices sounds unlikely.