Risk and Reputation: Obstetricians, Cesareans, and Consent

Abstract

When physicians performed cesarean sections in the nineteenth century, they customarily sought agreement from all present before proceeding. In contrast, after the introduction of electronic fetal monitoring in the late 1960s, obstetricians obtained permission for a cesarean by offering a choice that ensured consent—give birth by cesarean or give birth vaginally to a damaged or dead baby. This article argues that the manner in which physicians obtained consent for cesareans in the nineteenth century was one factor that kept the cesarean rate low, while the manner in which physicians obtained consent in the late twentieth and early twenty-first centuries was one factor driving up the cesarean rate. The dissimilar approaches to consent did serve a common purpose, however. Each preserved physicians’ reputations. With the surgery likely to end in a woman’s death in the nineteenth century, consensus ensured that a bad outcome would be a shared burden. And because the fetal monitor, in exaggerating the risks of vaginal birth, changed the nature of the malpractice climate for obstetricians, the late-twentieth-century approach to consent similarly protected physicians. As one early twenty-first-century obstetrician quipped, “You don’t get sued for doing a C-section. You get sued for not doing a C-section.”

Between 1965 and 1987, the cesarean section rate in the United States rose 455 percent—from 4.5 to 25 percent of births.¹ Today, almost one in three births is by cesarean.² These figures contrast sharply with earlier eras. Physicians performed cesareans in the nineteenth and early twentieth centuries extremely rarely; even in the 1940s and 1950s the nationwide average was only 2.5 percent of births.³ A lengthy series of medical innovations contributed to the postwar 2.5 percent rate. Cesarean surgery went from a notoriously dangerous medical procedure in the nineteenth century to a largely safe one by the mid-twentieth century thanks to anesthesia, first used in obstetrics in 1847; asepsis, introduced into surgical practice in the 1880s; improved surgical techniques specific to cesareans in the late nineteenth and early twentieth centuries; and antibiotics and banked blood made widely available after WWII.⁴ In other words, the cesarean rate increased—from negligible to measurable—in the 1940s and 1950s for medically justifiable reasons. What is less clear is why the once dreaded procedure became, by the first decade of the twenty-first century, the most commonly performed surgery in the United States.⁵ This article examines one of the factors that contributed to the precipitous increase in cesareans that began in the late 1960s—the link between the electronic fetal monitor, malpractice suits encouraged by the monitor, and a change in the way physicians obtained consent for the surgery.

Certainly cesareans are appropriate and necessary at times. In cases of cord prolapse, placenta previa, placental abruption, and persistent transverse lie of the fetus, the procedure can be life-saving. These life-threatening conditions are rare, however. Each occurs in fewer than one percent of births.⁶ In contrast, there are sound reasons to anticipate that a birth is likely to go well: 99 percent of the time there is only one fetus in the womb, 97 percent of infants deliver head first, and 97 percent of fetuses have no major structural or genetic abnormalities.⁷ Cesareans thus seem to be occurring far more often today than is medically necessary.⁸

Although the factors contributing to today’s high cesarean rate are numerous and complex,⁹ I argue in this article that how obstetricians have sought consent for cesareans since the advent of the fetal monitor has been one significant factor. While obtaining consent in a collaborative fashion helped maintain a low cesarean rate in the nineteenth century, obstetricians’ method of obtaining consent today has convinced women that vaginal birth tends to be problematic, and that cesarean surgery is often the best remedy for any problem. Initially, as the cesarean rate began its precipitous rise in the early 1970s, many mothers questioned the need for their surgeries, some challenging obstetricians publicly.¹⁰ As the surgery became more common, however, doctors steered women to the view that cesareans are routinely necessary, and mothers’ questions ebbed.

Nineteenth-Century Cesareans and “the Concurrence of the Patient”

Obstetricians avoided cesarean surgery in the nineteenth century, if at all possible. The reason for their aversion was obvious. The maternal death rate after a cesarean was so high—exceeding 50 percent in the United States and approaching 90 percent in some European countries¹¹—that the surgery, in the words of one physician, was tantamount to “sacrificial midwifery.”¹² With postpartum infection and hemorrhage likely side effects, and no effective treatment for either condition until after WWII, a cesarean section was usually deadlier than the condition it sought to alleviate.

Not wanting to shoulder the burden of a likely bad outcome, when the operation occurred in a woman’s home, as almost all cesareans did before the 1880s, doctors did not proceed until they had obtained, not only the consent of the patient, but also the concurrence of everyone present. In 1827, at the first cesarean surgery in the United States to be documented in a medical journal,¹³ the physician decided the woman’s life was likely lost anyway. As he wrote three years later in the Western Journal of the Medical and Physical Sciences, the surgery offered “the only means I could conceive of relief.” He shared his view with everyone present: the exhausted, semi-conscious patient; the two midwives who had summoned him for help; and several friends and family members of the patient. Everyone agreed to the plan “as affording some hope for life,” however slim. And defying the odds, the woman, although not her baby, survived.¹⁴

