The Racist and Sexist History of the Cesarean Section

An interview with author Rachel Somerstein.

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Greetings, everyone. On top of everything else, I’m currently recovering from Covid, so it’s a small miracle that this newsletter has landed in your inbox. But I didn’t want to postpone this one because it’s amazing. Today I’m interviewing Rachel Somerstein, an associate professor of journalism at SUNY New Paltz and the author of the extremely important new book Invisible Labor: The Untold Story of the Cesarean Section.

When I first heard about Rachel’s book, I knew I would inhale it. Both of my children were born via cesarean section. After 36 hours of labor, my eldest was born via emergency C-section; my doctor told me that his oxygen levels were dropping and they needed to get him out quickly. I so clearly remember being wheeled into the OR, screaming and crying, terrified on behalf of his and my safety. I also remember feeling the first cut and having to demand more anesthesia — it was awful, but, thankfully, my son was born healthy and my recovery wasn’t that difficult. Since then, I’ve done a lot of research on the circumstances of his birth, and I believe there were a series of medical decisions, starting early on in my pregnancy, that led to this birth outcome that perhaps could have been avoided.

In my second pregnancy, my (new!) doctor and I tried for a vaginal birth (VBAC) but that, too, didn’t happen, My daughter’s C-section birth was much less traumatic in the moment, but the recovery was much harder because the anesthesiologist accidentally punctured the membrane surrounding my spinal cord when administering the spinal anesthesia, causing my cerebrospinal fluid to leak out. This changed the pressure around my brain in ways that caused me to have an intense “spinal” headache for several days post-birth, so I could hardly sit or stand up and care for my daughter. By far the worst part was the anesthesiologist’s initial and very sexist dismissiveness — “you can’t possibly have a spinal headache; you’d be in more pain!” — which, thankfully, he eventually apologized for. And again, now my daughter and I are just fine.

Still, the fact that I — and many other mothers and children — have recovered from their birth traumas doesn’t mean we shouldn’t scrutinize the system that led to them. We so often say, “All that matters is that everything worked out okay in the end,” and certainly, that’s the most important thing. But it’s not the only thing. What I love about Rachel’s book is that it asks and answers the hard and uncomfortable questions. In today’s Q&A, we talked about the C-section’s horrifying racist history, the many factors that have caused C-sections to become so common, the ways in which C-sections can impact maternal health after birth, how pregnant people can prepare for the possibility of a C-section, and more.

Rachel, what inspired you to write Invisible Labor? Could you briefly share a bit about your own initial C-section experience?

When I was pregnant, I expected to have a vaginal birth. I was completely unprepared for a C-section. I wasn’t only taken by surprise by the way the birth went — it was really traumatic — but by the more-routine aspects of the operation too. I had skipped over any mention of C-sections in the books I’d read, and no provider suggested that it might be a possibility, either. So the first time I learned about cesareans was when I was going through and recovering from my own surgical birth.

Those first few months postpartum, I spent a ton of time reading about birth and motherhood. But in 2016, I couldn’t find anything that represented the kind of experience I’d had — probably the closest example is Taffy Brodesser-Akner’s Fleishman Is in Trouble, but that hadn’t been published yet. Frankly, I couldn’t find that much about C-sections at all. Much of what I did see was really insulting: that C-sections are the “easy way out,” a “designer delivery” for people “too posh to push.” That made me so mad! Even if my C-section hadn’t been traumatic, it’s physically and emotionally exhausting to care for a newborn while recovering from an unplanned major abdominal surgery, navigating breastfeeding, going through all of the changes of identity, especially as a first-time mom.

I decided to write Invisible Labor to fill the gap — the silences, really — about C-sections. I wanted to write the book that I needed when I was trying to make sense of what had happened to me. I knew there were other people out there who would need that too.

As for the particulars of my own C-section, when the doctor started to operate, he didn’t listen to me. I told him “I felt that.” He told me that I would feel pressure. I repeated, “I felt that.” I wasn’t feeling pressure — it was pain. And it got much much worse; I felt the whole operation. Once my daughter was born, the anesthesiologist put me under general anesthesia. I don’t remember my daughter’s birth. It is the worst thing that has ever happened to me on many levels: the pain, obviously, but also that my physician didn’t listen.

You suffered such immense pain during your C-section. How common is pain during a C-section and why is it so rarely talked about?

We have to see pain during C-section, and the relative silence around it, in the context of how we treat women’s pain writ large — which we do a terrible job of preventing, recognizing, and treating. The Times recently ran a piece about how fewer than 5 percent of physicians use any anesthetic to prevent pain during IUD insertion, for instance. Only now, because the topic has gone viral on social media, has the CDC made pain relief during those procedures a priority. That women’s pain is so routinely dismissed is one reason it takes an average of 10 years to be diagnosed with endometriosis. All of this is to say that when you look at the relationships among women, pain, and their bodies, it shouldn’t come as a surprise that pain during C-section is so under-discussed.

