The History of the C-section
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Hello, my lovely Betwixters. It's me, Kate Lister. You are listening to Betwixt the Sheets. And at the top of each show, I give you the fair dues warning, where I have to tell you this is an adult podcast, spoken by adults to other adults, about adulty things in an adulty way, covering a range of subjects, and you should be an adult too. And we have to give you that, because if you keep listening and you get upset, well, fair dues. We did tell you. And I do have to give you an extra dollop of fair dues today, because we are talking about, drumroll please, the history of the C-section.

Yeah, so you can imagine what this one's going to be like and it's going to get graphic and you just might not want to listen to that today and this is your opportunity to turn us off, go and listen to The Archers and just come back to us when we're on safer territory. Right, on with the show. We are in Switzerland at the start of the 16th century, in the middle of the countryside no less. I am

I am a long way from home, both in time and place, I'm not going to lie. And amongst the stench of livestock and the annoying bugs swarming around, something significant, something historic is taking place in a cottage over there. Elizabeth Nuffer is struggling in childbirth. Yikes. And normally, ah, that's not good news. That's not good news at all for the mother or the child. However, her husband, Jacob...

happens to be a pig gelder by profession and is a dab hand with a sharp knife. Huh. Okay. Did Elizabeth and her midwives trust him when he said that he could cut the baby out of his wife? Did anyone really have much choice? Well, what happened next, if it's to be believed, was one of the first successful cesarean sections documented in history where both the mother and the baby survived. I mean, thank fuck for that.

So let's go and hand round the cigars to toast the newborn and find out more about the history of this dangerous procedure. What do you look for in a man? Oh, money, of course. You're supposed to rise when an adult speaks to you. I make perfect copies of whatever my boss needs by just turning it up and pushing the button. Yes, social courtesy does make a difference. Goodness, what beautiful dance. Goodness has nothing to do with it, does it?

Hello and welcome back to Betwixt the Sheets, the history of sex scandal in society with me, Kate Lister. The history of the C-section involves a lot of myth-busting as well. For example, have you heard the story that it was named after Julius Caesar? Yeah, me too. Is that true? Well, we're going to find out.

as well as how did the procedure evolve over time? How were women of colour and poor women exploited in the research and development of the C-section? And why does the phrase too posh to push have to go? Well, joining us today is Hannah Marsh, author of Thread, a Caesarean story of myth, magic and medicine, and she's going to help us find out more. Are we all ready? Are we all good? All right, let's do this.

Hello, and welcome to Betwixt the Sheets. It's only Hannah Marsh. How are you doing? Oh, I'm well, thank you. Thank you so much for having me on. I'm really excited to be talking all things Caesarean section. Caesarean section. That's because your brain baby is about to be born, isn't it? We'll give it its full title, Therese.

Thread, a Caesarian story of myth, magic and medicine released in June. How are you feeling about it? I am feeling probably in equal parts terrified and incredibly excited, which is probably

probably the same emotion that I was feeling before I birthed my son by a cesarean section seven years ago so it's yeah it's a kind of weirdly weirdly similar vibe seeing your book baby getting ready to go into the world well I've had a sneaky peek at it and it is rather fabulous I do have to say I very very much enjoyed it I was reading through it last night

You've hinted at it there, but can I ask you just for the listeners, what was the impetus to write this book? What is its origin story? And you do talk about this a lot in the book, but can you share it with us? Absolutely, of course. Seven years ago, I gave birth to my son via cesarean section. Now that was very much not the plan.

Like lots of first time mothers, I was gearing up for my all natural, calm, on a lily pad, before hypnobirthing. Yeah, yeah, yeah, very much. I had an image in my head of what birth was going to be like, and I thought I'd kind of

prepared myself I ticked all the boxes I'd done all the things but anyway as I quickly learned that is just not really how birth goes I wonder that my friends because I don't have babies but all of my friends make things called birthing plans and I often look at it and think what use is this actually because surely the plan is just get baby out like does it ever go according to plan

Oh, I don't know. I mean, like if I've learned one thing, it's that everyone's bodies are so different. Everyone's stories are so different. So probably for some people, it might go to plan. And also maybe for other people, it's just really important to have like their thoughts and their priorities written down. And maybe that still helps them navigate it. Yeah.

because it is quite hard to remember what your thoughts and priorities are when you're in the thick of it. So possibly that is still a useful thing. I think for me, it was so different from what I could have imagined. This wasn't your plan, was it? This was not my plan. So first of all, I was induced. I had a really late diagnosis of gestational diabetes, which was a bit of a surprise. And due to a kind of series of decisions, and I waited as long as I kind of felt was safe and reasonable to wait within the guidelines.