Other articles written by physicians about the cesareans they performed in women’s homes confirm that doctors did not proceed without broad agreement. In 1868, after a woman had labored for more than five days, Dr. D. Warren Brickell of New Orleans arrived at the patient’s bedside to assist two other doctors and a midwife. After a lengthy physical examination, Brickell suggested a cesarean, “but some great fears of Caesarean section being expressed,” he tried forceps first, followed by a craniotomy, to no avail. Only then was it “unanimously agreed that Caesarean section should be resorted to, and the patient and her friends readily assented.”¹⁵ In an 1881 case, a woman with a misshapen pelvis suffered a stillbirth, followed by two miscarriages. When she became pregnant for the fourth time, a doctor suggested cesarean surgery but “the patient, taking advice of some female friends at this juncture, declared her unwillingness to have any interference. We could do nothing but wait.” Eventually, she did agree to the surgery and gave birth to her first living child.¹⁶

As long as virtually all births, including cesarean births, occurred in women’s homes, physicians sought the explicit permission of the patient before performing any procedure, especially one as risky as cesarean surgery. As Francis H. Ramsbotham, the premiere obstetrician in London in the mid-nineteenth century, explained, “no operation in what is called pure surgery, is undertaken without the concurrence of the patient, and I do not know why we should place the obstetric branch of the science on a different footing.”¹⁷ Walter Channing, the most renowned obstetrician in Boston in his day, agreed. He never administered treatment without the permission of the laboring woman. During a particularly difficult birth in 1857, Channing proposed applying forceps, described in that era as an “operative delivery.” He explained why he believed forceps was necessary: “The labor was proceeding slowly. Suddenly contractions ceased. There was slight haemorrhage. Sinking rapidly followed.” Yet the patient rejected his proposal. “She said she was perfectly easy and would sooner die than submit to any operation…She died in a few hours.”¹⁸

Doctors only afforded white women the courtesy of consultation, however. Before the Civil War, most, if not all, black women undergoing cesarean surgery were slaves; they had neither voice nor their own home. In these cases, physicians consulted only with women’s owners before proceeding. In 1863, immediately after one black woman’s second birth by cesarean due to a deformed pelvis likely caused by rickets in childhood, her owner instructed the attending physician to remove her ovaries to prevent a third pregnancy. The child survived; the mother died ten days later of peritonitis. The doctor attributed the deadly infection to the procedure ordered by the mother’s owner—“to render her barren”—rather than to the cesarean.¹⁹

In subsequent years, if a cesarean occurred in the hospital, and by the early twentieth century most did, the level of consent obtained by physicians from either black or white women is less clear. Rather than describe the explicit decision-making process in the medical record, doctors used the passive voice. A physician at the Philadelphia Lying-In Charity Hospital in 1900, for example, noted simply: “An operation was decided upon.”²⁰ A few years later at the Manhattan Maternity and Dispensary a similar notation appeared: “Profuse hemorrhage…Caesarean section was decided upon.”²¹

Ongoing Caution: “Cesareans Were a Super Big Deal”

Whether in the home or hospital, cesareans remained rare well into the twentieth century. Obstetricians continued to take pride in the “conservative obstetrics” that allowed them to avoid a procedure as drastic as cesarean surgery.²² As J. Whitridge Williams, head of the Department of Obstetrics at Johns Hopkins University, admonished his students in 1926: “any one with two hands and a few instruments can do a cesarean section, but…it frequently requires great intelligence not to do it.”²³ Even in the late 1940s, when, at 2.5 percent of births, physicians were performing more cesareans than previously, obstetricians still boasted of their ability to avoid the surgery. One physician, treating a patient suffering from “slight premature separation of the placenta,” consulted a local surgeon. The surgeon’s response outraged him: “[he] advised Section without even doing a pelvic examination!” The obstetrician ignored the advice and the woman “delivered uneventfully.” He was pleased that his intuition had been affirmed: “It took a little courage to say no operation in face of all the knives which were rattling around.”²⁴

In the 1950s, a California obstetrician was similarly inclined to eschew cesareans. He was infuriated that a mother of five, who had given birth vaginally to each of her children, had been forced to deliver her sixth baby by cesarean due to a physician’s diagnosis of a large fetal head and a small maternal pelvis. The California doctor complained, “I don’t understand how in the hell she could deliver a 9+ lb baby previously & then have cephalopelvic disproportion…with this pregnancy.” He was certain the stalled labor had been medically induced—by an almost 400 mg dose of Demerol.²⁵

Doctors’ efforts to avoid cesareans continued well into the following decade. A retired obstetrician explained that when he was a resident in the late 1960s, if a woman had placenta previa he and his colleagues constructed a “double set-up” in the delivery room. They gathered “nurses, and all the instruments…for the cesarean, and…also had a vaginal delivery table in the room.” They did not perform cesareans until they exhausted other options. “Cesareans were a super big deal,” he explained.²⁶

“Tuesday-Thursday-and-Saturday Obstetricians”

Even as American obstetricians’ attitudes toward cesarean surgery remained largely unchanged from the early nineteenth century through the 1960s, the training of obstetricians, the treatments they offered, and how (or if) they obtained patients’ consent for those treatments, underwent significant change. Abraham Flexner’s blistering 1910 criticism of the inadequacy of American medical education initiated the changes. In what eventually became known as the Flexner Report, Flexner reserved his harshest condemnation for the neglect of obstetrics in medical schools.²⁷

