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The Cesarean Section throughout American History
The Cesarean Section throughout American History
Throughout American history, women have faced scrutiny, discrimination, and unfair laws placed against their bodies. One of the most famous ones was Roe v. Wade in 1973, which declared that women across the United States had the freedom to choose the outcome of their pregnancy (1). What many do not know is that laws have been placed on the labor and birthing procedures of women throughout history as well. That is how the cesarean section was conceived. The cesarean section is an incision into the womb for a surgical birth (2). Cesarean sections have become prevalent throughout history (3), but the procedure leaves a trail of mortality behind it.
If it was such a dangerous procedure in the past, it is essential to explain why a mother might receive a cesarean, and why they are still receiving them today (4). Possible medical reasons for a cesarean section in America might include multiple births (such as twins), placental complications, exposure to HIV, or the birth not progressing as it should (4). The baby can also be breech or transverse, have a prolapsed umbilical cord, or the mother might be experiencing complications like preeclampsia. Dissimilar from past events, many expecting parents are now aware that a cesarean will be their birth plan and they even have the option to choose it over a natural birth. To prepare, women are instructed not to shave 24 hours prior (4). Once at the hospital, the mother will receive preliminary IV antibiotics to prevent any possible infection (4) and sign consent forms for the surgery (5). She will also have a bladder catheter inserted (5). The procedure involves general anesthesia to numb the waist down (5), and a 3-4 inch incision in the abdomen (4). The incision can be made horizontally or vertically (4). Depending on the state of the emergency, this process can take between 15 and 45 minutes (5). After 2-3 days in the hospital, the mother is discharged home. She cannot drive for 2 weeks, lift anything over 25 lbs., or have intercourse for the next six weeks to prevent infection of the incision (4). Although so common, the cesarean section is still a major surgery that requires delicate attention to prevent the same issues that caused mortality thousands of years ago.
Figure 1: Asclepius (3).
As a brief history, cesareans were first mentioned in Greek Mythology. Asclepius, later becoming the god of medicine, was described as being removed from the abdomen of his mother by Apollo (Figure 1). Again, that was seen with Adonis, who was believed to have special mystical powers (3).
Cesarean sections are widely practiced and recorded in the history of Western and Non-Western cultures (3). The fascinating aspects of the procedure are the shifting historical opinions surrounding it, along with the medical progression of the procedure itself. The origin of the practice has blurred lines, along with original reasoning and views (3). The 21st century is child and mother-focused, extending every effort to save both parties, but that was not always the case in the past. Cesarean sections have become a medically advanced and relatively safe procedure when compared to the history of the operation. However, today, the cesarean section is overused in Western cultures, specifically the United States, and proposes more threat to birthing mothers than help. Moving forward in 21st-century obstetrics and gynecology, the rate of first-time cesareans must be reduced to decrease the overall risk of the procedure by changing the cultivated attitude around the surgery that was initiated by 1920s doctors.
The cesarean did not have the “glamorous” and secure past reputation that the surgery has today. Historically, the operation was used as a last resort (2). Historians researching the origins of the procedure have described the outcomes as “horrific” for both mother and fetus (2). Compared to the sterilized instruments used today, the first cesarean was most likely performed with a stone that was formed into a cutting tool. The Romans were the first to declare and document the cesarean operation as a medical procedure (2). Many believed the surgery was named after Julias Caesar himself (Figure 2), as he was rumored to be delivered by the operation.
Figure 2: Caesar being deliver via C-Section (3)
Yet, it was recorded that his mother, Aurelia, lived to hear of his invasion in Britain- which led historians to believe that fact is unlikely (3). It is more probable that the procedure received its name from the Latin word caedare, which means “to cut'' (3). Under Caesar's rule, the law Lex Caesaria was enforced. The law stated that all pregnant women who died must have the fetus cut from their abdomen (2). Contrary to belief, that was not in any effort to save the child but in response to religious values, as pregnant women were not allowed to be buried by the church. In the recordings of these procedures, the babies had often already passed with the mother, but the ones that survived soon died of prolonged oxygen deprivation (2). Even if the mother had not died during this time, she would have during the procedure if required.
Figure 3: Newspaper Clipping from the Vergennes Gazette. Published November 20th, 1800 in Vergennes, Vermont.