But my boy was perfectly happy where he was. So I went into hospital and I was induced and I experienced a very long, very wild, very uncomfortable 30 hour labour. Ooh.

After which he had still not made an appearance. And, you know, that was the moment when they started to get a little bit worried. His heart rate was dropping. I was not in a fantastic place. And I was wheeled down the corridor into surgery and I swiftly became acquainted with the emergency caesarean section. And yeah, I mean, it was a shock. It was a huge shock for me. It was a huge shock for my body. It was a huge shock for my brain.

It was a lot to process and catch up on. And in the months that followed, I really struggled to come to terms with it. My healing was like my physical healing felt slow. So I was uncomfortable. I was unprepared for that. So my body was really suffering. I was breastfeeding my son and I was really focused on trying to

keep this newborn baby healthy. But my own body was, and my own mind were not in a great place. I really struggled emotionally and physically. But I tried to kind of go through all the affirmations and meditations and, you know,

trying to kind of redraw the lines of how I felt about this, I suppose. But they just didn't really, I don't know, they didn't really land. They seemed to have kind of lost their power a bit for me. And what I did start doing in those late night, long, sweaty, milky feeding times with a little newborn baby, when you...

start to kind of look for reading material by the light of your phone was begin to delve into what the cesarean section actually was because I didn't really know. I didn't really know anything. I purposefully avoided thinking about it because I just kind of wanted to put my fingers in my ears. I was really frightened of this idea of surgery.

So I didn't even really know like what it was. I didn't know anything about its history. I didn't, if I had guessed, I would have assumed it was like a kind of relatively modern thing. I mean, both my parents were born by cesarean section, which is pretty rare for the time in the 1950s. But I probably thought that was like maybe the beginning of it being a thing. But, oh, oh, I was so wrong. And I found myself kind of tumbling into this

I guess is the only way I can describe it. And this world was populated by goddesses, by gods, by folk heroes, and very importantly, their mothers.

often kind of side notes to the main story. It was populated by these extraordinary humans, real humans who had just participated in these kind of mind blowing exploits. And some of them were familiar. I guess I had heard of Joseph Lister, but I hadn't really connected his work

to what I experienced. And I didn't know huge amounts about him. And I just kind of found myself tumbling through this world of wild characters and extraordinary exploits and kind of dramatic developments in surgery and medicine. And I began to kind of

explore how this joined together have one of those brains that latches onto things and then becomes obsessed with them and I found myself really fascinated by how it kind of tied together with other stuff that I did know about and how it tied together to now like where we are now I was quite kind of

interested in how lots of the stories that I was reading are still really, really present now in how we think about the Caesarian section, how we talk about it, what we think we know about it and how we judge it. It's another thing that it seems to bring a lot of guilt to women, a lot of misplaced

There's a lot of mum guilt from what I see looking around at me. It's just this horrible, overwhelming feeling that whatever you're doing, you're not doing it right. And we'll get into why some people feel sort of ashamed that you've not earned your stripes somehow if you've had a cesarean section. I've heard people say that before. But just in case anyone's listening to this who's going, see what, sorry. Can we just explain what a cesarean actually is?

So this is how the NHS describes a caesarean section, which is very cosy and quite cuddly. They describe it as an operation to deliver your baby through a cut made in your tummy and womb. Well, that sounds very neat.

So that is slicing through muscles and you enter this organ, the uterus that sits right at the core of your being. So it's major abdominal surgery. It's huge, isn't it? It's a big, big operation. It's a big operation. And I think for me, it is just like,

It's more than that. There is this kind of, it's more than the literal. It is this contrivance that humans have come up with and developed over centuries to kind of outsmart nature. Mm-hmm.

make this way that women who aren't able to birth their babies vaginally for whatever reason, you know, physical or emotional, have this way of being able to birth their babies and become mothers. They find themselves like I did in a labour where that is just not happening. I mean, essential surgery, I suppose. You said there that it's major surgery, seven layers of tissue. And for that very reason,

Most people didn't survive this until quite recently. Is that right? Absolutely. The complexity of that surgery and the fact that it was happening within one of the central cavities of the bodies and involving this quite kind of mysterious organ structure.

the uterus, which had its own kind of behavior that made it tricky. You know, when a cesarean section is performed, the uterus is still contracting. So that made it quite difficult for surgeons. You know, the uterus has got its own job. It's got its own purposes. It's trying to get the baby out. So, and then it's got to contract itself back to shape. So it doesn't stop doing that when a cesarean section happens.

