Why Are So Many Babies Born Via C-Section?

Picture the magic trick that features a man, a woman, a long box, and blades. She’s inside, but the audience can only see the crown of her head, hair cascading down. The magician inserts the blades through the box at her chest and stomach. Then he pushes the boxes apart.

This is how LaToya Jordan describes the birth of her daughter in the spring of 2012. Lying in the box, chopped into thirds, her midsection extracted from the rest of her. The genders of the trick’s participants seem predetermined—male magician, female subject—and mirror the power dynamics in the surgery responsible for one-third of births in the United States.

Put simply, a cesarean is an operation lasting about forty-five minutes. A spinal block injection numbs below the neck. Then the surgeon cuts an incision above the pubic hair line, opening the skin, muscles, and fat of the abdomen, along with the corn-husk-like layers of fascia that buoy the stomach’s contents. Then the uterus is exposed, and the baby is removed.

Neel Shah, an OBGYN at Harvard who has performed thousands of C-sections, said that at this point, “The baby very quickly becomes the most interesting thing in the room. Then you very carefully put everything back the way you found it.”

C-sections have a colorful and gruesome backstory spanning thousands of years. The cesarean’s nomenclature honors the men who ordained its use, rather than the women who endured it. The practice goes back to ancient Rome, where, according to tradition, the city’s second king, Numa Pompilius, ordered that fetuses be removed from uteruses when mothers were dying or dead. This pronouncement, issued possibly as early as the eighth century BCE, became Lex caesarea, or royal law. There is no evidence for the common story that Julius Caesar was born this way.

Historically, the procedure was used to preserve royal bloodlines. As recently as the twentieth century, Germans called the surgery Kaiserschnitt after their emperors, Kaisers. When a mother was gravely ill or had died, a baby was cut out in an attempt to save him (not her) and the patriarchal lineage.

Later incarnations of the procedure continued to sacrifice mothers to save the unborn. Religious scholars in the 1700s favored babies over mothers because babies needed baptism to save their souls from purgatory, whereas adult women were heaven ready.

In 1930, Pope Pius XI forbade doctors from ending a baby’s life to save its mother, spiking C-section rates and maternal mortality at a time when the surgery was still quite dangerous.

In the US, the first successful C-section—as in, the first C-section in which the mother survived—likely occurred in 1794, in a rural, unsterile cabin in what is now West Virginia. Jesse Bennett believed his laboring wife, Elizabeth, might die, so he sidestepped the family doctor and operated on her himself after dosing her with the opium tincture laudanum, which put her to sleep. He also removed her ovaries, according to one account, saying later he “would not be subjected to such an ordeal again.”

Elizabeth and her child survived, but the historical record doesn’t include how she felt about waking up without ovaries, having gone to sleep without agreeing to their removal. Later, in 1876, an Italian professor recommended that cesareans routinely include hysterectomies, to prevent the hemorrhaging that many women experienced before suture use was widespread.

The cesarean was invented to save babies’ lives, but it does so today only in incredibly rare circumstances. The vast majority of C-sections are performed for other reasons, and the surgery is overused to a shocking degree. Cesarean birth is blindly assumed for many pregnancy conditions, when it might not be required at all.

Furthermore, pregnant people might actively reject surgery but aren’t able to exercise informed consent and refusal. They have no choice and are often coerced. Hospitals and individual doctors who overuse this surgery aren’t doing so out of an abundance of caution or medical necessity. They are practicing (and sustaining and rationalizing) an ancient form of social control.

In the 1970s, the C-section rate in the US was around 5 percent. Today it’s almost 32 percent—a 500 percent increase. The World Health Organization recommends a C-section rate of between 10 and 15 percent for a healthy population; America’s is more than twice that. Other countries’ rates are worse. Mexico’s is 50 percent for first-time mothers. Brazil’s private hospitals C-section up to 90 percent of the time.

Why the high rates? The blame often falls on birthing people themselves. Rather than wait to go into labor, women schedule babies to arrive at their convenience. Famous white women allegedly sought “designer” C-sections because they were controlling (Madonna) or lazy (Kate Hudson). Victoria Beckham was reportedly “too Posh to push,” scheduling her three C-sections around her husband’s soccer calendar.

Elective C-sections are “clear evidence of the self-obsessed behavior exhibited by some celebrity mothers finding new ways to push the narcissistic envelope,” according to one (white, male) commentator. Condemning women may be appealing, but elective C-sections are a very small fraction of the total—around 2 percent; they’re definitely not driving the increase.

People wonder if it even matters that C-sections are overused. After all, the procedure has been perfected in recent decades. It’s the most common surgery in the US, with more than a million of them performed every year. The fact that they’re routine must mean they are needed and safe.

In the majority of US hospitals, cesareans are compulsory for breech babies and multiples, and encouraged for pregnant women over age thirty-five, diabetics, and those who have been told they’re carrying big babies

As Wayne Cohen, a former hospital chief of obstetrics, asked me, “If we can maximize good outcomes, does it matter whether we accomplish that goal with a cesarean rate of 10 percent or 30 percent?” I guess it depends on your definition of a good outcome and whether you value the well-being and will of women. Or, as the obstetrician Neel Shah put it, “Women have goals in labor other than emerging unscathed. Survival and not being cut open is the floor. We should be designing a system that’s aimed at the ceiling.”

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Excerpted from Birth Control: The Insidious Power of Men Over Motherhood, by Allison Yarrow. Copyright © 2023. Available from Seal Press, an imprint of Hachette Book Group, Inc.