Cesarean section is the most commonly performed surgery in the United States today, a stark turnaround from the 19th century when physicians dismissed cesareans as “sacrificial midwifery,” for good reason. The maternal death rate associated with the operation was appalling. More than half the women who underwent cesareans in the US before 1871 died. With no effective treatments for infection and hemorrhage until after WWII, doctors avoided cesareans until well into the 20th century. Even as late as the 1960s, a cesarean was, in the words of one retired obstetrician, “a super big deal.” In contrast, in 2015, obstetricians performed 1.2 million cesarean sections. What prompted the change in medical practice? Several components of the answer to that question turned out to be surprising.
Since the 1970s, obstetricians have pointed to the threat of malpractice suits as the primary reason for the 633% increase in cesarean surgeries—from 4.5% to 33% of births—between 1965 and 2009. But the first lawsuits for “failure to perform a cesarean”—a legal strategy pioneered by John Edwards, the North Carolina senator and one-time vice-presidential and presidential candidate—weren’t filed until the early 1980s, more than a decade after the cesarean section rate began its precipitous rise. In other words, malpractice suits did not prompt the increase, it was the other way around. The surge in cesarean sections triggered the first lawsuits for failure to perform the surgery.
As the public and medical communities learned to view a cesarean section as a distinct possibility in every birth, they came to view the surgery more favorably. Helen Marieskind, the author of a 1979 US Department of Health, Education, and Welfare report that examined the reasons for the increase in cesarean sections, anticipated this public and medical embrace of cesareans when she warned, “the question must be raised as to how much a climate accepting of C-sections, in and of itself promotes more Cesareans.” By the early 1980s, just as Marieskind had predicted, patients and doctors alike had come to think of cesarean sections as a surefire means of rescuing newborns from an undesirable outcome. Lawyers filed most lawsuits for failure to perform a cesarean, for example, on behalf of children with cerebral palsy, under the dubious theory that a timely cesarean would prevent the condition. A disability that had long been viewed as unavoidable thus became, in the words of one prominent obstetrician, “the consequence of a mistake made somewhere by someone.” Yet most, if not all, of the malpractice suits filed for failure to perform a cesarean were without merit, despite the multi-million-dollar settlements the lawsuits produced. Cerebral palsy occurs almost exclusively during fetal development, not as the result of an untoward event during a full-term birth. That is why, despite the 633% increase in cesarean sections since the mid-1960s, the incidence of cerebral palsy, at 1 in 500 births, has remained unchanged.
I found counter-intuitive causes of the increase to be common. In the 1970s, at the height of the women’s movement, feminists calling for reform in American childbirth practices argued that more women becoming obstetricians would help to eliminate the heavy-handed, medicalized experiences created by a male-dominated specialty. Reformers insisted that obstetricians who were women would encourage “natural,” “women-centered” births. Yet rather than childbirth becoming less medicalized as more women became obstetricians, by 2011, when female members of the American College of Obstetricians and Gynecologists finally exceeded male members, cesarean sections, the chemical induction of labor, and the use of epidural anesthesia had substantially increased rather than ebbed. Female obstetricians not only displayed the same affinity for medical interventions as their male counterparts, they also spoke with a dual authority to patients—as trained physicians and as women who either had experienced birth or might in the future. They could thus be even more directive than their male colleagues when urging pregnant and laboring patients to choose medically unnecessary interventions.
Cesarean Section: An American History of Risk, Technology, and Consequence explains how major abdominal surgery emerged as a routine birth intervention and examines the many factors undermining what is normally a prerequisite for any medical treatment—an evidence-based foundation for its employment and frequency. As readers will discover, the history of cesarean surgery in the United States is riddled with specious justifications for the growing use of the intervention.
Jacqueline H. Wolf is a professor of the history of medicine at Ohio University. She is the author of Don’t Kill Your Baby: Public Health and the Decline of Breastfeeding in the 19th and 20th Centuries and Deliver Me from Pain: Anesthesia and Birth in America. Most recently she is the author of Cesarean Section: An American History of Risk, Technology, and Consequence. Jackie Wolf has been the host of two long-running radio shows, Live from Studio B from 2000 to 2006, and Conversations from Studio B from 2007 to 2017, on WOUB, the NPR affiliate in southeast Ohio and western West Virginia. Her radio shows, on contemporary health and medicine, aired monthly. Her podcast, Lifespan, featuring personal stories about health, medicine, and navigating the healthcare system, also produced by WOUB, will be launched in June 2018. She was also the host of the television show HealthVision, aired weekly on the local PBS affiliate, WOUB public television, from 2002 to 2009