All of these things made it. I've heard it described as surgery's bête noire many times. And when you read accounts of surgeons through the years, you really get the sense of it as just this conundrum, this like...

feared tool that they had that they did not want to use if anything else was at all possible because it was just dangerous it was you're navigating deep internal cavities of the body this uterus was contracting was complicated the risk of injury was huge the pain the shock pre-anesthetic that a woman could fall into the risk of hemorrhage was enormous having to stitch it back up

Having to stitch it back up again, which actually they did not stitch. The figuring out of how to effectively suture the uterus was a really major step in making cesarean section safer. But actually before silver sutures were available, which are one antibacterial and two dissolve within the body, silk was more usually used. And that was not really appropriate for stitching up the uterus because of course it had to be removed and can't remove it when it's kind of right in there. Yeah.

so it was left open to heal so this was a last resort this was not something that even after the dawn of anesthesia and even when surgery when we think of like amputations or kind of limbs things that were a bit further out on the body even when leaps were being made in that and actually surgery was becoming safer and you

you know, it was refining its techniques. Even then, the cesarean section remained a uniquely perilous position and it was to be avoided at all costs.

really until we get to the end of the 19th century turn turn of the 19th century into the 20th century but i guess people would have been willing to try it in extreme circumstances so what are some of the earliest records that we have of this can we address first of all the story that it's named after julius caesar or he was named after it or he's something to do with it what's that story

So that story, so we don't think that it is actually named after Julius Caesar. There is a story that that was how he was born, but we also know that his mother survived that. And I guess that's maybe the first surprise of the Caesarian section for me when I was researching was the sudden understanding of, oh, this was actually originally, and for most of its history, or for a good chunk of its history, a posthumous procedure. So this was not a procedure that was carried out on living women. This was a way of

extracting a baby if you could still feel its movements after its mother had already died in childbirth. So that was pretty sobering, I think, for me to understand that its origins were nothing really to do with trying to save the mother's life. They didn't even really expect the infant to survive for very long. Very, very difficult for an infant to survive without its mother. You know, there was no formula. And unless you're quite wealthy, it was probably quite hard to get a wet nurse. So really, there were kind of cultural or religious reasons why

you might still want to get a baby out maybe so you could baptize it or follow a cultural custom of burial rights but you know that was the sad reality so probably Julius Caesar was not born by caesarean section because his mother did not die during his childbirth she went on to have more children

So it might have been that the names have just got muddled. It could have been his father or his grandfather who also shared the same name, Gaius Julius Caesar. So it could have got muddled. There was also a piece of, there was also a law. It was existing law.

Roman law, but there was a change made under Julius Caesar that resulted in it being known as the Lex Caesarea. It was known as the Lex Regia before. And within that, there was a stipulation that women who had died in childbirth undelivered

had to have their child cut from them because otherwise you were causing a living being to die along with the mother. So there was this stipulation. So it could be tied in with that Lex Cesarea changes to that law. There's also speculation that it could come from the Latin caedere, which means to cut. So nothing to do with Caesar, actually. And also children who were born in that way were known as so sones. There's a few different possibilities, but probably not necessarily.

the man himself. And there is a long history of when you've got really like sort of mythical legendary leaders like Julius Caesar is there tends to be some strange story about how they were either birthed or conceived. That crops up a lot of the time, right? There's legends about King Arthur being born of a weird setup that Merlin does something slightly incestuous. It's all weird, but it's all like, like they've had an extraordinary birth. Therefore they must be an extraordinary person. But Julius Caesar, not born by Caesarian section.

