Since 1940, the trend toward medically managed pregnancy and childbirth has steadily accelerated. Many new hospitals were built in which women gave birth and in which obstetrical operations were performed. By 1938, approximately half of U.S. births were taking place in hospitals. By 1955, this had risen to ninety-nine percent.
During that same period medical research flourished and technology was greatly expanded in scope and application. Advances in anesthesia contributed to improving the safety and the experience of cesarean section.
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Currently in the United States slightly more than one in seven women experiences complications during labor and delivery that are due to conditions existing prior to pregnancy; these include diabetes, pelvic abnormalities, hypertension, and infectious diseases. In addition, a variety of pathological conditions that develop during pregnancy (such as eclampsia and placenta praevia) are indications for surgical delivery. These problems can be life-threatening for both mother and baby, and in approximately forty percent of such cases cesarean section provides the safest solution. In the United States almost one quarter of all babies are now delivered by cesarean section -- approximately 982,000 babies in 1990. In 1970, the cesarean section rate was about 5%; by 1988, it had peaked at 24.7%. In 1990, it had decreased slightly to 23.5%, primarily because more women were attempting vaginal births after cesarean deliveries.
How can we explain this dramatic increase? It certainly far exceeds any rise in the birth rate, which went up by only 2% between 1970 and 1987. In fact there were several factors that contributed to the rapid rise in cesarean sections. Some of the factors were technological, some cultural, some professional, others legal. The growth in malpractice suits no doubt promoted surgical intervention, but there were many other influences at work.
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While the operation historically has been performed largely to protect the health of the mother, more recently the health of the fetus has played a larger role in decisions to go to surgery.
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Since the advent of heart monitors in the early 1970's, fetal monitoring routinely tracks fetal heart rate and indicates any signs of distress. As a result of the ability to detect signs of fetal distress, many cesarean sections are swiftly undertaken to prevent such serious problems as brain damage due to oxygen deficiency.
With these innovations came criticism. Fetal monitoring as well as numerous other antenatal diagnostics have been faulted in recent years by some of the lay public and members of the medical profession. The American College of Obstetricians and Gynecologists and similar organizations in several other countries have been working to reduce some of the reliance on high-cost and high-tech features of childbirth and to encourage women to attempt normal delivery whenever possible.
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Some doctors have for many years expressed doubts about the rates of cesarean section. Recently many medical practitioners have responded to this situation and have begun to work with lay organizations to encourage more women to undertake normal delivery.
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The American College of Obstetricians and Gynecologists responded swiftly to calls from within the organization and from the patient population and in 1982, as a standard of care, recommended a trial of labor in selected cases of prior cesarean section. In 1988, the guidelines were expanded to include more women with previous cesarean births. Consequently, there was a steady increase in vaginal births after cesarean in the late 1980's. In 1990, an estimated 90,000 women gave birth vaginally after cesarean section.
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This study indicates that, while cesarean section continues to be a procedure that saves the lives of mothers and infants and prevents disabilities, both the medical and lay communities must bear in mind that most births are normal and more births should progress without undue intervention.
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As this brief history suggests, the indications for cesarean section have varied tremendously through our documented history. They have been shaped by religious, cultural, economic, professional, and technological developments -- all of which have impinged on medical practice. The operation originated from attempts to save the soul, if not the life, of a fetus whose mother was dead or dying.
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Finally, in the late twentieth century, in mainstream Western medical society the fetus has become the primary patient once labor has commenced. As a result, we have seen in the last 30 years a marked increase in resort to surgery on the basis of fetal health indications.
