A Personal History of the C-Section

I didn’t realize that I cared about getting a cesarean until I listened to myself telling the story of my cesarean. Describing my daughter’s birth during the first months of her life, I often stumbled over my words. “When she was born,” I would say, then correct myself: “When they got her out.” This was less poetic, but it seemed more accurate. I mean, of course she’d been born. She was here, wasn’t she? But it never felt quite right to say that I gave birth to her. The literal truth was something else: A doctor opened me up, parted my skin and reached inside to pull my baby into the world.

Whenever I told my birth story, I noticed myself stressing that it was an emergency C-section — wanting people to know that there wasn’t any other option, that I didn’t choose to forgo labor, wasn’t coerced into the procedure by an intervention-happy, efficiency-obsessed, liability-avoidant medical establishment. At first, I was mainly just relieved that my daughter survived the delivery, that I could wonder at her little burrito of a body in the swaddling blanket or her impossibly tiny fingernails. My C-section was simply the intervention that had been necessary; now it was just a set of physical inconveniences. When I laughed or coughed, I felt as though I was going to split open along my new seam. When I searched online for “C-section shelf?” it was only because I didn’t know what other word to use for the bulge of numb skin that hung like a rock formation over my scar. (Apparently “shelf” was good enough, yielding pages of message-board entries: Is it fat? Is it skin? How do I make it go away?)

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When I talked about the days after my daughter’s birth, I found myself emphasizing how much I held her, how I never wanted to put her down. It was as if I felt the need to compensate narratively for that first hour, when I wasn’t able to hold her at all — to insist that we bonded just as much anyway. I found myself exaggerating the part about not caring if I was numb before they cut me open, when in fact I did care; I told the doctors that I would actually love some more anesthesia in my epidural if they had a split second to spare. My impulse to exaggerate my stoicism felt like another shameful compensation — as if I were trying to make up for other kinds of pain I didn’t experience, unwittingly obeying the cultural script that insisted on suffering and sacrifice as the primary measures of maternal love.

Even now, three and a half years later, I still feel a pang when I hear women use the phrase “natural childbirth” or describe pushing out their babies after 40 hours of labor. Imagining all that effort inspires a deep awe but also a splinter of shame — as if my own birth story wasn’t one that merited pride or celebration but was instead a kind of blemish, a beginning from which my daughter and I must recover.

“That operation is called Caesarean by which any way is opened for the child” other “than that destined for it by nature,” wrote a late-18th-century French obstetrician named Jean Louis Baudelocque. Since ancient history, the “unnatural” quality of the cesarean has made it both miraculous and suspect, simultaneously a deus ex machina and a tyrannical intervention. It’s an apocryphal story that Julius Caesar was born by cesarean — his mother survived his birth to bear more children, and at that point, the C-section was impossible to survive — most likely spun to grant more drama to the story of his birth.

In his 1925 history of the operation, Herbert Spencer, a professor of obstetrics at University College London, speculates that it “was called Caesarean as being too grand to have been first performed on ordinary mortals” and calls it “the greatest of all operations, in that it directly affects two lives.” For most of its history, however, it saved only one of them. Mothers didn’t routinely survive the procedure until the 20th century. Before then, it was generally deployed as a last-ditch measure to save the baby once the mother was dying or already dead.

In many languages, the name for the procedure invokes its ostensibly regal lineage: The Danish, Dutch and Swedish terms are all variations of “the imperial cut.” In German, it’s kaiserschnitt; in Slovenian, it’s cesarski rez. (Hardly surprising that even though it’s the woman who is cut open, the procedure is named for a man.) A friend who grew up in Belgium told me his grandmother believed that all royalty were delivered by cesarean. It has retained an enduring association with privilege or indulgence: too posh to push.

Even before it was imperial, the C-section was associated with divinity. The Greek god of medicine, Asklepios, was born by cesarean, rescued from his mother’s body as she burned on a funeral pyre. In Shakespeare’s “Macbeth,” the cesarean-born Macduff famously arrives as the answer to a riddle: Although the witches have promised that “none of woman born shall harm Macbeth,” Macduff turns out to be exempt from the prophecy because he “was from his mother’s womb untimely ripped.” Macduff’s exceptional birth grants him a singular power, but its exceptionality also carries a whiff of monstrosity: “Untimely ripped” doesn’t exactly summon the epidural and the blue tarp.

Why do we want so much from our birth stories, anyway?