No, but there was, and you raise a good point there, because there is this really long held association, this kind of folkloric association with children who were born in this way and survived into adulthood, which is that they were in possession of some kind of supernatural fortitude or fortune. And

You know, maybe that was something that kind of worked for him or people, you know, maybe there's a kind of muddling in of that association that there was something quite exceptional. It was super rare, as I said, for children born that way to actually survive into adulthood. Some did. And I think that's probably where this folkloric association of supernatural strength and fortune came.

fortitude comes from so maybe that's kind of threading its way through his origin story as well they say the same thing about babies that are born in the in the sack as well in the car yes nelson apparently means that you can't drown that's what they say i know because my brother was born like that and they said that that nelson was born like that as well so it's strange we get these legends about birth cropping up

Yeah, it's fascinating, isn't it? And of course, that association comes from a time when this would have been super rare, really rare to happen in the first place, even more rare that that child would survive into adulthood. But of course, nowadays, it's really common. It's the most commonly performed surgery in the US. It's one of the most common surgeries performed globally. So yeah, I wonder if that association still exists.

No. Not so much. But you can see how it would have done in the past, can't you? Absolutely. So Julius Caesar, no. Do we have accounts of people undergoing, even if they don't survive, do we have medical accounts of what happened?

There's like a veiled reference, I think, on an ancient Syrian tablet of a baby that we think could have been born that way. I think that's kind of the first possible reference. But the first explicit mention that we have is around 715 BCE. And that is in the Lex Regia. That's the piece of Roman law that predated the Lex Cesarea. And that's the piece that sets out that babies must be removed from their mother if she's died in childbirth and she couldn't be buried before the child had been cut off. So that

Sorry, cut out. So that's really explicit. That's definite. Like, that's clear. That's happening. But we're talking posthumous. So we're not talking about the mother surviving that. And certainly not in any kind of routine way. I mean, obviously, very rarely women did survive this. And, you know, that was also really exceptional.

The first recorded incidents that we have of that happening is around the 1500s. And I love this story because this is the story of Jakob Neuffer, who was a Swiss pig gelder. So one more used to kind of working with the reproductive systems of pigs. He lived very rurally in Switzerland and his wife, Elizabeth, was due to give birth to their daughter. She went into labour and she laboured for three days. She was seen by 13 midwives.

none of them could coax the baby out. And so eventually, Jacob decides to take matters into his own hands. And there were permissions that he needed to seek. So he goes off, he seeks his permissions. He comes back.

presumably he gets out the equipment the toolkit that he uses to work with pigs and he operates without anesthesia without antiseptic on his wife Elizabeth and amazingly his daughter is born and both Elizabeth and the daughter survive which is an extraordinary fluke of luck and

It's just kind of an amazing story to think of this pig gelder. But actually, probably at this point, you know, surgery looks nothing like mainstream surgery does not look anything like we know surgery today to look like. So, yeah.

actually his profession gave him a bit of a knowledge of anatomy that maybe even a doctor would not have had at that point. And I wonder as well whether he knows something about pain as well and how to manage pain in animals. You know, if you watch Vet now, they'll know how to handle an animal and

I wonder whether he knew how to kind of cut quickly and cleanly and to kind of reduce, to manage the pain a little bit as well. Actually, probably his role with animals helped him a lot. All the same, it's extraordinary. That is extraordinary, actually. That's completely bonkers. But well done, Mrs. Noofa, quite frankly. Yeah, absolutely. She must have been made of pretty strong stuff. Yeah.

Because apparently she went on to birth five more children vaginally, including twins. Holy fuck. So that was not the end for her. She was there. That's extraordinary. Wow. Yeah. Elizabeth was definitely made of pretty strong stuff. I'll be back with Hannah after this short break. You know how we all have that one friend we go to with all our financial questions? Well, meet Experian, your BFF, as in big financial friend. I'm

I'm telling you, Experian is going to be your go-to app when it comes to taking control of your finances. Experian not only has a bunch of ways to help you save, but lets you check your FICO score, matches you with credit cards, and a bunch more things you'd expect from a big financial friend. Just download the Experian app and get started for free. Trust me, you'll be up to speed with this BFF in no time. Based on FICO score 8 model. Offers and approval not guaranteed. Terms apply. Offers not available in all states. See Experian.com for details.

Our skin tells a story.