There’s also this idea that if you talk about pain during C-section, you’ll scare women. I have a really big problem with this. First of all, there are many scary or sad things that can happen during pregnancy and birth. Not talking about miscarriage, or preeclampsia, doesn’t protect you from them. Instead, not talking about them means that you’re less prepared to deal with them if they do happen. And it’s a lot scarier, and more isolating, to experience something terrible that you had no idea was possible, and that no one ever talks about. Then you have isolation, or even stigma, layered upon trauma.

You can educate someone about risks without scaring them: something like, In the unlikely event of xyz, these are your options; what would you like to do if that happens? This is why I have life insurance, why I have a will, why my husband and I have identified who would be the guardian of our children should we die before they turn 18. Not my favorite topics, but to avoid dealing with them would only make it worse for everyone in the unlikely event that they do happen.

As for how common it is, researchers have only recently begun studying pain during C-section. So far, they’ve found that it happens in about 10 percent of cesareans. That pain varies a lot — from the kind of very intense pain that I felt to less but still significant pain. And yet, not all consent forms about C-sections in the U.S. even mention that it’s a possibility, which is another form of silence.

Why have doctors become so reliant on technology, such as electronic fetal monitoring, during labor and delivery? What are the downstream ramifications for women, babies and birth — and what role does this technology play in instigating C-sections?

There are two reasons for this: the role of technology and the financialization of medicine.

In our society we treat “objective” data that comes from a computer, or a machine, as if it’s better or smarter than what a person knows. A good example of this is Google maps. Sometimes Google will spit out a route, and I’ll follow it, even though I think that there’s probably a better or more direct way to get wherever I’m going. I know that some of what Google Maps tells me to do is smart, and some of it is irrelevant or not helpful, but usually I follow it anyway.

It's important to think about electronic fetal monitoring (EFM) in a similar way. EFM, which provides a continual stream of information about the baby’s heart rate, provides some information that’s important, but some that isn’t. A “bad tracing” may suggest that the mother needs to shift position or needs oxygen. Or it may mean that a baby is in trouble and needs to be born right away — maybe by C-section. It may also not mean anything. Because it relays every. single. change of the baby’s heart rate, there’s a lot of noise in the data. And, interpreting EFM is highly subjective. But in part because we’ve become so accustomed to trusting technology as the supreme arbiter, and believing that it reveals all there is to know, it’s ubiquitous.

EFM has driven up the C-section rate dramatically. There’s ample evidence that if you use it continually it will result in more cesareans. Yet it hasn’t made birth safer for babies. Rates of cerebral palsy and oxygen-deprived brain injuries have not gone down since EFM’s introduction in the 1970s. But the C-section rate has gone up from about 4.5 percent to more than 30 percent.

Then the question is — if it’s not reliable or doing what it was meant to do — why do we keep using it? That’s where you get into the financializaton of medicine, which basically means that hospital systems’ missions are drifting from a primary focus on healing and caring for patients to using medicine as a way, first and foremost, to make a profit. Increasingly, health systems’ cultures reflect that. EFM, as an example, enables a nurse to watch a patient from the desk — rather than provide support to her in the room. And at the desk, she can watch more than one patient at a time, which means that a hospital can employ fewer nurses, and save money. It’s cheaper, in that sense, than providing continual bedside support, which is what labor and delivery nurses used to do more of.

But EFM can’t help you get into a better position to bring down a baby for vaginal birth. It can’t hold your hand or tell you you’re doing a good job, that you’re safe, that you can do it. And that loss of in-person support also matters for C-section rates. That’s part of the logic of how a doula works; that kind of support has been shown to increase the likelihood of vaginal birth. But that kind of care, which is known as high-touch, low-tech care, is expensive and time-intensive — the average first-time labor lasts 24 hours. You can’t substitute a machine for a person. And a financialized medical system doesn’t value it — it values low-touch, high-tech care, which is efficient and speedy.

Obstetricians very real concerns about being sued are also at play here (more than 80 percent of OBs are sued at some point in their careers). Because if there’s a birth injury, a lawyer can come back and point to a blip on the EFM strip and say, Here’s where the baby was hurt, even if there is no way to know for sure if that’s true. And then, again, you have what a computer says (or supposedly knows) which we treat as the final word — as more trustworthy than an experienced provider’s.

In your book you talk about some of the lesser known downstream ramifications of C-sections. How do C-sections shape the risk for postpartum mood disorders? 

This is such an interesting and still-developing area of research.

Some studies suggest that unplanned C-sections can make a person more likely to develop a PPMD. That might be because of the stresses of an unanticipated operation and the difficulties recovering. Some mothers have the feeling of, What does this operation mean about me as a mother? Or they might feel, as some moms told me, that their bodies failed them. They might have lingering pain, which itself can be associated with a PPMD. C-sections also make it harder to breastfeed, and ending breastfeeding before six months is associated with postpartum depression. Other studies suggest that there is no difference between mode of birth and developing a postpartum mood disorder.