During the medieval era, some babies born by cesarean were called “the fortunate” or “the unborn,” deemed miraculous not despite being born from corpses but because of it. They were proof of hope and possibility salvaged from the jaws of death, emblems of life plucked from wombs growing cold. Cesareans were understood as both miraculous interventions from saints — the so-called apertura mirabilis, or “wondrous opening” — and unholy abominations. The birth of the Antichrist was sometimes depicted as a cesarean; in one 15th-century woodcut, a winged demon clutches the new baby by his wrist while the mother looks away with her head cocked from exhaustion, or horror, a gaping wound still furrowing her stomach. As one widely circulated medieval account of the birth of the Antichrist put it: “The devil will go down into the womb of Antichrist’s mother and fill her completely, possess her completely inside and out, so that she will conceive by man with the devil’s assistance, and what is born will be completely foul, completely evil, completely ruined.”

Now, 500 years later, the “greatest of all operations” has become one of the most common surgeries in America. By 2019, almost one-third of American births happened by C-section, more than double the share that the World Health Organization considers the ideal rate to reduce maternal and infant mortality (10 to 15 percent). In some countries, the rate is even higher: In the Dominican Republic, about 60 percent of all babies are born by cesarean, and in Brazil, the so-called C-section capital of the world, cesareans account for almost 85 percent of all births in private hospitals, where women throw parties around their planned C-sections. One “presidential suite” in a São Paulo maternity ward includes a balcony and a minibar; another ward has a videography wing where women can get blowouts, manicures and makeup before being filmed with their newborns.

But the rise of the C-section has brought with it a powerful backlash, in which legitimate arguments against the procedure’s ubiquity have become Trojan horses, carrying within them age-old ideals of motherhood that fetishize sacrifice and pain. The dismissive, often unspoken critique of the C-section understands it as birth without labor, birth without pain, birth without sacrifice. If a mother is supposed to do anything, she is supposed to sacrifice herself for her children, and pain in childbirth is the earliest barometer of that sacrifice, the punishment God bestows upon Eve in the Book of Genesis: “I will greatly multiply thy sorrow and thy conception; in sorrow thou shalt bring forth children.” A cesarean often involves pain, but it’s unnatural pain, and it’s typically medicated away. Even when a C-section isn’t elective, it still means a woman doesn’t undergo that supreme, heroic effort of pushing a baby through the birth canal.

Although the cesarean backlash arose from an impulse to empower women, it has perversely also become another way to shame mothers, or make them feel inadequate, as soon as they’ve given birth. When the British doctor Grantly Dick-Read coined the term “natural birth” in his 1933 book “Natural Childbirth,” he meant childbirth without any intervention that would disrupt or change the process of labor. In “Childbirth Without Fear,” his internationally best-selling 1942 manifesto, he wrote that childbirth is “nature’s first hard lesson in the two greatest assets of good motherhood. Children will always mean hard work and will always demand self-control.” The woman who has a C-section is a woman who doesn’t learn those lessons.

I can still remember the sheer awe I felt in birth class when a lovely woman holding a plastic pelvis explained the interlocking stages of the process: how the pressure of contractions pushing my baby’s head against my cervix would stretch it, prompting my body to produce more prostaglandins, making it more receptive to oxytocin, which would thin the cervix and help it dilate; how my endorphins would carry me through the pain and my adrenaline would surge for that final push. It struck me as almost beautiful, how all these parts fit together like jigsaw-puzzle pieces. It was less like the hydraulics of a machine and more like the choreography of a dance.

Although I was never ferociously attached to the idea of a natural birth, in that class I finally got it: the primal drive to let your body do its work without intervention. It wasn’t just a sense of wonder at what my body was capable of; it was also about how my baby and I could be joined together by this shared labor. Before my daughter was born, a friend sent me an email describing her own recent birth as utterly collaborative. “For the final two hours we were working together totally,” she wrote. “Once she transitioned into the birth canal, I was just following her lead. I was aware of it, and of her and of my body, totally.” I was viscerally compelled toward this collaboration: not just the idea of my body delivering this new body into the world, but the idea that it would be the first thing my baby and I ever did together.

My birth ended up being a different kind of collaboration, one between two doctors, an anesthesiologist, a team of nurses and a pediatrician. For those last moments, I was something more like an extension of the operating theater. In this sense, the intervention of a C-section not only disrupts the ideal of a “natural” birth but also the ideal of autonomy: the fantasy of a mother’s body as an unassisted miracle worker, a self-contained ecosystem of fertility and capacity. “Basically it has made me feel less than a total woman,” one woman, quoted in an anti-cesarean book from the early 1980s, said after her C-section. “I felt like I had failed.”