Cesareans were previously utilized as a last resort to retrieve an infant from a dead or dying mother. An 1800s Vermont newspaper article reviews events from the British Channel when the writer describes a cesarean being performed on a drowned pregnant woman (Figure 3). That showed 19th-century medical professionals practicing similar techniques to save the infant's life. However, the 1900s offered advancements in the medical field that would allow the procedure to become the vast phenomenon it is today. In 1920, Dr. Joseph DeLee published a paper on birth and new birth processes called The Prophylactic Forceps Operation (7). DeLee explained the new field of obstetrics and gynecology and the belief that natural birth was not a “normal physiological process” (7). Dr. DeLee began to practice cesarean techniques with Alfred C. Beck. It was through these practices that refined incisions on the lower abdomen began to be practiced, shaping the way the procedure is currently performed. The cesarean section was on its way to being perfected as penicillin entered the medical scene, reducing infection, and the risk of uterine rupture decreased with advancing surgical techniques (3). American women of the time began to lose the freedom of their births as the process grew to include numerous procedures, medications, and often- heavy sedation (8). Birthing mothers were alone in the operating room, and doctors made decisions for them (8). Joseph DeLee set out to change the way women give birth with the creation of modern obstetrics. As a male doctor, he aimed exclude midwives, often minority women, and implement a new "medicalized" process (8). In 1957, Dr. Theo R. Van Dellen wrote in the Boston Herald that women were losing their rights to birth and motivating factors (9). He explained that pain is a natural part of birth, and without it, women might forget that they are prepared for the next stage of parenthood. He was beginning to combat the initial opinions of Dr. DeLee, as he feared that birth under sedation would become dangerous for both mothers and infants (9).
Figure 4: Dr. Joseph DeLee
“Publications & Videos.” JHF. Accessed May 4, 2023. https://www.jhf.org/publications-videos/pub-and-vids.
However, the rates of cesareans did not decrease, and as the 1970s hit, numbers grew higher and higher. Jacqueline H. Wolf, a medical historian, explains that many doctors in the 1970s would pretend to hear babies speaking to them, encouraging their mothers to use interventions at birth. That was a technique to avoid natural birth and promote surgical procedures (10). The 1982 excerpt from Having a Cesarean Baby helps historians understand why the procedure was becoming so popular, “But today, because cesarean delivery has become one of the safest of major operations, doctors use it, not only one life or health is threatened, but also as a precautionary measure— a way to prevent problems that may arise and to avoid potential trouble. It is so safe and easy.” Additional testimonials from the 1990s helped show how admired and viable of an option the procedure was growing to be. In her book, Recovering from a C section, Margaret Blackstone wrote, “First of all, because you haven’t had a vaginal birth, you may be romanticizing it. Your C section has spared you having your vaginal canal stretched out, (and most honest mothers will tell you this means really stretched out), huge, egg-size hemorrhoids, and probably a painful episiotomy that may itch and cause major discomfort when you try and go to the bathroom. And that’s just for starters.” (11) The cesarean was viewed as “easier” than natural childbirth. It was deemed the less painful route and one that could save women their “vaginal conditions” which is precisely that attitude that Dr. DeLee strived to cultivate around the procedure. In the end, it contributed to its popularity in the late 20th century. One anonymous woman, C.M., in 1991 shared, “I labored for five hours, and there are things I would rather do. I hadn’t dilated. Nothing was happening, except for the pain, of course. I started thinking, ‘What are you trying to prove?’ If I had another child, I’d want to have a scheduled C section.” (11)
Figure 5: Rory speaking with Sherry's friend (11).
Today, cesarean sections have evolved into a vastly different practice than historically implemented. The operation is still seen as the safer route to natural, vaginal birth, and it can be pre-scheduled by the pregnant mother rather than solely utilized as an emergency procedure. However, it is a common media trope to witness a mother scheduling a cesarean and then ultimately being forced to deliver vaginally. This was seen in the 2003 episode of Gilmore Girls, “Dear Emily and Richard”, when Sherry, Rory’s stepmother, pre-books her cesarean section. Earlier in the episode, Sherry throws a baby shower with her friends (12). They all claim that they are too busy to have a baby and birth needs to be quickly “penciled in.” That plan quickly goes out the window when Sherry goes into labor. Her friends refuse to leave work, claiming that Sherry is the one who “screwed up” (Figure 5). Alone in the hospital, Sherry refuses to stop working until Rory and Lorelai come, providing her emotional support (12).