But the most important predictor of developing a PPMD I having a mental health disorder, like anxiety or depression, during pregnancy.

You also talk about the racist history of C-sections. I admit I had no knowledge of this, and it's horrifying. Can you share a brief overview? How does this history relate to today's ongoing racial disparities in maternal mortality?  

Yes, it really is horrifying. One thing that’s important to keep in mind is that in the 1800s, C-sections were experimental and only used as a last-ditch effort to save a mother, and her baby, if the baby was stuck. They were often fatal for the mother. At that time, they were practiced disproportionately on enslaved women for two reasons: their lives weren’t valued as much as white women’s lives, and their primary value to enslavers was to birth more slaves (because a baby had the same “status” as its mother).

And these women were not asked if they would consent to the surgery — their enslavers decided for them. Bear in mind that consent at the time, even for free women, didn’t look the way it does today. But physicians would at least ask everyone present at a white woman’s labor if it was OK to do the operation (though there’s also ample evidence they coerced women into it). It’s worth noting that even now, Black women are more likely than white women to be coerced into interventions they don’t want, including cesareans.

Today, Black women are still more likely than white women to have C-sections.

There are many reasons for this, but it comes down to racism at the systemic and individual levels. Access to midwifery is a good systemic example. In the U.S., demand for midwives exceeds supply for everyone, from all ethnic groups. But the gap between the availability of midwives and the demand for them is greatest among Black women. That matters, because midwives attending low-risk, first-time mothers have lower C-section rates than OBs attending mothers low-risk first-time moms. So if it’s your first baby, and you’re in good health, and you can’t access a midwife, then the likelihood you’ll have a C-section is already elevated — even if there’s nothing clinical that should make it so. And that sets you on a trajectory for future C-sections, because in the US the vast majority (around 90 percent) of mothers who’ve had a C-section will have a repeat cesarean with a subsequent birth.

The bottom line is that there is nothing biological about Black women that makes them more likely to have a C-section than women of other ethnicities. Likewise, there’s nothing about Black women biologically that makes them more likely to die during pregnancy or after. It’s racism, including social determinants of health, like access to midwifery, quality care, paid leave — none of which is equitable in our society.

What advice do you have for people who are pregnant and might face the possibility of a C-section? What can they do to prepare, if anything, and advocate for their needs?

I suggest learning about what happens during a C-section so that if you need one, the first time you think through aspects of surgical birth isn’t the moment that it’s happening. For instance, if you anticipate having a cesarean, and you think you might be anxious, do you want medication for anxiety? If you take medicine, what are the side effects (i.e. memory loss)? Are you OK with that? Or do you prefer non-pharmacologic support, and what would that look like, and who would provide it? Talking about this for the first time in or on your way to the OR is hardly the optimal moment to explore your desires or the full risks, benefits, and alternatives of whatever intervention.

I also think it’s important to reflect on what you hope your birth will be like and talk about how you might integrate those wishes, whether a birth is surgical or vaginal. I don’t mean a birth plan, which is fine, but can go out the window if suddenly you end up needing an intervention you hadn’t planned for. More of an examination of your values and priorities. Maybe you are a modest person and feel uncomfortable with how exposed you might be during birth; how can providers address that, in the OR, while also doing their job safely? Or maybe it’s important to you that you aren’t separated from your baby after birth. How can you and your baby stay together, provided you are both stable? Maybe you want to start breastfeeding as soon as possible, even in the OR! How can your providers support that? We wouldn’t bat an eye if someone having a vaginal birth made these requests. It’s OK, and important, to speak up—or to have a trusted advocate do so for you. And, ideally, to start these conversations before birth, when you’re still pregnant.

Is there anything else you'd like to add?

So many mothers I talked with felt shame about having had a cesarean. They asked,
Did I even really give birth? Or they felt that others looked at them as if they’d somehow failed to live up to an unspoken standard of motherhood. Still other moms felt troubled by what their C-sections meant about their bodies — as if, because they hadn’t had a vaginal birth, their bodies had failed them. This was especially the case for people who had an unplanned C-section.

I have two important things to say about these feelings: First, it is OK, and normal, and healthy, to grieve not having a vaginal birth, or having a major surgery, and a tough recovery, while also dealing with the harmful stereotype that C-sections are less than or the easy way out. We do a terrible job of allowing mothers to express negative feelings postpartum. It’s OK to feel and say these things, which don’t go away because you have a healthy baby.

Second, the way your baby was born — by cesarean, vaginally with an epidural, after an induction, vaginally without medication — doesn’t mean anything about your character or how good of a mother you are. You grew a baby in your body and brought it to this side of the veil. Another set of fingers and toes, a heart, a brain. How remarkable you are.