With disregard for obstetrics still a problem a decade after Flexner issued his assessment, the American Medical Association’s Council of Medical Education stepped in to remedy the deficiency. In 1921, the Council assembled a Committee on Graduate Training in Gynecology and Obstetrics. The Committee eventually recommended the establishment of three-year, hospital-based residencies in obstetrics and gynecology for training purposes. Founded in 1930, the American Board of Obstetrics and Gynecology (ABOG) became the third medical specialty examining board in the United States, after ophthalmology, in 1916, and otolaryngology, in 1924.²⁸

After creation of the ABOG, the growth of residencies in obstetrics and gynecology was impressive—from 104 slots at 48 hospitals in 1935, to 773 positions in 255 hospitals in 1945.²⁹ As obstetricians came to enjoy the advantages of the hospital setting, the primary site of childbirth transferred from laboring women’s homes to hospitals. While fewer than 5 percent of births occurred in hospitals in 1900, half of all births occurred there by 1939.³⁰ In 1954, when 95 percent of births took place in the hospital, 438 American hospitals hosted obstetric residency training programs.³¹ In their new worksite, obstetricians seized control in a way they were unable to in women’s homes, creating a protocol in hospitals that did not require patients’ consent.³²

The descriptions from obstetricians of routine practice in the 1940s, 1950s, and 1960s capture the contours of the resulting changes.³³ One obstetrician recalled that during his residency immediately after WWII at Chicago’s behemoth Cook County Hospital, he regularly “cleared out a labor line”—comprised of 20 women, 10 on each side of the ward—“by just going along and giving each one a little stab [of Pitocin]…right under the skin, usually in any part, their hands, their butts, their thighs…I would induce all these women into full labor and call a whole corps of interns down to deliver these kids. All of a sudden, seven births would take place at one time.”³⁴ After going into private practice alone—and as the father of two young children—he ensured both reliable office hours and family time on Sundays by earmarking Wednesdays and Saturdays as “delivery days.” Using Pitocin, he explained, “basically you could get the bulk [of births] out of the way and not have to worry about never being home” or canceling appointments with other patients.³⁵ By 1957, the practice had become common enough throughout the country that McCall’s magazine ran an article denouncing the “Tuesday-Thursday-and-Saturday obstetricians” who largely attended only pre-scheduled births.³⁶

The Chicago physician stuck to his routine for forty years. On designated delivery days, he performed gynecological surgeries in the early morning while nurses “prepped” his pre-scheduled obstetric patients. “The prep”—a term used universally by American obstetricians in the postwar era—included shaving pubic hair and administering an enema. “Then I would come from the operating room and would start them off with Pitocin. All of them.”³⁷ After administering “the pit,” he “twilighted” mothers using an injection of scopolamine and Demerol, re-administering the mixture as needed throughout labor.³⁸ As first-stage labor ended, he dispensed a dose of nalorphine to mitigate the newborn’s inevitable respiratory distress. “Because it was the scope,” he explained, using the medical slang for scopolamine, “that really smothered the baby down.” After moving the mother from labor to delivery, he administered general anesthesia, greased the pelvic canal with antibacterial soap, performed an episiotomy, and applied forceps.³⁹

Women confirmed this type of routine, as well as their inability to refuse any of its components. At the behest of the editors of the Ladies’ Home Journal in 1958, mothers sent letters to the magazine describing their recent births. An article described the letters, under the dramatic headline, “Journal Mothers Report on Cruelty in Maternity Wards.” One woman characterized maternity care as a series of “assembly line techniques.” Another protested, “They give you drugs, whether you want them or not.” A mother from Georgia complained, “I was helpless and at their mercy.”⁴⁰

Laboring women voiced similar grievances in ensuing years. One mother, who gave birth in Boston in 1979, refused fetal monitoring, “but the staff insisted I have this before I could use the birthing room.” Because she had looked forward to using the birthing room, nurses’ insistence that she first consent to the monitor was tantamount to coercion. Compounding the unpleasantness, the birthing room was not the positive experience the expectant mother had envisioned. She was forced to labor on her back “strapped to that damn monitor.” Eventually, the doctor cut an episiotomy, “even though I begged and pleaded not to have one.”⁴¹ As another mother said of her hospital birth at around the same time: “nobody even implied that I had a right to question or refuse these procedures.”⁴²

This autocratic approach included the relatively rare cesarean section. One woman, who gave birth to her first child in 1971, entered the hospital in spontaneous labor. Fetal monitors had not been introduced there yet, so nurses periodically checked her baby’s heartbeat with a fetal stethoscope. One of the nurses, unable to detect the heartbeat, summoned a colleague who could not find the heartbeat either. Doctors decided to perform a cesarean section. They did not disclose their plan to the patient, however. Instead, they informed her husband. While someone did ask the patient to sign a consent form, no one told her what she was signing and she did not ask. As she explained years later, she was in labor. Nothing going on around her, or being done to her, was ordinary. Someone asked her to sign something, she signed it. When an orderly wheeled her into the operating room, she was baffled. “I’m going, like, ‘what’s happening?’” A doctor told her, “We’re going to operate.” She was flabbergasted. “WHY?” Even then, no one offered an explanation. “They just ignored me.” She assumed that either her baby had died or that she was dying. No one attempted to reassure her. “It was like I was a non-entity.”⁴³