Figure 6: "C is for Coward," The Mindy Project.
Comparing that portrayal to Dr. Mindy Lahiri on The Mindy Project (Figure 6), both women are furious and in denial when they're forced to deliver naturally. Mindy, a prominent OB/GYN in New York City, plans to have a luxury suite and cesarean when she goes into labor on the train. In the episode, her boyfriend, another doctor, tells her “C is for Coward” and that she is taking the easy way out of labor (13). It is not until Mindy is forced to give birth vaginally that she accepts she is strong enough to do it “naturally.” These themes are seen mixed in with those of medical shows, like Grey’s Anatomy, where the characters are depicted as solely receiving cesareans. It cultivates the belief that cesareans are safer than a vaginal birth and easier. It also promotes the idea that those who elect to have them are somehow “weaker.”
However, are cesareans actually safer? Cultural and popular views exist for a reason, and modern medicine has made leaps and bounds since the 1800s, 1950s, and even 2000s. So, if the cesarean is safer, what is the problem? It is okay for a hospital to overutilize a procedure that is helping mothers and their babies have better outcomes in the end, if everyone is healthy.
The problem is that cesarean section rates have increased in the United States, but so have maternal mortality rates, particularly among black women (14). These discrepancies are particularly seen around pregnancy and cesarean complications, such as placental abnormalities (14). In other words, cesarean sections are increasing at a rapid rate, but the data to support maternal operative safety is lacking. The operation is perceived as the safer alternative to natural birth (14), with no evidence backing it up.
Figure 7: CNN: Are hospitals giving too many C-sections?
Since the mid-1970s, the operation has spiked by 500% in the United States (15). Statistics used to show that 1 in 20 births was delivered surgically, but now that is 1 in 3 (15). The rising rates are a global issue, particularly in Western culture (15). In Figure 7, Senior Medical Correspondent at CNN, Elizabeth Cohen, provides viewers with statistics on cesarean rates among two hospitals that are only 15 minutes from each other. The drastic difference shows that a pregnant woman’s birth plan is associated with the hospital she chooses or happens to live closest to, not necessarily her desires. Dr. Shah of Harvard University continues to explain that when a woman is in labor and complications arise, she is most likely going to receive a cesarean out of the best interest of the child and to avoid malpractice. If the child comes out pink, doctors believe they made the right decision, and if the baby is delivered with complications- doctors believe they made the right decision.
Savannah, 34 yrs., now smiling with her cesarean scar (15).
One personal account to the Huffington Post from Savannah, a 34-year-old mother who received an unexpected cesarean claimed: “I wanted to give birth vaginally.” Another testimonial stated, “I still feel like I have all of this trauma” (16). These statements display how women are not as eager to receive a cesarean as they were in the 1970s or 1990s but are still being operated on anyways.
The cesarean section is overused. It is an extensive surgery and can produce many complications like blood clots, sepsis, infections, hemorrhage, and organ injury. Women who have one cesarean have a 90% chance of having another in future births (15). The surgeries cut in the same spot, which produces excessive scar tissue and further dangers. Dr. Shah explained that 1st-year residents learn about first-time cesarean sections, but attendings and chief are often needed for a mother delivering their third child or more due to complications from scar tissue (15). The placenta can become attached and mixed with the tissue, creating dangers for the fetus. The placenta gets 25% of everything the heart pumps, so as complications arise, the mother and fetus are at risk of bleeding to death (15).
Medical procedures have advanced and changed throughout American history, along with the cultural beliefs around them. However, it is time to examine current practices, such as the cesarean section, and ponder why the procedure is performed so often and what the historical driving factors are behind the American perspective. It is time for people to take back their births and reclaim the birth plan that is properly theirs. With that, maternal and infant rates can increase as only those who need cesareans will receive them.
References
Biden, Joseph. “A Proclamation on 50th Anniversary of the Roe v. Wade Decision.” The White House. The United States Government, 2023. https://www.whitehouse.gov/briefing-room/presidential-actions/2023/01/20/a-proclamation-on-50th-anniversary-of-the-roe-v-wade-decision/#:~:text=Wade%20Decision,-Home&text=Fifty%20years%20ago%2C%20on%20January,woman's%20constitutional%20right%20to%20choose.
