A Cesarean section (C-section) is a surgical procedure to deliver a baby through incisions in the mother’s abdomen and uterus. Historically a perilous intervention, it has evolved into a widely accepted and frequently performed medical practice, fundamentally reshaping childbirth.
Early Beginnings and Survival Challenges
Historically, C-sections were rare and a last resort, often performed when the mother was deceased or near death to save the infant. Ancient texts and folklore describe such procedures, with Roman law mandating post-mortem deliveries. For centuries, the maternal mortality rate was extremely high, often exceeding 50%. This was largely due to uncontrolled bleeding and rampant infection, as medical understanding and techniques were rudimentary. The procedure was an act of desperation rather than a planned medical intervention.
Medical Breakthroughs and Shifting Practice
The landscape of C-sections began to change with significant medical advancements in the 19th and early 20th centuries. The introduction of effective anesthesia, such as ether in 1847, allowed for pain-free surgery, enabling more meticulous procedures and increasing survival rates. Simultaneously, the understanding of germ theory and the development of aseptic and antiseptic techniques by the late 1800s drastically reduced post-operative infections. Surgeons began sterilizing instruments and washing hands, curbing the spread of bacteria.
A significant improvement in surgical technique was the widespread adoption of uterine suturing. Early C-sections often left the uterine incision unsutured, leading to severe hemorrhage and infection. Max Sänger in 1882 advocated for uterine closure, and Ferdinand Adolf Kehrer introduced the transverse uterine incision in 1881. These innovations helped control bleeding and promote healing, making the procedure much safer. The availability of blood transfusions, particularly after World War II, further enhanced safety by allowing clinicians to manage blood loss.
Factors Driving Increased Use
As C-sections became safer, medical, societal, and technological factors contributed to their increased adoption. A major shift occurred in the early to mid-20th century as childbirth transitioned from homes to hospitals. In the United States, hospital births rose from under 10% in the 19th century to over 90% by the mid-1950s, as hospitals offered perceived safety and pain relief. This institutionalization of birth facilitated greater medical intervention.
The development of electronic fetal monitoring (EFM) in the mid-1960s allowed continuous fetal monitoring during labor. While intended to detect distress, EFM has been associated with higher C-section rates, as subtle changes could prompt intervention. Changes in obstetric training and protocols also favored earlier C-section for various indications, moving away from prolonged, higher-risk labors. Concerns about malpractice litigation, particularly since the 1970s, influenced obstetricians to opt for C-sections defensively. Increasing maternal health conditions (e.g., diabetes, hypertension) and a rising average maternal age also contribute to medical indications for C-sections.
The Era of Commonality
The latter half of the 20th century, particularly from the mid-1960s, marked the rise of C-sections as a common medical practice. From 1965 to 1985, C-section rates increased over 400% in many developed nations. In the United States, the rate rose from approximately 4.5% of births in 1965 to around 33% by 2009. This rapid escalation transformed C-sections from an infrequent, high-risk procedure into a routine and often planned method of delivery.
Today, C-sections are one of the most frequently performed surgical procedures globally. In the United States, about one in three babies is delivered by C-section, with rates consistently around 32-33%. The World Health Organization reported in 2023 that 21% of all childbirths worldwide occur via C-section, with projections indicating a rise to 29% by 2030. This widespread adoption reflects the procedure’s evolution into a generally safe and often necessary intervention, significantly improving outcomes for mothers and infants when vaginal delivery poses risks.