After a traumatic C-section, journalist takes on the medicalization of birth

Transcript

TONYA MOSLEY, HOST:

This is FRESH AIR. I'm Tonya Mosley. When journalist and professor Rachel Somerstein had an emergency C-section with her first child, the anesthesia doctors gave her didn't work. The experience was a nightmare. She could literally feel the operation as it was happening. It was an excruciating experience that left Somerstein traumatized and in search of answers on how something like this could happen. Somerstein's search led her to some surprising history. Today, 1 out of 3 babies in the U.S. is delivered through C-section. And while this medical procedure is one of the most significant advancements in medicine - one that has saved countless lives - cesarean section, Somerstein writes, is not without significant and sometimes life-changing consequences.

Rachel Somerstein has written a new book titled "Invisible Labor: The Untold Story Of The Cesarean Section," which explores the history and controversy surrounding the operation. The book delves into some of the current-day failures of the medical system, emerging research on the way C-sections impact both mother and baby and why we're seeing an increase in them. Rachel Somerstein is an associate professor of journalism at SUNY New Paltz. She's written for several publications, including The Washington Post and Wired.

Rachel Somerstein, welcome to FRESH AIR.

RACHEL SOMERSTEIN: Thank you. Thank you so much for having me.

MOSLEY: Rachel, can I have you read a description that you give of exactly what a C-section entails?

SOMERSTEIN: Unplanned or scheduled, the operation is usually the same. An anesthesiologist or nurse anesthetist uses spinal anesthesia, known colloquially as a spinal or an epidural, to anesthetize the mother regionally. Use of regional anesthesia is very important, not only because it means the mother can be awake during the birth, but because it is much safer than general anesthesia. Then the surgeon uses a scalpel to cut open the abdomen above the mons pubis, slicing through layers of skin and fat and the fascia that covers the abdominal muscles.

The physician parts but does not cut the rectus abdominis muscles, the six-pack, with her hands. Then she cuts through the peritoneum, the layer of tissue that contains organs in the abdomen, as if in a tightly sealed bag. She moves the bladder aside to reach the uterus, making yet another incision to open it. She presses on the uterus to push out the baby, the source of the pressure C-section moms are told they might expect during the operation. Once the baby is born, the surgeon removes the uterus from the patient's body, sometimes lifting it out completely like a bowling ball, to sew it closed. Then she sutures the other layers of the patient's abdominal wall and finally closes the topmost layer.

MOSLEY: Rachel, I wanted you to read that because it puts into perspective what you went through when you had your first child without anesthesia. And first of all, I'm sorry that that happened to you.

SOMERSTEIN: Thank you for saying that.

MOSLEY: Can you describe what happened to you, starting with the decision, after 24 hours of labor, to perform a C-section on you?

SOMERSTEIN: Sure. So if it's OK, I actually would like to start with the labor because I think that that's important. When I got to the hospital, the providers who were taking care of me did not really seem to believe the level of pain that I said that I was in. And I should say that I have a very high tolerance for pain. I don't usually scream when I'm in pain. And it turned out that I was having back labor, and that's why it was so incredibly painful and the contractions just would not stop. It was like bam, bam, bam.

MOSLEY: And when you say back labor, for those who don't understand what that means, what do you mean?

SOMERSTEIN: So it just means that the baby was positioned in a way that makes it harder for her to be born vaginally. And that also causes the person, the laboring person, to feel pain in their back. And it's excruciating pain. And it's common. You know, I think that the estimate is that it happens in about 1 in 5 births. You know, the sense seemed to be that I was exaggerating when I said I was in a lot of pain. And I asked for an epidural and the anesthesiologist was not available, so I was told, which maybe they were trying to put me off for a bit.

MOSLEY: This is something common, though, that many women do here when it comes to ordering anesthesia, that it takes a while and sometimes a person will never arrive, the anesthesiologist.

SOMERSTEIN: Yeah. And, you know, there can be lots of reasons for that. I mean, right now, you know, hospitals may not have that many anesthesiologists available. They may not have, depending on the hospital, someone who's committed specifically to labor and delivery. You know, this might be somebody who's serving the entire population of the hospital. So eventually he arrived. And I got, you know, hooked up to all the monitors, which monitor contractions and the baby's heart rate. And once I was hooked up to the monitors, that was when some of the providers were like, oh, you really are having these monster contractions. At that point they believed me because the computer said. And it at the time was remarkable to me that a computer would have more authority than me.