“Cesarean Section History.” History and Evolution of C-Section | Cesarean Sections, 2023. https://www.birthinjuryhelpcenter.org/c-section-history.html.
Sewell, Jane E. “Cesarean Section - A Brief History: Part 1.” U.S. National Library of Medicine. National Institutes of Health, (2013), https://www.nlm.nih.gov/exhibition/cesarean/part1.html.
“C-Section.” Mayo Clinic. Mayo Foundation for Medical Education and Research, 2022. https://www.mayoclinic.org/tests-procedures/c-section/about/pac-20393655.
“C-Section (Cesarean Section): Procedure, Risks & Recovery.” Cleveland Clinic, 2022. https://my.clevelandclinic.org/health/treatments/7246-cesarean-birth-c-section.
Cherney, Kristeen. “History of the Cesarean Section.” Healthline. Healthline Media, 2016. https://www.healthline.com/health/pregnancy/history-cesarean-section#first-c-sections.
DeLee, Joseph B. “The Prophylactic Forceps Operation.” American Journal of Obstetrics and Gynecology 187, no. 1 (2002): 254–55. https://doi.org/10.1067/mob.2002.123205.
Blower, Brooke. “Pregnancy and Birth.” Lecture at Boston University, January 29, 2023.
Boston Herald (Boston, Massachusetts), January 18, 1957: 22. Readex: America's Historical Newspapers. https://infoweb-newsbank-com.ezproxy.bu.edu/apps/readex/doc?p=EANX&docref=image/v2%3A1386BF60B4F67060%40EANX-1404024EE7DA0023%402435857-1403C594B8E6D774%4021-1403C594B8E6D774%40.
Jamison, Leslie. “A Personal History of the C-Section.” The New York Times. The New York Times, July 21, 2021. https://www.nytimes.com/2021/07/21/magazine/c-section.html.
Homayun, Tahira, and Margaret Blackstone. “1.” Essay. In Recovering from a C Section, 1–4. Stamford, CT: Longmeadow, 1991.
Amy Sherman-Pallidno, writer. Gilmore Girls. Season 3, episode 13, “Dear Emily and Richard.” Directed by Gail Mancuso, featuring Lauren Graham and Alexis Bledel. Aired February 4, 2003 on WB Television Network.
Kaling, Mindy, creator. The Mindy Project. Season 4, episode 2, “C is for Coward.” Directed by Alex Hardcastle, featuring Mindy Kaling, Chris Messina, and Ed Weeks. Aired September 22, 2015 on Hulu.
Antoine, Clarel and Young, Bruce K.. "Cesarean section one hundred years 1920–2020: the Good, the Bad and the Ugly" Journal of Perinatal Medicine 49, no. 1 (2021): 5-16. https://doi.org/10.1515/jpm-2020-0305
Shah, Neel. “The Surprising Factor behind a Spike in C-Sections.” News, 2018. https://www.hsph.harvard.edu/news/multimedia-article/csections-delivery-risk-podcast/.
Pearson, Catherine, and Damon Dahlen. “13 Photos That Show C-Section Mums Are Strong as Hell.” HuffPost UK. HuffPost UK, March 28, 2017. https://www.huffingtonpost.co.uk/entry/13-photos-that-show-c-section-mums-are-strong-as-hell_uk_5c7ea183e4b078abc6c1c062.
About the Author
About the Author
Layla Kirchhoff was born in Rhinebeck, New York, where she grew up on a farm with her parents and three older siblings. During her first year of Boston University, Layla took a female biology course and discovered her passion for midwifery. She is graduating in the Spring and will move on to get a Master's Degree as a Nurse Practitioner. She hopes to be a midwife or work in acute care for pediatrics. In her free time, Layla enjoys cooking, running, and traveling to any new place.
Layla Kirchhoff was born in Rhinebeck, New York, where she grew up on a farm with her parents and three older siblings. During her first year of Boston University, Layla took a female biology course and discovered her passion for midwifery. She is graduating in the Spring and will move on to get a Master's Degree as a Nurse Practitioner. She hopes to be a midwife or work in acute care for pediatrics. In her free time, Layla enjoys cooking, running, and traveling to any new place.
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