A Cesarean section (C-section) is a surgical procedure for delivering a baby through incisions made in the mother’s abdomen and uterus. Although documented for centuries, for most of history it was an extremely uncommon and dangerous intervention, used only as a last resort. The modern frequency of C-sections is a striking departure from historical practice. Understanding the evolution of this operation requires tracing the medical and societal shifts that transformed it from a rarity into a common form of delivery.
The Pre-Modern Era
For thousands of years, C-sections were typically performed after the mother had died or was near death, often with the primary goal of retrieving the baby for religious rites or a separate burial. Before the 20th century, the maternal mortality rate was nearly 100%, primarily due to massive hemorrhage and subsequent infection. Surgeons lacked the ability to safely suture the uterine wall, causing catastrophic blood loss. The absence of antiseptic practices meant that puerperal fever, a devastating post-operative infection, was almost guaranteed.
The procedure was therefore never considered a viable option for an elective delivery or even a routine intervention to solve prolonged labor. In the rare instances where a mother survived, it was considered a medical miracle rather than a predictable outcome. If a complicated delivery required surgical intervention, the alternative method of craniotomy—the purposeful destruction of the fetal skull for extraction—was often chosen to save the mother’s life.
The Mid-Century Turning Point
The safety of C-sections improved significantly between the 1930s and 1950s. The introduction of general, spinal, and epidural anesthesia reduced trauma and pain, minimizing the risk of maternal shock. Concurrently, the widespread use of antibiotics, starting with penicillin in the 1940s, dramatically reduced life-threatening post-operative infections.
Surgical technique also underwent major refinement with the adoption of the lower uterine segment incision, popularized around the 1920s. This technique involved a horizontal cut across the thinner, lower portion of the uterus, replacing the older, vertical “classical” incision. This change greatly reduced the risk of uterine rupture in future pregnancies and minimized blood loss, making the operation substantially safer for the mother. Advances in blood transfusion technology allowed practitioners to safely manage unexpected or heavy blood loss during surgery, further securing the mother’s survival.
The Rapid Increase
Despite medical advances, Cesarean rates remained low, hovering around five percent of all births in the United States until the mid-1960s. The transition from a rare procedure to a common one began in the late 1960s and accelerated dramatically through the 1970s and 1980s. Rates climbed rapidly, doubling between 1970 and 1980 alone.
By the late 1980s, the rate in the United States peaked near 25 percent of all deliveries, representing a five-fold increase in just two decades (from 4.2 percent in 1970 to 24.7 percent by 1988). This growth signaled a fundamental shift in obstetric practice toward greater reliance on surgical intervention. This statistical curve shows when C-sections truly became common in developed nations.
Contributing Factors to the Surge
The acceleration in C-section rates was driven by medical, legal, and technological factors. The rise of electronic fetal monitoring (EFM) in the 1970s provided continuous fetal heart rate data. Interpretation of EFM often led to a diagnosis of “fetal distress,” prompting immediate surgical delivery. However, many early interpretations of EFM were overly sensitive, resulting in operative deliveries that were not strictly necessary.
The policy “once a Cesarean, always a Cesarean” became standard practice based on the historical risk of uterine rupture from the older classical incision. This policy created a growing population of women who were automatically scheduled for repeat C-sections in subsequent pregnancies, regardless of the relative safety of the modern lower transverse incision.
Legal pressures led to “defensive medicine,” where physicians favored C-sections in ambiguous or prolonged labor cases. They believed surgical intervention was more easily defensible in court than waiting for a complicated vaginal delivery. Furthermore, the change in managing breech presentations, where the baby is positioned feet- or buttocks-first, also contributed, as many institutions shifted away from attempting vaginal breech deliveries to performing nearly all of them by C-section.
Current Global Context
Today, the C-section is one of the most frequently performed major surgeries worldwide, with rates in many developed countries far surpassing historical levels. In North America, the rate currently hovers around 30 to 32 percent of all births, and in Europe, rates are typically around 25 percent. Across the globe, the average rate stands at approximately 21 percent, a significant increase from the seven percent global rate recorded in 1990.
This current level of surgical delivery is often contrasted with the recommendations of the World Health Organization (WHO). The WHO suggests the ideal rate for a population to optimize maternal and neonatal outcomes is between 10 and 15 percent. Rates above this range are not consistently associated with further reductions in maternal or neonatal mortality. The procedure’s current commonality illustrates the profound medical and cultural transformation that has occurred since the mid-20th century.