(Mis)Interpreting the Electronic Fetal Monitor

While doctors were able to skirt consent for most obstetric procedures from the late 1940s through the late 1960s, the electronic fetal monitor, introduced in 1968, initiated another approach to consent—an explicit, but intimidating, means of asking permission to perform cesarean surgery. Monitoring labor was nothing new; birth attendants had always practiced some form of surveillance during childbirth. By the mid-nineteenth century, physicians were using a stethoscope to listen intermittently to the fetal heart rate (FHR) during labor. They theorized that changes in the FHR indicated fetal distress and, depending on the continuity and severity of any change, a quick delivery with forceps might be required. Use of the stethoscope became so integral to obstetric care that, in the early twentieth century, obstetricians created the fetal stethoscope, or “fetoscope.” By the 1950s, however, they had lost faith in their ability to accurately count the fetal heartbeat during labor—the normal FHR of a fetus can, at times, be twice that of an adult.⁴⁴

To replace human fallibility with the theoretical infallibility of a machine, Edward Hon, a Yale University obstetrician, began developing electronic techniques in the late 1950s to continually evaluate and record the FHR during labor. He unveiled his monitoring device a decade later.⁴⁵ The ability of Hon’s electronic monitor to continually record every nuance of the fetal heartbeat seemed so demonstrably superior to intermittent use of the fetoscope that the fetal stethoscope eventually disappeared from maternity wards. “Yeah,” noted one obstetrician who began her residency in 1991, “nobody does that anymore. Zero. I have seen one in Africa.”⁴⁶

The theory behind Hon’s device was persuasive. A machine constantly recording the fetal heartbeat as a mother labored would enable obstetricians to learn instantly of fetal distress, perform an emergency cesarean section, and save a child from the lifelong neurological consequences of in-utero asphyxia. Some obstetricians were so convinced of the inherent value of electronic monitoring that, before conducting any studies, they confidently predicted the machine would reduce by half intrapartum deaths, “mental retardation,” and cerebral palsy.⁴⁷

Although Hon likewise was sure of the utility of his device, he did not intend it to be employed universally, at least not initially. Rather, he characterized electronic monitoring as “fetal intensive care,” implying it should be used only in situations identified by a physician as potentially dire. Hon’s early articles describing his monitor listed the conditions warranting continual fetal monitoring—including amnionitis, Rh sensitization, placental abruption, prolapsed cord, postmaturity, toxemia, and meconium staining.⁴⁸ Despite Hon’s narrow inventory, however, many physicians and hospitals quickly decided that the continual monitoring of all births would be an aid to all fetuses, not just those facing tangible threats. The benefits of the universal employment of Hon’s monitor seemed obvious, the harms nil.⁴⁹

Hospitals adopted the fetal monitor so rapidly that by the time the American Journal of Obstetrics and Gynecology published the first study of the device in 1976, in which researchers randomly assigned laboring women to be monitored either continually by electronic monitor or intermittently by fetoscope, half of all hospital births in the United States were already electronically monitored.⁵⁰ Even more significantly for continued growth in the use of the monitor, no matter the studies, by 1976 all but one of the country’s hospital-based obstetric residency programs employed the technology.⁵¹ In other words, when the first study appeared, members of the newest generation of board-certified obstetricians had already spent considerable time learning how to interpret fetal monitor strips and had come to believe the machine was essential to their patients’ well-being and their own success as physicians. Consequently, they were unconvinced when the article published in the American Journal of Obstetrics and Gynecology demonstrated that the monitor was not only no more effective than the fetoscope, it also increased the cesarean rate dramatically.⁵²

Specifically, whether the electronic monitor continually observed the FHR, or a physician checked on the fetus intermittently with a fetoscope, the newborns of both groups had effectively identical Apgar scores; the same rate of all forms of neurological disability; and equivalent numbers of stillbirths, neonatal and perinatal deaths, and admissions to the neonatal intensive care unit. The sole difference was that the electronically monitored group had a cesarean rate of 16.5 percent; the fetoscope group had a cesarean rate of 6.8 percent.⁵³ By then, however, most obstetricians were not comfortable attending births unless they had access to the information provided by Hon’s device. In 1979, one obstetrician inadvertently admitted that bias. “The benefits of monitoring have already been so great,” he insisted, “that it is unlikely that a truly objective double-blind study in either high or low-risk patients will—or should—ever be completed.”⁵⁴

By then, physicians and hospitals had many reasons to adhere to monitor use. The device eliminated the need for some costly personnel. “It is easier,” one obstetrician observed, “to buy 10 machines than pay 10 nurses.”⁵⁵ An obstetrician who completed her residency in 1977 agreed. “What happened…is that institutions invested so much in the hardware that no matter what randomized trial came out showing the lack of benefit—and virtually all of them did…it was so engrained that we couldn’t get rid of it.”⁵⁶ The machine eventually became so central to obstetric practice that hospital maternity wards were reconfigured to accommodate central monitoring stations so residents could observe many fetal heartbeats simultaneously.⁵⁷

