• Lara Freidenfelds

An Incisive History of Cesarean Section

This is a pre-publication draft of my review of Jacqueline Wolf’s Cesarean Section: An American History of Risk, Technology, and Consequence, published in ISIS, v. 111 n. 2, 2020.

Jacqueline H. Wolf. Cesarean Section: An American History of Risk, Technology, and Consequence. 320 pp., notes, bibl., index. Baltimore: Johns Hopkins University Press, 2018. $49.95 (cloth), ISBN 9781421425528.

In Cesarean Section: An American History of Risk, Technology, and Consequence, Jacqueline Wolf investigates a vexing long-term trend with profound health and economic consequences: the explosion in the rate of cesarean section, from a rare and desperate surgery in the nineteenth century, to an occasional necessity making up a few percent of births in the mid-twentieth century, to the method of delivery for nearly a third of American babies in the twenty-first century. Understanding this history is crucial to addressing the future of birth in America, not only to understand how we got to a rate of operative delivery that clearly hurts more than it helps, but also to understand why, even once there is widespread agreement that the cesarean section rate is far too high, it will take strategic, concerted, and long-term effort to bring it down.

Wolf begins her investigation in the nineteenth century, when a cesarean was a last-ditch and often deadly effort to save a mother when her anatomy was so constricted that a baby could not be delivered even by the extreme measure of dismembering it to remove it in parts. Surgeries were disproportionately performed on enslaved women, and the mortality rate was approximately 50 percent. Surgical innovations of the late nineteenth century, including aseptic technique and anesthesia, allowed cesarean sections to be a deliberate rather than a desperate measure, but physicians remained cautious well into the twentieth century. Even those who advocated for relatively more interventionist birth practices prided themselves on their very low cesarean rates.

In the first decades of the twentieth century, obstetricians began to treat the fetus as a full-fledged second patient at a birth, increasingly balancing the risk to the birthing woman against the survival of her child. Those decades also saw the beginning of routine prenatal care, including taking pelvic measurements that doctors (incorrectly) believed could predict whether a woman would be able to expel her baby.

Innovations from outside obstetrics – antibiotics and blood transfusion – made all births, including by cesarean, significantly safer in mid-century. Physicians and the public, their faith in modern medicine and technology stoked by these successes, pursued a range of statistical, technological, and medical tools to normalize birth. From the Friedman curve to the Apgar score to the electronic fetal monitor, these tools seemed to offer the possibility of making birth safe by standardizing it to a set of timeframes, processes, and procedures. As it turned out, though, creating predictable births did not necessarily create safer births. Americans often equate control with safety, but highly medicalized and technologized births in which surgery is normalized are not, in fact, safer on average than a model of birth that allows for unpredictability of process.

Wolf interviewed a number of obstetricians as well as women who shared their birth stories, creating a unique and valuable set of sources for this history. Contributing to previous studies of experiences of birth, Wolf persuasively documents a fundamental shift in women’s attitude toward birth in the late twentieth and early twenty-first century, to an acceptance of a culture of risk and a fatalistic assumption that cesarean sections are common and likely to be necessary. Obstetricians’ narratives reveal that many practitioners were uncomfortable with the changes in standard practice concerning cesarean delivery, but found it hard to resist pressures from employers, insurers, and younger colleagues who took a high cesarean rate for granted. These interviews both validate Wolf’s archival findings and give the reader a powerful sense of how difficult it was for an individual practitioner to buck the trend. The balance of these narratives tilts strongly toward physicians who are critical of today’s high cesarean rate; if in follow-up research Wolf were able to collect the voices of those who were enthusiastic about cesareans, it would surely reveal additional fascinating insights.

Wolf’s explication of the tangled web of economic, social, and physical structures that shape and constrain medical practice; perverse incentives to overtreat; and deskilling of physicians in alternatives to cesarean section persuasively and depressingly demonstrate why it has been so difficult to reduce cesarean section rates even once broad agreement was established that rates of the surgery are far too high. Wolf briefly offers some possibilities for reform, including the employment of midwives for routine births. The midwifery model of birth, which largely serves as an alternative to the culture of risk in its entirety, stands out as an appealing option.

Cesarean Section is a deeply researched, meticulously argued, and highly readable investigation of the problematic consequences of our culture of risk for the American way of birth. More broadly, it holds important lessons for all of the many areas of life that are touched by our culture of risk and our tendency to equate predictability and control with safety and the possibility of perfection.

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