My birth tableau was a far cry from what childbirth looked like for most of human history. Before the 1900s, women rarely even labored in hospitals. Increasing levels of intervention across the course of the 20th century — of which the C-section was the most extreme manifestation — were fueled by a radical shift in our understanding of labor itself. It ceased to be seen as a natural process that required largely passive oversight and became a dangerous predicament from which mother and baby each needed to be protected. Joseph DeLee, an early-20th-century obstetrician, understood childbirth as a process riddled with inherent risks: “So frequent are these bad effects that I often wonder whether nature did not deliberately intend women to be used up in the process of reproduction, in a manner analogous to that of salmon, which dies after spawning.” By 1964, an article in Harper’s warned that “a soldier in wartime has a better chance for survival than a baby during birth.”

As the medical historian Jacqueline H. Wolf recounts in her 2018 history, “Cesarean Section: An American History of Risk, Technology and Consequence,” the cesarean became perceived as “an avenue to perfection” within an increasingly quantitative approach to childbirth in the 1950s and ’60s: the Friedman curve (measuring length of labor), the Bishop score (measuring readiness for induction) and the Apgar score (measuring health of newborn). The C-section rate rose by 455 percent between 1965 and 1987. Many doctors were frustrated by mothers who, inspired by the natural-birth movement of the 1970s and early ’80s, fought for births without intervention. As Wolf recounts, one obstetrician used to press his fetoscope to women’s abdomens and pretend to listen to the voices of their unborn children: “You know, I can hear your baby!” he would tell them. “Your baby is telling me: ‘Don’t listen to my mother! She doesn’t know anything!’”

The same medical paternalism that judged women for resisting C-sections also judged women — just a few decades earlier — for having them. In a 1921 medical analysis of the procedure, Franklin Newell, a doctor affiliated with Harvard Medical School, describes an ideal candidate as a woman with “poor nervous equipment.” Even though this type of woman doesn’t have a deformed pelvis or a medical condition, Newell argues, she is suited to a C-section because she is so averse to pain and so constitutionally weak. “Such women are very prone to respond badly to the strain of labor, and to them pain is a real evil,” he writes. “What they cannot recover from is a long strain, particularly if much pain accompanies it, and all pain is exaggerated to them.”

Newell cobbles together a set of enduring female stereotypes: a woman who likes to play victim, hates to work and constantly inflates her own discomfort. She is incapable of the self-sacrifice that is the hallmark of virtuous motherhood. In fact, he argues, centuries ago she most likely would have been killed off by natural selection. “These patients are the abnormal product of an overcivilization and are much like hothouse plants,” he writes. “They represent in our civilized communities a type which would have been largely eliminated, if medical care had not interfered with the law of the survival of the fittest.”

Rising from the natural-birth movement of the 1970s and consolidated by the 1977 publication of Ina May Gaskin’s canonical text, “Spiritual Midwifery,” the strong cesarean backlash found its stride in the 1980s. In the digital era, it eventually bloomed into a proliferation of websites and forums, including the popular “Unnecesarean” blog. A slew of recent books has criticized the overabundance of C-sections, including “Cut It Out: The C-Section Epidemic in America” (ha!). The International Cesarean Awareness Network offers meetings for women looking for a “safe space to process cesarean experience and/or getting support for a VBAC” (vaginal birth after cesarean). In one cesarean memoir, a woman describes herself murmuring “VBAC” like a mantra during her third pregnancy: “My soul craved natural birth the way a lover’s very being calls to her mate.” It’s surprisingly intuitive to frame the longing for natural childbirth in terms of romantic desire. Both kinds of intimacy promise to deliver consummation. They promise to let you become — by giving birth to another human being, or making life with another human being — the fullest version of yourself.

When I first encountered the taxonomy of “cesarean mothers” created by the cesarean-prevention movement in the early 1980s, paraphrased in Wolf’s book, I couldn’t help wondering where I fell: “The ‘cesarean mourner’ had never made peace with not having a vaginal birth. The ‘cesarean victim’ suspected her surgery had been unnecessary. The ‘cesarean learner’ was now empowered to seek a vaginal birth the next time around. The ‘cesarean surrender’ had given up the fight. The ‘cesarean gratitude’ was thankful for the surgery that had saved her and her baby. The ‘cesarean activist’ was determined that no woman ever have unnecessary surgery again. The ‘cesarean phoenix’ rose ‘victorious from bitter ashes!’”

Some part of me yearned for natural childbirth as a threshold of redemption.