Yet, despite embrace of the machine, of the eight randomized trials conducted from 1976 through 1987—one involving almost 35,000 women—only one study revealed any advantage of the electronic monitor over the fetal stethoscope. That study found that neonatal seizures were twice as likely to occur among infants monitored intermittently with a fetoscope. The significance of that finding became unclear, however, in a follow-up study. A review of infants who had survived for one year after a neonatal seizure found that infants in the fetoscope group and those in the EFM group had similar rates of abnormalities.⁵⁸ And all the studies confirmed the correlation between continual electronic monitoring and higher cesarean rates, three and more times higher in most studies.⁵⁹ Under the perpetual gaze of the monitor, formerly infrequent diagnoses of fetal distress had become commonplace, resulting in a precipitous increase in cesarean births.⁶⁰ Edward Hon summed up his colleagues’ untoward reaction to his monitor: “They’re dropping the knife with each drop in the fetal heart rate.”⁶¹

An obstetrician who started medical school in 1947 knew why. He contrasted his use of the fetoscope with his response to the electronic monitor. He recalled that using a fetal stethoscope, “I would listen to the heart tones after contractions. And [in a roughly 20-year period] I may have done one, two that I can remember, cesarean sections because the heart tones went bad while I was listening.” The electronic monitor, however, issued urgent, seemingly authoritative messages about the fetal heart rate frequently. “You see the abnormalities,” he said, “and you jump at it.”⁶² Another obstetrician recalled that the monitor “made you realize that there were these wide variations that you did not expect to see, these decreases in heart rate that you don’t pick up with a stethoscope…As we started seeing these dips and things all over…it helped increase the section rate a lot.”⁶³ Similar reactions among doctors were soon apparent nationwide. “Every drop in the [fetal] heart rate precipitated a rush…to do a cesarean,” one obstetrician who finished her residency in 1977 remembered. “The rest is history.”⁶⁴

Some obstetricians, however, puzzled by the sudden need for an inordinate number of cesareans, began to scrutinize interpretations of the monitor’s messages. In one of several efforts around the country in the late 1970s, senior obstetricians at one large Chicago hospital measured umbilical cord blood gases after every birth and compared the results with obstetric residents’ interpretation of the monitor strip. And often the pH, oxygen, and carbon dioxide levels in the newborn’s blood bore no relationship to residents’ interpretation of the fetal monitor’s printouts. Attending physicians would then scold residents: “You did an emergency cesarean and the pH of the baby was perfectly normal! And it had Apgars of 9 and 9! So the next time you see that pattern, think!”⁶⁵

Difficulty interpreting electronic fetal monitor strips was by no means unique to that hospital. From the machine’s inception, reports in the medical literature indicated that the meaning of a fetal monitor tracing would not be easy to deduce. Hospitals regularly saw false positive rates of 40 percent for fetal hypoxia.⁶⁶ Initially, physicians assumed insufficient training was the problem. To assure more accurate interpretations, almost a decade before fax machines became workplace fixtures, some hospitals began to send monitor tracings by phone, via a Xerox 400 Telecopier, to experts waiting to confirm a diagnosis.⁶⁷ The endeavor failed to solve the problem, however. Even the most intensively trained specialists agreed on the meaning of a particular pattern only 68 percent of the time.⁶⁸ Misinterpretations remained so common that in 1984, the American College of Obstetricians and Gynecologists (ACOG) issued a terse warning: “Electronic fetal monitoring is highly sensitive but has low specificity.” That is, the monitor strip was adept at indicating when a fetus was tolerating labor well (demonstrating high sensitivity), but did not do a good job of indicating when a fetus was compromised (exhibiting low specificity).⁶⁹

Obstetricians nevertheless persisted in performing cesarean sections based on their interpretation of the machine’s printouts.⁷⁰ One obstetrician trained in the 1990s explained, “In medicine there’s always what they call evidence-based practice, and I think there’s also practice-based evidence.”⁷¹ And as early as the mid-1970s, interpreting electronic fetal monitor strips had become such a vital component of the training and accrued experience of American obstetricians, they were loath to relinquish the messages they had come to rely on for decision-making. One group of academics (a mix of obstetricians, ethicists, sociologists, and anthropologists) point out that during childbirth in the U.S., medical interventions continue to be used even when studies show they do not work. They cite two oppositional themes as driving this behavior—“purity in pregnancy,” when medical interventions tend to be avoided even at the risk of maternal health, and “control in birth,” when medical interventions are used “unreflectively” to deflect “any risk to the fetus, however small or theoretical.” Both inclinations, these researchers contend, “can lead to reasoning about risk that is oriented more by magical thinking than evidence.”⁷²

“That’s Where the Baby Was Damaged”: The Monitor and Malpractice Suits

In addition to the fetal monitor magnifying obstetricians’ perception of risk during birth, the device increased the number of malpractice suits filed against obstetricians. As part of a 1979 Department of Health, Education and Welfare study of the increase in cesareans, the study’s author interviewed dozens of obstetricians. Most cited malpractice threats as the primary reason for the increase. Certainly obstetricians had reason to worry about malpractice costs at that time, if not lawsuits. The National Association of Insurance Commissioners had recently estimated that obstetrician/gynecologists faced ten times the risk of being sued compared to other medical specialists.⁷³ Yet the vast majority of the suits brought against them in the late 1970s was for gynecologic, not obstetric, errors.⁷⁴ And fewer than 10 percent of the obstetric claims were related to cesarean birth.⁷⁵ The few suits at the time that were linked to cesareans stemmed from bad maternal outcomes as a result of the surgery, not from a damaged infant who might have been saved by the surgery.⁷⁶ The nature of those suits seemed to indicate that patients and attorneys still identified cesareans as problems, not solutions.

