Medical Examiner

How the C-Section Went From Last Resort to Overused

The history of the surgery is rife with horror, but today, 1 in 3 American babies are delivered via the procedure, twice what the World Health Organization recommends.

C-section scar.

Here’s a doozy of a birth story: In an 1830 issue of the Western Journal of Medical and Physical Sciences, Dr. John L. Richmond describes an impromptu surgery he performed in rural Ohio. Richmond had made his way through a storm to a “bleak home, with its dirt floor and gaping crevices in the logs that constituted walls.” He found a woman who had been in labor for hours, but each contraction was followed by “general convulsions” and “alarming faintings.” He dosed her with laudanum and sulphuric ether, which helped with the “fits,” but he could not figure out why her labor wasn’t progressing.

Richmond told the woman, the midwives who had been attending her prior to his arrival, and the friends and family watching and worrying that only a cesarean section would give the patient and the baby any chance to survive. “Feeling a deep and solemn sense of my responsibility, with only a case of common pocket instruments,” Richmond made the incision. “The woman’s friends,” Jacqueline Wolf writes in her absorbing new book, Cesarean Section: An American History of Risk, Technology, and Consequence, “helped by holding blankets in front of candles to prevent the howling wind from leaving the surgical scene in total darkness.”

Richmond couldn’t pull the baby out through his incision and ended up fishing around in the woman’s uterus, looking for the feet. “The mother begged him to stop,” Wolf writes. “She couldn’t endure the pain.” The doctor referred to the medical ethics of that time and place, and made a horrifying decision. “Reminding himself that ‘a childless mother is better [off] than a motherless child,’ ” Wolf writes, “Richmond altered course and proceeded to remove the fetus, in pieces, from the wound in the mother’s abdomen.” The mother survived and went back to work 24 days after the surgery. “After she healed, Richmond examined her thoroughly and discovered an abnormally shallow vagina with no discernable cervical opening,” Wolf reports. Richmond’s story is the first published account of a C-section performed in the United States.

C-sections remained extremely rare throughout the 19th century. Even after the mid-20th-century advent of antibiotics and blood transfusions, which rendered the surgery much safer, the national rate of C-sections remained low. Then, the procedure exploded. Between 1965 and 1987, it rose 455 percent. Today, despite the work of the birth-reform movement of the ’70s and ’80s, 1 in 3 babies are still delivered by C-section. That’s twice the recommendation set by the World Health Organization, which states that a 10–15 percent rate is the ideal, since a rate higher than that has been assessed to have no effect on mortality rates, even as it pushes up medical costs and increases other risks for both mother and baby. Wolf’s book explains how we got here, taking a long, historically informed view of a modern problem. It’s an activist text, committed to the proposition that our C-section rate is dangerously high, but it’s also plainly excellent in its account of how medical and cultural factors combined to get us to this point.

Nineteenth-century medical texts “counseled physicians to refrain from interfering with the birth process.” Births were mostly attended by midwives. When a doctor had to come in, like Richmond, they worked under the assumption that it was more important to save the woman’s life than the baby’s. As a pregnant woman is prone to hemorrhage, the surgery was perceived as far too dangerous to undertake lightly. It was a last resort, only after drastic interventions that could include the use of forceps or the execution of a craniotomy, in which the doctor would collapse a baby’s skull in order to extract it from the woman and save her life. The section of Wolf’s book that covers craniotomy is very difficult to read, but as an illustration of how medical priorities around women and babies have changed over the past two centuries, its vividness is unrivaled.

Given that many doctors shied from C-sections because of the value they placed on the mother’s life, it makes a terrible kind of sense that many 19th-century cesarean patients were enslaved women, whose owners, performing their own calculations as to the relative value of woman and baby, gave consent to the surgery. Wolf cites an 1863 case in Arkansas in which the slave owner asked the doctor to remove the patient’s ovaries after a second cesarean, to prevent her from getting pregnant again: “The child survived the birth; the mother died 10 days later of peritonitis.” Another slaveholder celebrated a successful cesarean by setting the baby, named “Cesarinne,” free.

Wolf’s chapter on the 19th-century record draws from the data left behind by Robert P. Harris, a Philadelphia physician who became a medical statistician. Harris took an interest in the C-section surgery and solicited accounts from doctors who had performed them. “His accounts appear to be inviolable,” Wolf writes. “After receiving the initial description of a surgery, he followed up by contacting witnesses and the patient, if she had survived, for corroboration.” A majority of the cases Harris documented were black patients; 20 percent of surgeries occurred in cases where the women were (in his description) “dwarfs.”

Though curious about the surgery’s possibilities, Harris was no cesarean booster. He found a 52 percent death rate in his records. He also collected stories of situations in which women had been “gored by cattle and forced to deliver their babies through the gaping wound,” as Wolf memorably explains. He found nine, and noted that of those situations, the rate of survival of the women and children involved actually exceeded that of the C-sections performed in New York state before the late 1880s. “There is a far better showing for the cow-horn than the knife,” he observed.