The truth is, before I started reading books by and about women who felt traumatized by their C-sections, I never felt particularly traumatized by my own. After enough reading, however, I started to think: Maybe I shouldn’t feel like a real woman either? Was I a “cesarean surrender” for having capitulated so easily to the narrative that my surgery was necessary?

Wolf’s history of the American C-section made me think of my cesarean as part of a long history of intervention. Bolstered by technological triumphalism, the procedure became commonplace as an attempt to standardize an essentially variable experience so that it would hew as closely as possible to an “ideal” birth and an ideal baby. Of course, it is now the very thing an “ideal” birth seeks to avoid. This was the uncomfortable truth of my labor experience, of anyone’s labor experience: It feels deeply personal but has in fact been shaped by impersonal societal forces. Wolf describes the drastic increase in the use of electronic fetal monitors, which offered a technological peephole into the well-being of the unborn and, in so doing, effectively created more situations where a C-section was deemed necessary — as one doctor put it, “dropping the knife with each drop in the fetal heart rate.” I started to wonder if the surgery I understood as lifesaving had in fact been a mere symptom of risk-averse medical culture. But I could still hear those nurses calling out my baby’s falling heart rate — “It’s in the 60s! It’s in the 50s!” — and the memory of their voices, their utter panic, still lifted the hair on my arms.

Maybe my cesarean was necessary. But what did it say about the cultural ideals of motherhood I had internalized that I felt such a frantic desire to insist that it was an emergency? It was as if I needed to prove I wasn’t a bad mother for having given birth by C-section, or as if I still believed, in some sense, that I hadn’t given birth at all. Was I another “cesarean victim” who was emotionally blackmailed into surgery? Or had my baby been saved from death? These were very different stories to live inside. They were very different ways to understand the start of my daughter’s life.

It would be a lie — or at least an incomplete truth — to deny that some part of me yearned for natural childbirth as a threshold of redemption. I had never fully treated my body as an ally. I had starved myself to whittle it down and spent years drinking myself to blackout and various other perils. Pregnancy already felt like a more redemptive chapter in this fraught relationship between body and spirit: I was taking care of another tiny body inside my own! Everything my body ate was feeding hers. All the blood pumping through my heart was flowing through hers. Giving birth to her would not only be the culmination of her nine-month incubation but would also be a refutation of all the ways I abused or punished my body over the years, all the ways I treated it as an encumbrance rather than a collaborator. My mind resisted this logic, but I could feel — on a visceral, cellular, hormonal level — its gravitational pull.

“Silent Knife: Cesarean Prevention & Vaginal Birth After Cesarean,” an influential anti-cesarean manifesto published by the writers Nancy Wainer Cohen and Lois Estner in 1983, insists that what it calls a “purebirth” is “not a cry or demand for perfection,” though the definition ends up sounding a little … demanding: “Birth that is completely free of medical intervention. It is self-determined, self-assured and self-sufficient.” The unstated tension of the entire book is also the unstated tension embedded in the broader backlash against C-sections: between recognizing the trauma of a C-section and reinforcing or creating that trauma by framing the C-section as a compromised or lesser birth. A section called “Voices of the Victims” quotes women traumatized by their C-sections: “It felt as if I was being raped,” one woman says. “I couldn’t do anything but wait until it was over.” A father says: “A c-sec is one of the worst mutilations that can be perpetrated on a woman as well as a denial of a fundamental right of a woman to experience childbirth.”

Inspired by Ina May Gaskin’s famous pronouncement that “you can fix the body by working on the mind,” Cohen and Estner argue that our wombs are cluttered with “unaddressed stresses or fears” that obstruct the birth process, but that they can be swept aside through self-awareness to “clear a passageway for normal birth.” The implication is that, conversely, emotional baggage could be “blamed” for a cesarean. Reading the book 38 years after it was written, I immediately dismissed this notion. But another part of me — the part that had been conditioned for my entire life to feel accountable to impossible ideals of motherhood — wasn’t immune to this magical thinking. In secret, I had indulged my own pet theories about the possible psychological causes of my C-section: my eating disorder, my abortion, my maternal ambivalence. Had I mistreated my body so much that it refused to give birth naturally as an act of retaliation? Had I been more attached to the idea of being a mother than I was prepared for the actuality of being a mother? Was my labor stalling out — as my baby’s heart rate dropped — a sign of this subconscious unwillingness?