Yet while malpractice suits against obstetricians for failure to perform a timely cesarean had nothing to do with the initial, precipitous rise in the cesarean rate between the late 1960s and late 1970s—because those suits did not yet exist—the electronic fetal monitor eventually played a role in forging the notion that self-preservation dictated that obstetricians must practice so-called “defensive medicine” in the form of more cesareans. Before the monitor, malpractice suits against obstetricians for any reason were rare simply because a would-be litigant was seldom able to prove negligence. While the use of fetal stethoscopes during labor had allowed doctors to periodically assess fetal wellbeing, physicians’ memories and written notes were the only record of those evaluations. The fetal monitor, on the other hand, provided tangible documentation of entire labors.⁷⁷

With monitor strips as seemingly incontrovertible evidence, medical malpractice claims against obstetricians burgeoned. An obstetrician trained in the 1970s “still grieve[s]” the litigiousness spawned by fetal monitoring. Given the device, she observed, a lawyer could point to a squiggle on a page and claim, “‘Well, that’s where the baby was damaged.’ How do you disprove that?”⁷⁸ Lawyers began to tell juries: if only the obstetrician had been paying attention, and performed a timely cesarean section in reaction to the message provided by the stalwart monitor, lifelong damage would have been prevented and there would be no court case. The pioneer of this type of litigation was John Edwards—eventually a U.S. senator from North Carolina and one-time presidential and vice-presidential candidate. Edwards was instrumental in inventing the claim that a physician’s failure to recognize fetal hypoxia during labor, as signaled by a fetal monitor printout, was the primary cause of cerebral palsy and other forms of neurological damage.⁷⁹

Admirers cast Edwards as the champion of severely disabled children. The Boston Globe described his efforts on behalf of damaged babies as going “beyond a recitation of his case to a heart-wrenching plea to jurors to listen to the unspoken voices of injured children.”⁸⁰ He often stood before juries, playing the role of the fetus in the womb begging to be let out before it was too late. Juries responded sympathetically, allowing Edwards to amass a personal fortune of thirty-eight-million dollars, win at least 205 million dollars for his clients, and almost single-handedly create the concept of failure to perform a cesarean as a valid medical malpractice claim.⁸¹

Yet most, if not all, of his lawsuits were without merit. Cerebral palsy occurs almost exclusively during fetal development, or because of extreme prematurity, rather than as the result of an untoward event during a full-term birth. That is why, despite a more than five-fold increase in cesarean sections since the advent of the near-universal use of the electronic fetal monitor, the incidence of cerebral palsy, at one in 500 births, has remained unchanged.⁸² Nevertheless, by the mid-1990s, 60 percent of malpractice premiums paid by obstetricians went to cover allegations of cerebral palsy caused by failure to perform a cesarean.⁸³ The successful claims ensured that cesarean sections would become one of obstetricians’ primary strategies to immunize themselves against lawsuits.⁸⁴

If some obstetricians were nervous before Edwards launched his litigation tactics in the mid-1980s, his success in the courtroom universalized their anxiety, as if by contagious infection. “There is no question,” one obstetrician observed, “it’s had a steady incremental effect on how conservative obstetricians are in their practices.”⁸⁵ This physician’s use of the word “conservative,” however, denoted a change in meaning since the 1950s. While in earlier decades, “conservative” obstetricians employed every skill at their disposal to avoid a cesarean, by the late 1980s they performed a cesarean in the face of even niggling doubt about the trajectory of a birth.

“They Said Her Heart Was in Distress”: Monitoring and Consent in the Late-Twentieth Century

For many women giving birth in the 1970s, the routine use of the fetal monitor was an unexpected development, and they were unprepared for its consequences. Until then, cesareans had been so rare that most women did not anticipate the possibility of a surgical birth. The experience of one mother, who gave birth for the first time in 1976, illustrates how monitoring triggered a cascade of events: the heightened perception among obstetricians, and later mothers, of risk in childbirth; the increase in cesarean sections; and a new approach among obstetricians to consent for this surgery.

The twenty-year-old expectant mother entered the hospital in spontaneous labor. A doctor ruptured her amniotic sac. “I went,” she said, “from feeling nothing to being totally in excruciating pain.” Nurses attached her to a fetal monitor. Shortly after, physicians relayed frightening news. “They said I had to make a decision because they said either that I would die, or my baby would die, or both of us would die, if I didn’t have a cesarean…They said her heart was in distress.” She was stunned. Her pregnancy had been trouble-free. “I walked. I exercised. I really felt good. And it just seemed like this diagnosis came out of nowhere.” She tried to stay calm “but I think I just felt disoriented to what was going on and I was feeling stress with the fetal monitor and the conversations.”