Join me, Holly Frey, and a slate of incredible guests as we are all inspired by their journeys with psoriasis. Along with these uplifting and candid personal histories, we take a step back into the bizarre and occasionally poisonous history of our skin and how we take care of it. Whether you're looking for inspiration on your own skincare journey or are curious about the sometimes strange history of how we treat our skin, you'll find genuine, empathetic, transformative conversations here on Our Skin.

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There's another story that you cover. Is it Isabella della Volpe? Yes, Isabella della Volpe. And this is a really amazing story. And this is a piece of research that was shared by the historian Catherine Park. And she uncovered this set of accounts. And this was kind of interesting for me. You know, Caesarian sections are part of birth. This is in the 1600s. When the story happened, birth would have been very much part of the domestic sphere. So it wasn't really seen as

something to be recorded officially. So we don't really have accounts. We know through medical textbooks and instructions that caesarean sections may

were happening posthumously technically but we don't have first-hand you need a doctor to write it down don't you basically yeah so we have we have the story of jacob nufa because a doctor went around looking for stories and it was a second-hand account you know and he wrote it down so we have it as a as an account but it's not a first-hand witness account so

This set of accounts, the reason that it is in existence, it was a set of witness accounts prepared for a possibly impending court case that hinged on the large inheritance of Isabella de la Volpe, the mother in this story, who had sadly died shortly before she was due to give birth to her daughter Isabella.

So, I mean, it's a really, it's a juicy yarn. It involves a priest, a barber surgeon, because surgery was often carried out by barbers within the community, being the dudes with the knives, a maid servant and a physician. So it's got all the makings of a bit of a cracker. But yeah, poor Isabella, she possibly was suffering from eclampsia and

That wasn't something that was known or understood at the time. So she fell very, very poorly before she was heavily pregnant. She was due to give birth. She fell very poorly and unfortunately she died. But the women who were attending her could feel the movements of her child. So they summoned the family physician. They begged him to deliver her so that this child could be baptized, so that its soul could be saved. Obviously, this really...

was hugely important. And he, I don't know whether he had an inkling that he was about to unlock something quite complicated, but he also had a personal relationship with this family. And so possibly it was also just really distressing. He said he couldn't operate on her. He just couldn't kind of stomach that. But he summoned a barber surgeon and he said he would instruct him to operate. So a midwife and a barber surgeon arrive on the doorstep very quickly. And the barber surgeon is instructed to,

on the cesarean section. A baby is born and she's quickly baptised. The priest is also summoned. She's named Camilla. And, I mean, according to these witness accounts, she's alive when she's born. She's also at full term, so she's moving her arms and legs around as a baby should. There was an issue around inheritance that if she had been born too early to sort of... Oh.

to sort of count legally, then that could be an issue. But also it was crucial that she was alive when it came to the inheritance. And when it came to the baptism, she couldn't be baptised if she wasn't alive. So she was reportedly pulled out alive. She was baptised and she sadly died a few hours later. And if the inheritance had not been at stake, we would not be hearing about this. That would have just been a thing that happened many years ago. It would have been lost to the past.

But Isabella was sitting on quite a large inheritance. And it looks like who would inherit that really hinged on the details of the Caesarean section. So if she was indeed born alive and at term, that inheritance would stand to go to her husband through their joint issue. Right.

But if there was a possibility that she was not alive when she was born, or that she was not at full term, technically that inheritance could have reverted to her paternal uncle. So we think this is where the crux came in. So actually, we don't know whether this case ever did go to court, but it looks that her husband...

prepared these witness statements because he might have been thinking he was about to be taken to court and he needed a strong defence. So because of this inheritance, because there were...

two men in her family who were potentially battling over who was going to inherit it. We have these amazing witness accounts and they tell us extraordinary amounts about this procedure, about the rituals, about the roles, about where the caesarean section sat. Because interestingly, Catherine Park makes the point that there's no suggestion of medical malpractice. This was very accepted. So there was no surprise when the women said,

We can still feel the movements of the child. You need to get the baby out. Please, can you operate? That was accepted. So it tells us that that was like normal procedure. I mean, rare, but in that rare situation, that was an acceptable procedure. It wasn't like out of the ordinary. And it also gives us these really clear insights into these roles and rituals, the priest, the midwife, the barber surgeon and the physician, how they kind of acted together and what that looked like

who would direct and who would operate, who would baptise, who would have the baby, gives us this startlingly precise information. Who would be carrying out these things? Would this be something that midwives would do? Because you said there was a barber surgeon. You'd have to go and get, I guess, just anybody to do it. But do we have any kind of understanding of, like, were people trained to do this? Or was it just...