Eventually, when it was time for me to push, my daughter's heart was decelerating. She was having decelerations, which means that her heart rate was going down and not coming up in a timely way. And I should say, like, a baby's heart rate goes down with every contraction. That's a part of labor. But it is a potential concern if the decelerations take a long time to recover or don't recover a regular heart rate. And the midwife put her face close to mine and said, I think it's time to do a C-section. And I was so scared. I was not at all prepared for the possibility of a surgical birth. I had not read anything about it. I was convinced I would have a vaginal birth.

And I should add that, you know, during the labor, I felt really abandoned by many of the providers. I don't recall being told, like, you can do this. I certainly was not put into positions that would have helped the baby come down in a, you know, timely way. And I know that because I've since had another baby and I've experienced a different kind of care. So I was scared. My husband was with me. And then we went into the operating room. And I was saying things like, I'm afraid I'm going to die and my baby's going to die. And the mood in the room was really that I was hysterical.

MOSLEY: They were dismissive.

SOMERSTEIN: Yeah. Like, oh, my God, you know, this lady. And from their perspective, C-sections are a really common surgery and they happen all the time. And they're mostly safe. So you can see maybe why people would kind of have that outlook. It was 1:30 in the morning. I was exhausted, I'd never had a baby before and this wasn't how it went, according to the books I'd read or, you know, the movies I'd watched.

MOSLEY: When did you realize that you were going to feel what was happening to you?

SOMERSTEIN: Well, when I was in the operating room, they gave me a spinal anesthetic and laid me down on the gurney. And when - you know, there's a drape that's rigged so that you don't see what's happening. So I don't know exactly at what point I felt what was happening, but I expect it was, really, the very beginning. And I said, I felt that. And the surgeon, who I'd met once before - I did an OB visit - he said, you know, you'll feel pressure. And I said, I felt that. And he just kept going.

MOSLEY: What happened next?

SOMERSTEIN: So my legs were kicking. I don't remember it, but my husband says that I was moaning. And eventually the baby was born. I don't remember that, either.

MOSLEY: You don't remember your child being born.

SOMERSTEIN: No, I don't. And that might be from the shock. It might be because they gave me a medicine that can cause memory loss. I don't know for sure. And then they brought the baby to my face. This is from - my husband tells me that they brought her right to my face and said, here's your baby. And then they sent him off with her. And then they put me under general anesthesia and sewed me up. And I woke up in recovery. I think the doula was holding the baby to my breast so she could nurse, and I heard the doula say, a good latch. But no one knew I was awake. Nobody asked me if I wanted to nurse. And my eyes were closed, and I wanted to not be near my baby. And I, for a long time, felt very guilty about that because how could I send her away? She was just born. And then later I understood that that was so insightful and protective of me because I didn't want to associate her with what I was feeling.

MOSLEY: Let's take a short break. If you're just joining us, my guest is Rachel Somerstein. She's an associate professor of journalism at SUNY New Paltz and has written a new book called "Invisible Labor: The Untold Story Of The Cesarean Section." In the book, Somerstein explores the medical, social and cultural history behind the operation, which is the surgical delivery of a baby through an incision made in the birth parent's abdomen and uterus. Somerstein investigates why we've seen an increase in the procedure over the decades. We'll continue our conversation after a short break. This is FRESH AIR.

(SOUNDBITE OF SOLANGE SONG, "WEARY")

MOSLEY: This is FRESH AIR. And today I'm talking to author Rachel Somerstein, who has written a new book called "Invisible Labor: The Untold Story Of The Cesarean Section." Somerstein experienced an unplanned C-section with her first child. A series of errors by her clinicians led to what she calls a real-life nightmare. She had the surgery without anesthesia. Somerstein is an associate professor of journalism at SUNY New Paltz. She's written for several publications, including The Washington Post and Wired.

The lack of anesthesia during your C-section was a mistake. Did they give a reason?