Doctors became increasingly concerned about infants in the early 20th century, when progressive activists took on the cause of reducing infant mortality rates and pressed the federal government to take an interest in children’s health. Two (male) obstetricians helmed opposing sides in the debate over several years, as the surgery’s rate rose slightly but not dramatically. J. Whitridge Williams, head of the department of obstetrics at Johns Hopkins and head of the “non-operators,” made his case against the procedure in 1926, arguing, “Any one with two hands and a few instruments can do a cesarean section … It frequently requires great intelligence not to do it.” (Williams generally advocated that doctors should do as little as possible while attending a birth.) Joseph DeLee, an influential Chicago obstetrician and a prominent “operator,” argued for more intervention in birth, famously writing in a 1920 article, “So frequent are these bad effects [of labor] that I often wonder whether nature did not deliberately intend women to be used up in the process of reproduction, in a manner analogous to that of salmon, which dies after spawning.”

In his actual practice, Wolf points out, DeLee was more likely to let poor women labor naturally and to apply “complex, prophylactic techniques to service the wealthy.” Alice Roosevelt Longworth, a 40-year-old first-time mother, traveled to Chicago to consult with him and asked him for an elective cesarean. DeLee told Williams in a letter that he was thinking of doing it, because he had begun to practice a new European-style incision for the operation—the low transverse incision that’s still standard in 2018 and that makes uterine rupture less likely in subsequent births. Eventually, Longworth had a vaginal birth, though not without medical intervention; DeLee administered ether, performed an episiotomy, used forceps, and removed her placenta manually.

In the midcentury period, public opinion on the surgery shifted, albeit slowly. There was a 25-year gap between the simultaneous advent of widely available antibiotics and safe blood transfusions, and the ’70s-era increase in the C-section rate. Wolf uses the two births of John F. Kennedy Jr. and his brother Patrick, in 1960 and 1963, to show how mixed public opinion was on the surgery during this transitional time. Jackie Kennedy already had a fraught reproductive history: a miscarriage in 1955, a C-section to deliver a stillborn daughter (Arabella) in 1956, and a daughter, Caroline, born by C-section in 1957. After John-John was born by C-section in 1960, Americans celebrated, “ignorant of the risks for an infant born more than four weeks prematurely.” John-John survived. But when Patrick, also born via cesarean, died in 1963 after just 39 hours of life, newspaper coverage associated the death with his C-section, not his prematurity. (Hyaline membrane disease, the cause of his death, was not yet well understood.) To some people, Wolf writes, “the cesarean was a heroic effort that preserved life and health”—for others, “a cesarean was a macabre surgery associated more with death than life.” For Wolf, the story of John-John and Patrick shows how cultural factors may have upped the rate of C-sections in the ’60s and especially the ’70s.

In the ’50s and ’60s, diagnostic tools to help physicians assess the health of fetuses and neonates, including the Friedman curve, the Bishop score, and the Apgar score, “heightened obstetricians’ perception of the risks of childbirth,” Wolf writes. In her eyes, these tools were widely misused. Emanuel Friedman acknowledged that his curve, which he first described in a 1954 article as a means of assessing whether the length and pace of a woman’s labor were “normal,” was not the final word on the subject, since many of the labors he observed were of women who had been sedated, treated with synthetic oxytocin (Pitocin), or anesthetized. But even though Friedman himself realized that labors varied, by the early 1960s, Wolf writes, “American physicians had adopted the Friedman curve for use at every birth.” Edward Bishop’s 1964 Bishop score, assessing five cervical and pelvic characteristics in late pregnancy, was meant to help physicians decide when to induce labor with Pitocin, which was first made available in the 1950s. Later, obstetricians Wolf interviewed believed that the score had normalized induction, and “with the increasing number of induced labors, cesarean surgery not only became more likely, it became more acceptable.” The Apgar score (1952), developed by Virginia Apgar, an anesthesiologist who was concerned about the effects of analgesics and anesthetics on neonates and intended to measure a newborn’s physical condition, prompted “a focus on perfection” that, Wolf argues, “contributed to medical and public complacency toward the burgeoning cesarean rate.”

You can’t find a clean assignment of blame for the high C-section rate in Wolf’s argument, but the advent of electronic fetal monitoring, or EFM, is a watershed in this narrative. “The rush to perform a cesarean based on doctors’ interpretations of monitor strips profoundly altered the birth experience,” Wolf writes. She interviews Carol (a pseudonym), who, at 20 years old in 1976, came to the hospital in spontaneous labor. There, medical personnel reviewed a fetal monitor strip and found its offering dire. “They said I had to make a decision because they said either that I would die, or my baby would die, or both of us would die, if I didn’t have a cesarean … They said her heart was in distress,” Carol tells Wolf. She consented to the C-section, despite having serious misgivings. The baby survived, but when interviewed 28 years later, Carol was not convinced the surgery had been necessary.