cut away and hope for the best. So interestingly, within Northern Europe anyway, we look back to the early medieval period, midwives were usually nuns from within the community and your medical care or your midwifery care would come from the same source as your spiritual care

So it would normally be, it would have been anyone using a knife on a woman at that point in an emergency would have been a woman. That would have been a female surgeon, likely a nun. So that midwife would be responsible in an emergency like the situation with Isabella de la Volpe of conducting that emergency baptism for the child, which is kind of wild because even now the Catholic Church don't allow female priests. Right.

And it speaks something of the power and the exceptionalism of the birth space and the birthing room, that this was a female-held space. And within this space, women were granted this really extraordinary power of being vested by the church with the power to carry out emergency baptisms, which is one of the most important rituals of the Catholic Church. And then...

We see kind of around the 12th century, this shift where surgery begins to pass from the church into lay hands. And with that shift, surgery begins to become professionalized. So when the church were carrying this out, it was more vocational. It was a community, you know, an act of community care and service. As it passes into lay hands, it begins to become professionalized. And I'm sure this will shock you, but as money becomes involved...

also become involved and we see this shift where it begins to be professional male hands that hold the knife and

And that's where we begin to see this character of the barber surgeon, because, yeah, the two professions were often intersected. Surgery was really a service performed within your community. It did not belong to the learned spheres of kind of higher education where...

you might see physicians kind of sitting in this quite learned, highly educated sphere. Surgery was something that belonged to the community. It wasn't surgery as we know it now, you know, navigating deep internal cavities of the bodies. It was lancing of boils and this sort of thing. So yeah, the man with the blade within the community was usually the barber. So you'd often see these two combined. And it really wasn't until much later that surgery would kind of begin its own journey towards healing.

becoming a specialism.

So when do we start to get a sort of a professionalism around, well, as much as they could do, cesarean section? I suppose because the profession of gynecology itself starts to emerge sort of 18th century, I suppose, more so than anything else, becoming as the medical profession starts to emerge. Gynecology becomes its own kind of institution, doesn't it? Absolutely. So we do see men in the bathroom before then. You have this character called the man midwife.

And in his early form, he's still pretty rare in the 1700s. But then in the 1800s, we see this shift. So it's kind of interesting because we have this enormous societal shift in the form of the kind of prolonged age of enlightenment where we see such change.

Huge shifts in the way that women and their roles and the family kind of sit within a society and this positioning of women within the domestic environs as kind of nurturing and emotional and alongside children in the kind of care category, as opposed to the logical, rational environment.

And at the same time, yeah, we're seeing this specialisation within medical care. And before that, it was really this kind of three-tiered structure of physicians who were like super learned, university educated, clever dudes. And then surgeons who you would go to for like bloodletting and lancing of boils. And they were kind of more rough and ready within the community, almost quite like manual labour kind of people.

in terms of how they were seen. And then below them, the apothecaries who were like, you know, giving you your powders and your remedies. Yeah, that was like the three tiers of medical care. And then we see specialisation begin to happen. And yeah, this is really the dawn of...

obstetrics and gynecology. And it would be a long time, actually. Obstetrics and gynecology would be a bit maverick, a bit left field. It really had to battle for its place. It kind of bounced around in the 19th century between the colleges of physicians and surgeons because no one really knew where this...

SATS, like was it even a valid specialism? It had to really kind of battle for its legitimacy. And with that comes a bit of a power struggle that I think

We saw a little hint of it as men entered the professional surgical sphere. But this pops up again and again. And I feel like we feel its echo now in the birth room, this kind of power struggle within the birth room. So as obstetrics and gynecology began to emerge as a specialism, the birth room begins to attract attention. And that attention is male. And at this point, it is still male.

a female held space. It's still this kind of rare cornerstone of female held power, but

In the UK in 1739, there are some figures that seem to point to a fall in population. And it's a bit worrying because it draws attention to like really appallingly high levels of maternal and infant mortality. And this attracts attention. And this attention is male and it's professional. And, you know, rightly, these men decide that something has to be done about this. And I guess this is where there's nuance because, of course,

things come in that are really good they're really healthy they're really helpful and we see this again and again you know whenever attention is drawn by really poor maternal mortality or infant mortality which does happen from time to time um you know a war will happen and a country will suddenly realize it really needs to put focus on its maternity care because it needs a

healthy new population of young men. And of course, women and infants benefit. So it's not without merit. There are good things that happen. One of the things that is just quite interesting to point out is that this comes at the expense of female midwives. So at this point, female midwives become a bit of a scapegoat.