SOMERSTEIN: Well, this was pretty disappointing. After the fact, there's somebody who came to my room and told me that my body hadn't processed the anesthesia correctly, that there was something wrong with me. And in the off chance that that would be true, to tell a patient that it's her fault that she experienced the pain she experienced is abusive and especially so soon after, right? It's not like, OK, it's been six weeks. I'm ready to have a conversation. What do I need to know for my future health and medical experiences to be safe? This was blame. I do have to say that the anesthesiologist whose mistake it was came to my bedside and apologized, and he looked ashen. And that was probably one of the bravest things that he could have done as a professional because it opened him up to potentially to litigation. And I felt no desire to sue him because he apologized to me and he recognized the harm he had caused me, and he met me as a human from his human self.

MOSLEY: You did consider it, though, because lots of people asked you, are you going to sue? But you came upon a challenge even when you started to look into it. Lawyers wouldn't even talk to you.

SOMERSTEIN: Yeah. At a certain point, it became clear to me how seriously I had been affected by the birth. And, you know, friends of mine were like, you should really sue for this, not about getting money but because it was so wrong. And when I tried to find a lawyer to represent me, you know, because I didn't - thank goodness - experience or suffer from any long-term physical damages and neither did my daughter, we didn't really have a case. And I probably could have continued looking, but the truth is that I didn't even know if I wanted to go through with it. I wanted justice. I didn't know if I wanted to put my energy into a lawsuit, and instead I wrote a book. And I hope that that helps people more than a singular lawsuit, which probably would have ended in a settlement with some non-disclosure agreement around it.

MOSLEY: How often does this happen - a person going under anesthesia for a C-section and feeling, actually, the C-section?

SOMERSTEIN: So what's interesting about this is that only recently have researchers begun to look into that, and it seems to be about 10% of births. And I should say that what's important is that includes a range of experiences of pain. That can be people who feel pain just in the beginning and then the providers adjust their anesthesia accordingly. That could be people who start to feel pain in the - during, like, the middle of the operation. That could be people who feel mild pain, and that could be people like me.

MOSLEY: There's a poignant part in the book where you talk about pain and how pain, in the context of childbirth, is seen as closely tied to ecstasy because in the end, it's worth it. You have this beautiful child. But when the pain is too much, like the outcome of a C-section, it's actually seen differently, which - I just thought that was a way to put it that I had not considered before.

SOMERSTEIN: Yeah. And I think that this idea goes along with expectations around mothers, which is that sacrificing yourself for your children is worth it, whatever that sacrifice could be, and that that's your responsibility. And to suggest or to speak against that is dangerous. I mean, that goes against not only expectations around motherhood, but even right now our legal framework puts fetal rights - not even baby or children's rights, fetal rights - in some cases over the mother.

MOSLEY: Rachel, I want to talk for a moment about the history of C-sections. I was just curious to know the connection between the name itself and Julius Caesar. We've heard that it might have been named after him, but was it really named after him, and why?

SOMERSTEIN: So that's a great question. It's probably a misnomer, or it's probably wrong that this belief that C-sections come from Julius Caesar being a C-section baby. There's two ways to understand that, you know, the first is that at the time, mothers really didn't survive their operations. The procedure wasn't really practiced on mothers expected to survive birth. And we know that his mother lived to see his return.

MOSLEY: When was the earliest known C-section and what did it exactly entail?

SOMERSTEIN: So it sort of depends if you're talking about C-sections practiced on a person expected to survive. And those really probably can be traced to the late 1700s, early 1800s. By that point, it was an operation that would be used as a way to rescue a mother and her baby from an otherwise hopelessly obstructed labor.

MOSLEY: Because prior to that, it was used, but in another way. It wasn't necessarily for that purpose.

SOMERSTEIN: Right. So prior to that, there were C-sections done on dead women or who were pregnant or in labor who died in labor, or people expected to die during labor. And the reason was so that their babies would have an opportunity to live even briefly and be baptized by the Catholic Church. And I think one thing that's so interesting about this history to me, is that it shows that the forces promoting C-sections have always had something to do with an external pressure. It's not just about what's happening to the birthing person. There's something else at stake.

MOSLEY: And in the late 1700s into the 1800s when we started to see this procedure to help save the mother and the child, you write about a physician who pioneered them in the U.S., a French-born slave master. What did you learn about the ways that he would perfect this as a procedure to save lives?

SOMERSTEIN: Sure. So this is another example of how external forces promoted the operation. And I should say, just to be totally clear, at this time, when we're talking about babies who couldn't make it out of the birth canal, like, they were really stuck. So the options available at the time to physicians were either to let the baby and the mother die to - and I should say to midwives too, because they were the practitioners.