Even after the first randomized, controlled trial of EFM, published in 1976, showed that outcomes for labor in high-risk women monitored by an EFM and similar women screened with a fetal stethoscope differed only in that the first group experienced a higher rate of C-sections, doctors continued to use them; indeed, Wolf writes, “most doctors had become uneasy attending a birth without the information the device provided.” And in the 1980s, lawyers began to use evidence from EFM readings in seeking malpractice settlements for birth injury, which further encouraged doctors to go for the “just in case” C-section.

The birth-reform movement of the ’70s and ’80s was an offshoot of second-wave feminism that fought for women to be allowed power over their own birth experiences—to have the right to give birth at home, to refuse interventions like induction, anesthesia, and episiotomy at hospitals, and to have access to nurse midwives and amenities like birthing tubs. (This set of commitments will sound familiar to anyone who’s read Ina May Gaskin’s Spiritual Midwifery, a document of the natural-birth movement first published in 1975.) In an accident of history, Wolf argues, the jump in the C-section rate happened at just the wrong time for the surgery to be one of the targets of these reformers. “The most precipitous increase in the surgery, between 1970 and 1985, paralleled a portion of the peak militancy, and greatest successes, of birth reformers,” Wolf writes. But the movement didn’t focus on C-sections initially, and its core momentum dissipated just as the C-section rate became an object of public concern. By the mid-1980s, Wolf explains, “the changes wrought by the birth reform movement proved to be more cosmetic than systemic.” This would be why we are now allowed to have loved ones in the room with us while giving birth, but the C-section rate remains too high.

So, here we are, living with our 1 in 3 rate. C-sections are so common as to be unremarkable now. Of course, they are often necessary, but even in our modern age, they still have consequences. Some women recover easily from the surgery; others find the first weeks of their new baby’s life to be difficult and painful. Mothers who have C-sections may react poorly to the necessary anesthesia, are more prone to develop postpartum blood clots and infections, and may experience placenta accreta in future pregnancies. As for the baby, studies have found that children born by C-section have higher rates of obesity, asthma, and diabetes—though what’s causing these correlations is not yet understood.

Birth is, of course, a deeply personal experience, the sort that you don’t quite understand until it happens to you. And indeed, you might not even know that this country has a high rate of C-sections until you have one. When I had an unplanned C-section in 2017, I had no misgivings about it whatsoever. (I had also been in labor for a day and a half, which influenced my perspective.) If I have any fault to find with Wolf’s excellent book, it’s this: I think some women may feel no trepidation or qualms at all about the surgery. Some may find the prospect of a scheduled C-section downright preferable, even considering the risks—like writer Meaghan O’Connell, who recently wrote about the relief of scheduling a second C-section after a very stressful first birth experience, for the Cut.

And then, for some women who are in labor already, an unplanned C-section might look like a clean, medical way to guarantee an outcome that seems likely to be good. Many women fill out birth plans detailing all of the choices they want to make in labor, then are faced with deciding whether to stick to them as their doctors’ advice changes, often while they’re having an experience that tests limits of their endurance. For some of those women, the C-section offers the right solution, and they don’t regret it. Not every C-section of borderline necessity turns out to be bad for the woman who has it—and we should take those experiences into consideration here as well.

But given the increasing awareness that we may be overusing the surgery, the question is—what’s the average woman who’s trying to avoid an unnecessary C do? How can pregnant people approach the prospect in 2018? Chavi Eve Karkowsky, a maternal-fetal medicine specialist based in New York City (and sometime writer for Slate), told me that patients should evaluate whatever data they can find about their hospitals’ C-section rates. “A lot of people don’t realize, they’ll pick their doctor, but you’re committing to a hospital,” she said. “And the hospital has all sorts of baggage and protocols and culture you really might not know about. We’re coming to understand that institutional culture and institutional numbers do vary.” (Wolf would agree; the “call to action” at the end of her book recommends that hospitals should be required to make their C-section rates public as well as information about the kinds of diagnoses that have led to surgeries in the past.)

Make your priorities for vaginal birth known to your provider, Karkowsky said, and look for some clue as to whether the doctor you’ve chosen has an evidence-based practice. How to ask this question, without being rude or confrontational? “The discussion of any decisions should come with at least some mention of scientific literature, studies, experiments, what we know, and what we don’t know,” she said. “It should always be modified to fit the individual experience, but a doctor who is evidence-based will bring you that evidence.”

Evidence, data, word-of-mouth. Of course, pregnant people have enough research to do without adding another book to the pile, so instead of pushing Wolf’s history on them, I’ll recommend that everyone read it. The more we know about how we got here, the better.