It's really useful for these male obstetricians as they are trying to scrabble their way up and get attention and legitimacy for their profession of obstetrics and gynecology if they have a scapegoat. And that scapegoat is traditional female midwives. So there's this amazing essay by William Cadogan. He writes an essay on nursing and the care of infants. And

He says, in my opinion, this business has been too long fatally left to the management of women who cannot be supposed to have proper knowledge to fit them for such a task. And he talks about how delighted he is that finally the care of women and children is falling into the hands of men of sense. And I think it's just really it's important to recognize that nuance that a lot of these advances that we then see happening, which are amazing advances.

and obviously great news for women and babies. They do come at the expense of female-held knowledge that at the same time as obstetrics, it's making its own advances.

It's bringing learning into the lecture theatres, into universities, and it's closing the doors. So those are spaces that women cannot enter. Female midwives have got the advantage of actually practising a lot, like being within their communities. Some of these midwives are attending 300 births a year. You do start to see depictions of midwives as drunken, irresponsible, dirty.

often linked with abortions. Witches. It's kind of... You do start to see them being demonised as that roundabout this time. Yeah, kind of derided as quackery, superstitious, possibly occult. The wise woman. Yeah, really...

juxtaposed with the learning that is happening and a lot of emphasis put on the value of classroom learning and away from the kind of practical element of the birth room. And we see that real separation and the emphasis that is put on obstetrics and learning and, you know,

higher education I guess as opposed to like on the ground community involvement where frankly obstetricians couldn't really compete because these women were in their communities all the time delivering babies so they had the practical know-how so yeah that's I guess it's just a kind of uncomfortable but nuanced position but yeah you're right so the 19th century we see so really up until this point which is extraordinary when you think about it like up until the 19th century

Caesarean sections are just, yeah, they're like absolutely your last resort. Last resort. Nobody wants to perform them. And if they are being performed, the mother is usually deceased at that point. Yeah, either deceased or soon to be deceased. Yeah. So there are lots of accounts. I mean, obstetricians were wrangling with this and some of the accounts, they're so human because you just read these words from these men who were trying, like they were

and and sometimes they were forced to carry out cesarean sections on women who you know might have had a misshapen pelvis rickets was really rife in a lot of the slums um in european cities and a lot of those women may have had a pelvis that just did not allow them to give birth vaginally and even sometimes would make something like there were other options for giving birth and they were not pleasant ones but there were things like the craniotomy you know where a

the baby's head was pierced and broken down so that it could be brought forth vaginally, or the embryotomy where a baby was dismembered and brought forth vaginally. They weren't great options. It was a pretty bleak situation that an obstetrician faced. But sometimes even the pelvis was so small or misshapen, there just wasn't even space to carry those

those options out. So a caesarean section was the only option. But yeah, the women would often then just die because the risk of hemorrhage and the risk of infection just seemed insurmountable, even if the caesarean section resulted in the live birth of the child. And by this point, children were maybe surviving a bit more, but it just seemed insurmountable to surgeons. I'll be back with Hannah after this short break.

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Listen to Our Skin on the iHeartRadio app, Apple Podcasts, or wherever you get your podcasts. When does it start to be slightly surmountable? You have the introduction of anesthesia, but then just because you can knock someone out doesn't mean they're going to live through the procedure. That's not what that means. So when do you start to get...