MOSLEY: A big part of this, yes. They were - the majority of them. Yeah.

SOMERSTEIN: The majority. Thank you. Yes. Or to do an embryotomy or a craniotomy, which are procedures so the fetus could fit through. And these were really horrifying, arduous procedures. We have descriptions of them from the 1800s that are awful. And so there would be, like, a human desire, obviously, to find another way. So Prevost, the slave master and physician who was educated in France and came to the United States - he practiced the procedure on enslaved women. And he did that in cases where, you know, the labor was obstructed, like - right? - that the baby wasn't coming out. But when we look at the records of who had C-sections in the United States during this period of time of the early to mid-1800s, it's disproportionately enslaved women because they had no agency. They couldn't say no. They couldn't say, I prefer if you would do a craniotomy. And he would do this without anesthesia.

MOSLEY: Let's take a short break. Our guest today is Rachel Somerstein, author of the new book, "Invisible Labor: The Untold Story Of The Cesarean Section." We'll be right back. I'm Tonya Mosley, and this is FRESH AIR.

(SOUNDBITE OF HARRY CONNICK JR.'S "VOCATION")

MOSLEY: This is FRESH AIR. I'm Tonya Mosley. And if you're just joining us, my guest is Rachel Somerstein. She's an associate professor of journalism at SUNY New Paltz and has written a new book called "Invisible Labor: The Untold Story Of The Cesarean Section." In the book, we learn that 1 in 3 babies is born via C-section, a rate that has grown exponentially over the last 50 years. As Somerstein writes in her book, while the procedure is often used to save both the mother's and the baby's life, it sometimes comes with life-changing consequences, and mothers are often left to navigate the complications alone. Somerstein experienced an unplanned C-section with her first child. A series of errors by her clinicians led to what she calls a real-life nightmare. She had the surgery without anesthesia.

In thinking about what we're seeing today, overall, C-sections are more common, and there's an increase in them. But there's also something else we're seeing. Women of color are also more likely to have C-sections. And do you have an understanding of why that is the case today?

SOMERSTEIN: So the simple answer is racism. There's nothing biological about women of color that makes them more likely to have a C-section. So that's, like, the most important thing to put out about these disproportionate rates. And if we break it down, you know, that happens because of so many different kinds of racism. So we can think about, for instance, the social determinants of health. So that's everything that shapes your health before you get pregnant even, and of course during pregnancy - whether you have insurance, what kind of community you live in, how much money your family has, where you go to school. And it includes also access to midwifery care. And midwives are - when we're talking about particularly caring for people who are low risk in their pregnancies, you know, that's a way to ensure a better outcome and also promotes vaginal birth. And Black women have less access to midwives than white women. And that's not because of lack of desire. There's the gap between - I mean, there's not enough midwives, period, for the demand in the United States. But the gap is largest for Black women's demand versus availability. And that is a social determinants of health. Right? If you have no choice but to see an OB who, by dint of training, is more likely to do interventions that are more aggressive, perhaps, than a midwife who has a different kind of training and a different kind of professional ideology, then you might end up having a C-section that, with a different provider, could have been avoided.

MOSLEY: How did we even come to this? Because basically you write about how birthing in America used to happen at home with midwives. Midwives were very common. And I want you to just slow down for a moment, because this is a very important point in turn in our history. Because at some point it began to change. Now the majority of births in America happen in hospitals. What was it like in that time period when midwives were at the center of helping a woman through her birth in the United States? And when did it begin to change?

SOMERSTEIN: So it was really different. Childbirth was much more social and community-oriented. So you'd be attended - and I'm speaking here about free people, not enslaved women per se - but you'd be attended by a midwife. You'd be attended by the community of women in your town, the women in your family, your friends. And these were women who had a lot of knowledge about babies. I mean, in 1800, in the United States, the average birth rate was - I believe it was eight children per woman. And that doesn't include pregnancies that ended in miscarriage or stillbirth. I mean, people - women were pregnant for the majority of their lives once they were married. And those numbers were higher, of course, for enslaved women. And, you know, midwives had so much knowledge that now would not really count as knowledge in the same way as it did then. So anything from massages or helping people into positions that would help ease the baby down, singing, bringing in teas or bombs, there was food, you know, you think about now, most the majority of people in the United States have a baby in the hospital. And one thing you're told most of the time is you can't eat. And you need energy, right? I mean, it's like running a marathon. And the reason is in case you need to be intubated, right? If you have a C-section and you need to be put under general, that's why you're told not to eat. It's safer if you have an empty stomach. But again, at the time people would make things called groaning cakes to eat and to share. And also, I should say at the time, the majority of midwives were Black or immigrant or Indigenous women. And today midwifery is transformed into a profession that is predominantly white, although that's changing and it's perceived as being for white women, even though midwifery is for everybody.