She consented to the cesarean. “That’s something I guess I’ll never forget…that the baby would die, or I could die, or both of us…What they were saying, it just didn’t seem right.” The edict issued by doctors in 1976 seemed even less right to her when she described the birth twenty-eight years later. “Since then, of course, I’ve read these books that said that half of them [physicians] don’t know how to read [the monitors].”⁸⁶

Although doctors had presented the young, first-time mother with a dilemma she had not anticipated—and that continued to disturb her almost three decades later—her quandary soon became a common one for laboring women. With the advent of electronic fetal monitoring, obstetricians confronted many mothers who were in the throes of labor with a prediction of serious risk to their babies if they continued to labor and give birth vaginally. One nurse witnessed such a scene in the early 1980s. A monitor signaled fetal distress. A doctor told a laboring mother that the baby had to be born immediately. The mother consented to a cesarean section. The baby was born “healthy, pink.” It was not fetal distress, the nurse complained later, “it was physician distress. And now I’m distressed from working at this hospital.”⁸⁷ Yet, as this nurse’s protest implied, the fetal monitor’s perceived messages were as upsetting to doctors as to patients.

Physicians’ monitor-induced stress prompted them to steer mothers toward cesarean surgery. Rather than the collaborative approach to consent common in the nineteenth century, or the mid-twentieth-century approach that largely eschewed patient consent, doctors responded to disturbing monitor strips by issuing veiled threats to laboring women—do you want to risk damage to your baby’s brain, or a threat to its very life, or do you want a cesarean section? Physicians used their professional authority to ensure women would respond with only one answer. As one obstetrician observed wryly, “I think if you told a mother that you’d have to cut off her arm to get a healthy baby she’d say, ‘Go ahead, just give me anesthesia.’”⁸⁸ One woman who had undergone particularly traumatic cesarean surgery confirmed that sort of observation: “mother’s overwhelming focus is on the safe delivery of her baby and, to that end, mothers will allow significant injury to themselves.”⁸⁹ As this physician and mother implied, women would always consent to cesarean surgery, given how doctors framed the consequences of refusing it. And as more women gave birth by cesarean, pregnant women began to anticipate the distinct possibility of cesarean birth, as well as the notion that the surgery mitigated the seemingly omnipresent risks of vaginal birth.

Cesareans Increase Despite Embrace of Birth Reform

The greatest irony of the normalization of cesarean surgery is that the most precipitous increase, occurring between 1970 and 1985, paralleled the peak militancy, and greatest successes, of the birth reform movement emanating from second-wave feminism.⁹⁰ In response to the technocratic approach to childbirth developed in the 1940s and 1950s, a largely white, college-educated audience of pregnant and aspiring-to-be-pregnant women began purchasing books in the early 1970s bearing such titles as: Spiritual Midwifery and Immaculate Deception: A New Look at Women and Childbirth in America.⁹¹ Some women worked with feminist organizations that were focused on eliminating the chauvinistic approach to gynecologic and obstetric care. Many expectant mothers began attending childbirth education classes. The classes, activists advised, would enable women “to resist the hospital routine of medication and interventions.”⁹² Reformers characterized childbirth as a physiological event, “part of the natural order of things,” that pregnant women should approach “matter-of-factly, instinctively, and without fear.”⁹³ Birth reform organizations burgeoned, giving rise to Birth Day in Cambridge, Massachusetts; the International Childbirth Education Association headquartered in Seattle; the Midwives Alliance of North America; and The National Association of Parents & Professionals for Safe Alternatives in Childbirth, to name a few.⁹⁴

Initially, the rapid rise in cesarean sections did not appear on the list of feminist activists’ healthcare grievances. Even the 1976 second edition of the best-selling feminist health manifesto, Our Bodies, Ourselves, described the surgery as only “occasionally” performed “in the case of a very long, hard labor that seems to be accomplishing little.” Although the cesarean rate had more than doubled (from 4.5 percent in 1965 to 11 percent in 1975) in the decade before release of the 1976 edition of the book, even the otherwise defiant Boston Women’s Health Book Collective, author of Our Bodies, Ourselves, commanded readers, “If the doctor recommends a cesarean section, you must trust that judgment.”⁹⁵

By the time the increase in cesareans did appear on activists’ radar, it was too late for orchestrated protest. Although one grassroots organization focusing on the growing number of cesareans—Cesareans/Support, Education, and Concern (C/SEC, Inc.)—appeared in 1973, most did not emerge until after the influence of birth reform organizations had ebbed.⁹⁶ While advocates for birth reform had hoped their fight would culminate in birth as a woman-centered experience, unfettered by medical interference unless treatment was necessary, by the 1980s, birth reformers were not getting the focused publicity they once had enjoyed and their vision never came to full fruition. Anti-cesarean voices went largely unheard in this environment.

