In her new book on the history of cesarean section in the United States, Ohio University Heritage College of Osteopathic Medicine professor Jacqueline H. Wolf, Ph.D., solves a mystery posed by her previous book.
In her 2009 volume Deliver Me from Pain: Anesthesia and Birth in America, Wolf, a historian of medicine, described the salient characteristics of U.S. childbirth today: chemical induction of labor, epidural anesthesia and a high cesarean section rate.
An expert on the history of American childbirth practices, Wolf became curious about the cesarean rate – now nearly 32 percent of births. Her research into how this surgery was “normalized” became Cesarean Section: An American History of Risk, Technology, and Consequence, published by Johns Hopkins University Press.
Based on birth records from the 18 th through the early 20 th centuries, Wolf found, “Historically, about five percent of human births run into trouble. Knowing that, I wondered: How, in an era with better nutrition, better pre-natal care, and better medical care in general, did we end up with one in three births being deemed such a serious problem that they end in major abdominal surgery?”
She offers a multi-faceted answer that considers medical technology; the malpractice climate; health care financing; public, medical and media perceptions of childbirth; changes in obstetrician training; and the effect of the women’s movement, all of which influenced assessments of the risks of labor and birth.
“At the Heritage College, we emphasize the need to pay attention to social determinants of health,” noted Ken Johnson, D.O., executive dean of the Heritage College and OHIO chief medical affairs officer. “Dr. Wolf’s scholarly work reminds us that those factors go beyond issues like race, income and education; they also include the perceptions and assumptions of patients and the medical community.”
Safety measure or risky procedure?
In the 19 th century, doctors avoided cesareans at almost any cost. Before antibiotics and blood-banking, surgeries were often more perilous than the conditions that prompted them, so a c-section was typically a last-ditch measure to save a mother’s life. Yet as surgery became safer, cesareans increased only slightly; by the mid-1960s, they accounted for 4.5 percent of births.
The large increase since then reflects changes in perception. Today, many physicians and patients see vaginal birth as the risk, and c-section as a way to avoid that risk.
Evidence contradicts this view, however. U.S. maternal mortality is the highest among developed countries – and cesareans contribute to it. Its risks include infection, hemorrhage and placental abnormalities in subsequent pregnancies. After researchers control for factors that prompted a cesarean, Wolf said, “They have found that mothers who have cesarean sections die at three times the rate of mothers who have given birth vaginally.”
Cesarean birth also poses risks for newborns; in bypassing the birth canal, where fluid is squeezed from the lungs, cesarean-born infants are more likely to suffer from asthma, for example.
So how did cesarean surgery come to be thought of as safer than vaginal birth?
From avoiding to normalizing cesareans
The cesarean rate began rising sharply in the late 1960s, when childbirth was continually in the news, often making birth seem dangerous. When First Lady Jacqueline Kennedy gave birth by c-section, she made the once-arcane surgery a household phrase. When her second son died shortly after birth, his death was national news. Damage done during fetal development by the drug Thalidomide, and the ubiquitous March of Dimes campaign to prevent birth defects, similarly associated childbirth with danger.
The “Friedman curve,” charting a typical labor, was introduced in the early 1950s. Once its use became common, labors not conforming to it were labeled as not progressing properly, and possibly requiring a c-section.
The linking of birth to danger encouraged widespread acceptance of the electronic fetal monitor, introduced in 1969. EFM let physicians constantly monitor the fetal heartrate, but its printout was hard to interpret, often leading doctors to wrongly conclude a baby was in distress and in need of a c-section. Yet as late as 2008, one study found that four obstetricians shown the same fetal heart tracings agreed on their meaning only 22 percent of the time.
Intervention trumps patience in the delivery room
Changes in obstetric training also played a role in the rise of cesareans. For Emanuel Friedman, creator of the Friedman curve, training included sitting by women’s beds and observing entire labors. The bedside vigil was abandoned as the EFM became standard; when Wolf has told medical residents about this once-fundamental part of obstetrician training, “all of them said the same thing – ‘I can’t even imagine doing that.’”
Without the experience of viewing entire labors, physicians are apt to intervene sooner, rather than letting a long labor take its course. And today, physicians will often choose what Wolf calls “the one procedure that more recently trained obstetricians are especially comfortable performing,” – the cesarean. More pregnant women view c-section as normal than did mothers 40 years ago, too.
How to lower the cesarean rate
Wolf believes it’s time to correct skewed perceptions of the risks of birth.
“The onus of risk, once squarely on cesarean section, is now on vaginal birth,” she said. While a cesarean is sometimes necessary and even life-saving, she added, the types of conditions requiring one occur only rarely. “Most of the cesarean surgeries performed today are not medically necessary,” she concludes. “Vaginal birth not only has many benefits for both women and babies, it is considerably safer than a medically unnecessary cesarean.”
Dr. Wolf’s research for the book received funding support from a $150,000, three-year grant from the National Institutes of Health.