MOSLEY: You spoke with a sociologist, Barbara Katz Rothman, who talks about this shift towards medicalizing birth, and she wanted to make a point, and we should make a point that, C-sections have helped save many lives, and medical advancements in birthing has helped save many lives, the lives of mothers and babies. But she says this shift towards medicalizing childbirth and doing away with midwifery almost exclusively outside of this medical setting is biomedical imperialism. And I would love for you to explain her theory. Also understanding that she feels medical imperialism has done a lot of good.

SOMERSTEIN: Yeah, and I really appreciate you putting that context because sometimes the conversation around birth ends up seeming so polarized. And, you know, C-sections are bad, and we shouldn't do them. Medicine is bad, and we shouldn't have any of it. Or the opposite - natural is bad. Nature is not the way to go. Or, you know, non-evidence-based therapies, like, are not the way to go. But really, I think that understanding the nuance of what's the benefits and the drawbacks to medical imperialism is really important and about C-sections, too.

Basically, her argument is that when birth came into the hospital, which we're talking about, really, turn of the century, 1920s. This is an era when science was the national mood - tremendous faith in what medicine could do and what technology could do. This is the era of modernism. You know, life expectancies rose dramatically from the beginning of the 20th century to the 1940s because of changes and improvements to filtration systems of water. We had the development of vaccines. Ultimately, the discovery of antibiotics - I mean, these things have transformed humanity and saved so many lives. So the faith was with the scientists and with the physicians.

However, as people moved into the hospital to have babies, they then got separated from their communities and these midwives, who had really generations of knowledge accumulated - when medicine took over birth from midwives, and I should say, actually, when doctors in a hospital took over birth from midwives, they fenced off what counts as authoritative knowledge and got rid of everything else, right? Only knowledge considered knowledge through a scientific lens is useful. But we got rid of things that really do matter and that are not easily visible or quantifiable things that now actually were recognizing, for instance, a doula can provide. You know, social support, encouragement, techniques during labor to help a person get her baby into the right position for a vaginal birth.

MOSLEY: Let's take a short break. If you're just joining us, my guest is Rachel Somerstein. She's an associate professor of journalism at SUNY New Paltz and has written a new book called "Invisible Labor: The Untold Story Of The Cesarean Section." We'll continue our conversation after a short break. This is FRESH AIR.

(SOUNDBITE OF THE AMERICAN ANALOG SET'S "IMMACULATE HEART 2")

MOSLEY: This is FRESH AIR. And today I'm talking to author Rachel Somerstein, who has written a new book called "Invisible Labor: The Untold Story Of The Cesarean Section." Somerstein experienced an unplanned C-section with her first child. A series of errors by her clinicians led to what she calls a real-life nightmare. She had the surgery without anesthesia. Somerstein is an associate professor of journalism at Suny New Paltz, and she's written for several publications, including The Washington Post and Wired.

Rachel, you document in the book some of the potential long-term impacts of C-sections, all of which are really still being studied. So a lot of what we're going to talk about is emerging science. But one of the things you write about is research that finds a mother who has had a C-section is actually less likely to have more children. Can you explain why?

SOMERSTEIN: This can be really devastating for people. For a long time, researchers have known that C-sections are associated with having fewer children. And there was a belief that, well, to explain that maybe, you know, people who have C-sections don't want more children. But in a way, the operation ends up being this sort of unexpected mode of family planning - like an unexpected way of planning the number of children you'll have. So there's a lot of reasons for that. To start, a C-section elevates the likelihood of having problems with the placenta in a future pregnancy, and those can be really serious conditions. There's research that having had a C-section makes it less likely that you'll conceive again. So there's this really interesting study from the NIH called the first baby study, where the researchers interviewed women and birthing people before they had their first baby, and then after they had their baby, and then subsequent to that, to see how many children they wanted to have and whether the birth and how the birth, if the birth changed that. And then what did they do? You know, did they end up having more children? And the researchers found that people who'd had a C-section, even though they actually tried harder to conceive, meaning they had more frequent unprotected sex, were less likely to be able to conceive another baby.