As more women gave birth by cesarean, pregnant women began to anticipate that during labor an electronic fetal monitor might very well issue a message signifying their fetus faced imminent harm. And unlike women giving birth in the earliest days of fetal monitoring, members of a subsequent generation were more likely than not to express gratitude for both the warning and their cesarean birth. After one woman’s obstetrician ruptured her amniotic sac during her first birth in 1984, the fetal monitor indicated her baby’s heart rate was fluctuating between 60 and 140 beats per minute. The obstetrician told her “We’ve got to get this baby out of here.” She responded unhesitatingly, “just do what you need to do.” Afterward, she harbored no doubt that the surgery had been necessary and beneficial. “We got him out. We got him healthy. We didn’t lose me. We didn’t lose him. Everything was fine.”⁹⁷ Another woman who had two cesareans in the 1990s similarly viewed both surgeries as “saving me and my babies.” She explained, “I really do feel strongly that I would have been one of those women who would have died in childbirth. I feel that…based on the fact that he [the doctor] said that I have small pelvic bones.”⁹⁸ As the incidence of cesarean section increased, due in no small part to the electronic fetal monitor and its link to the malpractice climate and approaches to consent, both obstetricians and mothers became acculturated to the idea that risk was omnipresent during labor and that major abdominal surgery mitigated the risk.

Conclusion: The Normalization of Cesarean Section

J. Robert Willson—an obstetrician who eventually held a host of leadership positions in his specialty, including presidency of the ACOG and directorship of the ABOG—reminded colleagues in 1953 that maternal and neonatal morbidity and mortality had been reduced over the decades by eliminating medical procedures that increased the possibility of infection, not by performing more procedures.⁹⁹ Nevertheless, obstetricians today identify not intervening as the risk. The electronic fetal monitor and its consequences—including obstetricians’ dubious interpretation of its messages, a heightened perception of risk, and the malpractice climate resulting from the “evidence” that monitor strips provide to malpractice attorneys—prompted obstetricians to use consent as a means of ensuring that women would agree to cesarean surgery each time it was offered to them.

For almost forty years, obstetric texts have reflected this normalization of cesarean birth. The authors of the 1980 edition of Williams Obstetrics noted, “In modern obstetric practice, there are virtually no contraindications to cesarean section.” Simultaneously, the same authors sprinkled the contraindications to vaginal birth throughout the text, in “recognition of [fetal] impairment, actual or suspected,…if…vaginal delivery were attempted.”¹⁰⁰ The onus of risk had transferred from cesarean surgery to vaginal birth.

Certainly some increase in cesareans has been warranted. The risk of cesarean surgery diminished significantly between the first decades of the nineteenth century and 1950, rendering the surgery far safer. By the post-WWII era, the medical innovations advancing surgical practice were legion—anesthesia, asepsis, improved surgical techniques, antibiotics, and the ability to store and transfuse blood. Yet even in the mid-1960s, obstetricians’ attitude toward cesareans had not changed significantly in the face of diminished risk. The cesarean rate remained modest, despite an increase. The dramatic rise came later, suggesting the bulk of the upsurge can be attributed to something other than medical need. This article argues that a change in how obstetricians obtained consent to perform a cesarean, prompted by the malpractice environment and public and medical perceptions of risk due to the electronic fetal monitor, was a significant contributor to the increase.

Thus far, physicians and hospitals have proved stubbornly resistant to changing the practices and moderating the attitudes that maintain the high cesarean rate. While medical deliberation dominated the first half of the cesarean story—from the early nineteenth century through WWII—with physicians determinedly keeping the rate low and taking pride in the skills allowing them to do so, the most recent portion of the cesarean story has been dominated by experimentation. Helen Marieskind, the author of the 1979 U.S. Department of Health, Education and Welfare study on the increase in cesarean sections, summed up the contemporary approach to cesarean surgery that still prevails: “Caesarean section appears to be a sometimes useful and much needed technology presently utilized in an undocumented, unclarified, and uncontrolled manner.”¹⁰¹ Introducing the electronic fetal monitor without any proof of efficacy, and ignoring subsequent studies demonstrating the technology was largely ineffective and increased the cesarean rate considerably and unnecessarily, exemplified that trend.

Using their professional authority to warn laboring women of dire consequences if they balked at a recommendation for cesarean surgery, obstetricians normalized cesarean birth. Given how doctors framed the cost of withholding permission for the surgery, women invariably offered their consent. The starkly different approaches to obtaining mothers’ consent in the nineteenth versus the late twentieth century did share one motive, however. In the nineteenth century, because doctors insisted that all present agree to the cesarean before proceeding, when a mother did die, which was more likely than not, the physician’s reputation remained intact. The burden of a bad outcome was a shared burden. In the late twentieth and early twenty-first centuries, steering a woman toward consenting to cesarean surgery similarly protected obstetricians’ reputations. As an obstetrician practicing in the western United States noted: “You don’t get sued for doing a C-section. You get sued for not doing a C-section.” During both eras, the actual and perceived risks posed by childbirth drove physicians to seek consent for performing cesarean surgery in starkly different manners albeit for the same reason—to preserve their reputations.¹⁰²

FUNDING

National Institutes of Health/National Library of Medicine Scholarly Works in Biomedicine and Health Grant # G13LM010878 funded this article.

Acknowledgements

I am grateful to Paula Michaels, Chris Crenner, Steve Miner, Katherine Jellison, Paul Milazzo, and Wendy Kline for their helpful comments on previous drafts of this article.