If “Silent Knife” was written to restore agency to women by pushing back against the tyrannical paternalism of C-sections, then there’s a different tyranny embedded in its ostensible restoration of agency, a tyranny that abides today: a script of self-possession that can become another straitjacket, another iteration of the claustrophobic maternal ideals. Expressing compassion for a woman who feels like an inadequate mother because she hasn’t given birth “naturally” can easily slide into implying that she should feel that way. Many of the ideas that “Silent Knife” made explicit years ago are still deep forces shaping childbirth today, even if people might be less likely to confess to them: the notion that birth by C-section is less “real,” that it might imply some lack of willpower or failure of spirit.

Motherhood is instinctual, but it’s also inherited: a set of circulating ideals we encounter and absorb. The fact that we are constantly shaped by external models of an internal impulse makes women intensely vulnerable to narratives of “right” or “real” motherhood, and all the more susceptible to feeling scolded or excluded by them. A woman’s right to state her preferences during the birth process is increasingly prioritized, and rightly so, but it’s easy to fetishize these preferences as the ultimate proof of female empowerment, when they are, of course, shaped by societal forces too. It’s a kind of partial vision to hold up a woman’s desire for natural birth as a badge of unpolluted female agency, when that desire has been shaped by all the voices extolling natural birth as the consummation of a woman’s feminine identity.

As my daughter has grown from newborn to infant to toddler, I have been daydreaming about getting a tattoo on my abdominal scar. There are entire Pinterest boards full of C-section-scar tattoos and Instagram hashtags devoted to them (#csectionscarsarebeautiful): angel wings, diamonds, draping pearls, blazing guns. Ganesh, the remover of obstacles. A blue rose unfurling into cursive: “Imperfection is beautiful.” Bolder Gothic script: “MAN’S RUIN.” A “Star Wars” scene of two snub fighters approaching the Death Star. A zipper partly unzipped to show an eye lurking inside. A pair of scissors poised to cut along a dotted line, inked beside the scar itself. A trompe l’oeil of a paper clip piercing the skin, as if it were holding the abdomen together across the line of its rupture. My favorites are the ones in which the scar is intentionally incorporated into the design itself. A low transverse cut becomes the spine of a feather or a branch bursting with cherry blossoms. These tattoos don’t try to hide the scar from view but instead put it to work as part of a larger vision. I have started to imagine, on my skin, a row of songbirds on a wire.

The fantasy of this tattoo has been part of a deeper reckoning with the question of whether I want to narrate the birth — to myself, to others — as miraculous, traumatic or simply banal, a commonplace necessity. Around the time I started to consider a tattoo, I read a memoir by an Oregon writer named Roanna Rosewood called “Cut, Stapled and Mended: When One Woman Reclaimed Her Body and Gave Birth on Her Own Terms After Cesarean.” My inner Sontag (“Illness is no metaphor!”) bristled at the endorsement from a mother on the front flap: “I blamed my midwife for my failure to progress but secretly knew it was me; my lack of confidence led to my failure.” Though I resented what I interpreted as the book’s veneration of vaginal birth as the only “real” kind, I could recognize — if I was honest with myself — that my resistance also rose from the fear that I had missed out on an extraordinarily powerful experience. When I read Rosewood’s declaration that a “clean and passive birth resembles an empowered one in the same way that an annual exam resembles making love,” it made me feel deeply foolish — as if understanding my daughter’s birth as the most powerful experience of my life (which I did) was somehow akin to mistaking a Pap smear for an orgasm.

Partway through Rosewood’s memoir, however, I encountered a moment that resonated so strongly that I had to put the book down. When she describes her body shaking uncontrollably after her C-section and her anguish at being unable to hold her baby, I was taken back to the flurry of my own post-op desire, my arms twitching beneath their gurney straps while the doctors carried my daughter away from me. Rosewood and I each found ourselves — in the first moments after our births — strangers to our own bodies and separated from the bodies of our children. The difference between us didn’t live in those moments of fear and loss but in what we wanted to do with them afterward. When I read about Rosewood’s desire to “write over” the story of her eldest son’s birth, it made me feel defensive on my daughter’s behalf. I don’t want to write over her birth story. I don’t want anyone else to, either. Maybe it wasn’t ideal, but it was ours.

Why do we want so much from our birth stories, anyway? It’s tempting to understand life in terms of pivotal moments, when it is actually composed of ongoing processes: not the single day of birth but the daily care that follows, the labor of diapers and midnight crying, playground tears and homework tantrums, speeding tickets and long-distance phone calls — all that work of sustenance and reinvention. If we’re lucky, birth is just the beginning. The labor isn’t done. It has only just begun.

Leslie Jamison is the author, most recently, of “Make It Scream, Make It Burn.” She last wrote for the magazine about visiting Istanbul’s public baths weeks before the lockdown.

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