MOSLEY: Why?

SOMERSTEIN: There's really not good explanation or evidence for this, right? So we can only speculate at this point. But when you go to have a baby and the way that we talk about a C-section, the ways that a C-section will complicate and perhaps make it less likely to have future pregnancies is really not part of the conversation. And I think the other way that this happens, I should say, is, you know, each subsequent C-section gets more dangerous. So by the time a person is having a fourth C-section, the dangers to the birthing person are much greater, you know, in terms of having a severely bad outcome.

MOSLEY: What have been some of the long-term impacts of your C-section?

SOMERSTEIN: Well, I developed PTSD, and what that means for me is that I get really nervous when I go to the doctor, and especially if it's a new provider who I don't know. I have a hard time trusting people in medicine. I try to remind myself of all the providers who've helped me before I go see somebody, because there's so many people I've seen who've taken really good care of me and helped me and listen to me. You know, I used to have a really hard time around my daughter's birthday, and that's really finally improved. You know, she's 8. And, you know, it also affected how long I waited to have another baby. And I think that I would have had a third baby if I hadn't had this birth. Maybe I wouldn't have. I can't say absolutely. You know, I have a wonderful family. I just want to say. I love my children so much. They are the absolute joy and sunshine in my life, and I wish I'd had one in between my daughter and my son, and I didn't.

MOSLEY: OK, we have to end by you telling us the story of your second birth, because there's one moment during your labor that you thought you might actually need to have another C-section, but then something happened. Can you take the story from there?

SOMERSTEIN: So I was pushing. I had elected to have a vaginal birth after a caesarean. And I was pushing, and I could tell, I could feel, that the baby was not lined up to come out vaginally. And I was like, well, we did our best. This is why there are C-sections. And I wasn't thrilled, but it didn't feel like a catastrophe. And my midwife, she said, is it OK with you if I try to turn his head? And she explained that his head was kind of cockeyed and the angle wasn't - it just wouldn't - he wouldn't fit with his head at that angle. And she tried, and it didn't work because her fingers weren't strong enough.

And then she went and she got the obstetrician. And she explained to him, this is what I'm trying to do. And at first he groaned and was like, oh, you know, there's a higher risk. And she said, will you do it? And he said, OK. And he said OK because they have a really good working relationship. They've worked together for more than 17 years. He trusts her authority and her expertise, and she trusts him.

And he came in and he was able to turn my baby's head, and then he just practically shot out. It was incredible. And that decision is why I didn't have another C-section. And I didn't even know that that was a technique that was possible. I wouldn't have known to ask in advance. And it would have been an unnecessary operation - right? - if they hadn't tried that. You know, if they tried it and it hadn't worked, then OK, that's it.

MOSLEY: Reflecting on both of those experiences, your first experience and your second experience, what do you wish you would have known going in to give you a little more agency?

SOMERSTEIN: I wish I would have known that C-sections are super-common and to be prepared for one as much as I was prepared for a vaginal birth. And I also wish I had less pressure on myself, actually, to have a vaginal birth. I wanted to avoid a C-section because I thought a vaginal birth was superior. And actually, there are very good reasons to want to avoid a C-section. You know, vaginal birth is safer for the mother, everything in terms of how it can affect future births and so on. But I just had this stigma about C-sections and I wish I hadn't had that. And I wish I had understood that the reasons I had that stigma had to do with who the operation had been practiced upon in the past, and that the way your baby is born has nothing to do with your character as a mother, how much you love your baby, how good a mother you're going to be. I wish I knew all of that.

MOSLEY: Rachel Somerstein, thank you so much for this conversation.

SOMERSTEIN: Thank you so much, Tonya. It was really a delight.

MOSLEY: Rachel Somerstein's new book is called "Invisible Labor: The Untold Story Of The Cesarean Section." Coming up, TV critic David Bianculli reviews the return of the Paramount+ series "Evil." This is FRESH AIR.

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