Cesarean Section: An American History of Risk, Technology, and Consequence by Jacqueline H. Wolf

Abstract

Reviewed by: Cesarean Section: An American History of Risk, Technology, and Consequence by Jacqueline H. Wolf Isabel Córdova Jacqueline H. Wolf. Cesarean Section: An American History of Risk, Technology, and Consequence. Baltimore: Johns Hopkins University Press, 2018. 320 pp. Ill. $49.95 (978-1-4214-2552-8). Wolf delivers yet another careful historical analysis, which builds upon her previous publications on U.S. women’s public health and childbirth in her third book, Cesarean Section. This time she unpacks the relationship between the shifting public and medical perceptions related to childbirth and medical interventions that culminated in pathologizing vaginal births and normalizing cesarean sections. Wolf argues that the changes in risk perception that redefined vaginal birth as inherently difficult and dangerous were more a result of significant cultural shifts in the United States than a response to medical needs or realities. She points out that perceived risk is not always the same as actual risk and “alleviating risk has become a particularly pronounced focus of contemporary medicine” (p. 8). In the eighteenth, nineteenth, and early twentieth centuries, when life spans were shorter, effective medical treatments rare, and hygiene a challenge, fewer than 5 percent of births on record were listed as difficult or problematic. Today, about a third of U.S. births are deemed problematic enough to require surgical [End Page 280] intervention, and nearly all require assisted technologies and medical interventions. Although cesareans can be life-saving procedures, the increasing cesarean rates after the 1980s did not translate to lower infant or maternal mortality or morbidity rates. In fact, since 1999, postpartum complications have increased by 75 percent, many associated with cesarean sections. Obstetricians have more expertise and training in surgical deliveries than in obstetric maneuvers. In Cesarean Section, Wolf traces the path that got us to this point. Cesarean Section is organized chronologically. Each chapter considers the medical and public perceptions of risks related to childbirth and medical interventions, the common medical practices and tools available at the time, and how these changed to redefine birthing. The book begins in the nineteenth century and ends in the second decade of the new millennium. One chapter is dedicated to the nineteenth century and six to the twentieth century, with references to the beginning of the twenty-first century. Likely a consequence of her many years of research in the field, Wolf draws from an impressive array of medical archives, medical literature, popular women’s magazines, secondary source material, and her own oral history interviews. The outcome is a monograph that contemplates the complex factors behind the evolution of risk, technology, and birthing. Wolf deftly crafts a narrative that uses the stories of women’s recollections of their birthing experience as well as those of physicians as way to reinforce her historical analysis of medical sources and data. During the mid-1800s until the early 1900s, obstetricians dedicated much of their energy to applying forceps in difficult labors and avoiding what were risky cesareans (p. 35). At the time, cesareans were often deadly. Doctors and the public assigned greater importance to the mother than the fetus. Anesthetics, germ theory, and later asepsis and antibiotics would change the survival rates of mothers after a cesarean. By the 1930s, cesareans could be performed to save the life of a fetus as well. Between the 1930s and 1960s popular magazines and newspapers helped to educate the public about cesareans. With the birth of postwar baby boomers, overworked medical staff administered more pain medications and sedatives and practiced more inductions, and surgical births increased from about 2 to 4 percent (p. 85). By the 1950s women and doctors began describing labor as too long and difficult, forever altering perceptions and responses regarding birth. The factors that Wolf identifies as having among the greatest impacts on perceptions of risk in childbirth were the tools focusing on the fetus, such as the Freidman curve, the Apgar and Bishop scores, and the electronic fetal monitor. The overreliance of obstetricians on machines led to the deskilling of physicians. The trifecta of pathologizing birth, new technologies and diagnostic tools, and the deskilling of obstetricians converged to inflate the perception of risk and led to the overreliance on cesarean...