It must be with the introduction of antiseptics and when doctors find out, maybe we should wash our hands. Maybe that's an idea. Maybe we should not go straight from autopsies to delivering babies. Awful, isn't it? Awful. Yeah, it's shocking. When does it start to become... I know that you've got the account of the pig gelder, but when... This was rare. Yeah, that was a fluke. When do you start to get the...

doctors and physicians, they've kicked the midwives out, bastards. But when do you start to get that this is actually something that's viable, that could be done? In the 19th century, there are three moments that really change things. The first one is, yeah, anaesthetic. That's huge. 1846, Robert Liston

amputates a leg in 28 seconds while his patient is knocked out by ether. And that is the first use of ether in a surgical setting. It has been used in dentistry and that's how it's kind of come to Robert Liston's ears.

that's a game changer that's a game changer for surgery right like the first barrier is the pain barrier and that's huge but I love the fact that in the audience during that operation is a young Joseph Lister and he watches this operation and he is really aware of the significance he knows that

that he is watching the first barrier to successful surgery, pain being removed. And of course, it's he who will dedicate his life to the removal of the second barrier, which is infection. And that's huge because the caesarean section, it's so difficult to prevent infection. And infection is what will often take the life of a woman.

who's experienced, you know, maybe what sort of seemed pretty successful surgery. But then, yeah, as I kind of briefly mentioned earlier, because of the nature of the cesarean section, even with those huge advancements, which are, you know, great for surgery in general, but it still has this really unique challenge, which is that the uterus is still contracting and it sort of defeats contemporary logic to suture it. So they are leaving it

unsutured, so hoping that it will just bring its edges together by itself and heal, which sometimes it does.

There's this kind of interim moment when an obstetrician named Eduardo Porro comes up with a technique where he's essentially carrying out a hysterectomy. So he carries out a cesarean section, carries out a hysterectomy, which is extreme, but really lowers the chance of infection. So actually it's pretty effective, but you know, it's also pretty rough. And those women were not going to have any more children. Yeah.

And it's pretty controversial. But then in 1882, an obstetrician named Max Sanger decides that he is going to trial silver sutures using a new technique on the uterus. And silver sutures have been developed by a really controversial figure named James Marion Sims in the US. Ah, yes. Who is known for his extremely controversial and racist ideas.

We can just say shithead, can't we? Just shithead experiment. He's just an arsehole. Yeah. I mean, he's a man who for many years was hailed as the father of American gynecology, but actually many of the learnings that he made were on the bodies of enslaved black women who did not even own the right to consent to...

over to what was happening to their own bodies. So as well as a legacy of innovation within surgery, he left a deeply stained legacy of misogyny and racist violence towards these women that manifests today in beliefs that exist now among sort of understanding and assumptions of Black women's pain. For example, he believed that Black women did not feel the same levels of pain as white women, which is why he

you know, experimented so freely upon their bodies. And this is a myth that exists now that echoes down through the ages and harms black women. It's a lot of experimenting that went on to get us where we are, isn't it? On the bodies of enslaved women. Poor women as well were experimented on just...

It's a grim, grim history. There is inequity in birth now and it is racial and it is social. And the colour of your skin and the amount of money in your wallet are still really important contributing factors to your safety during birth.

And that is a legacy that comes from learnings that were made upon the bodies of sometimes enslaved black women in America and Haiti, sometimes just incredibly poor, vulnerable women living in the slums of these European cities who didn't have a choice but to birth in a hospital, which is not where you wanted to birth because infection was rife or sick.

whose pelvises were malformed by something like rickets, which is caused by malnutrition. So these were incredibly poor women, incredibly vulnerable, but their bodies offered up learnings, which we benefit from today. And the legacy of the success of the cesarean section really owes a great debt to those women and the extraordinary suffering that they must have endured.

Was it Dr. Sims that pioneered a C-section then? No, he didn't. But he did pioneer silver as sutures. And Max Sanger sees this and he thinks this might be what he's looking for. This might help him crack the problem of how to suture the uterus. Because one, silver is antibacterial, so infection is going to be lower. Yeah.

But miraculously, kind of magically, it dissolves within the body. So it solves the issue of how you remove sutures from the uterus once it's healed, which just was really, really difficult. And he develops a new technique of suturing the uterus. And that is huge. So that silver suturing and Sangha's techniques...

Joseph Lister and his work on germ theory and antiseptic and the earlier discovery of anaesthetic and surgery. I think those three things are like the things that really change the game for the C-section. They really together bring it to a point where it can move on at quite a pace from that point, really. Is it a safe operation today? Yeah.

Yes and no. I mean, yes, when you position it along its history, it is a nuanced answer because it depends where in the world you live. So from a Western point of view, yes, it's pretty safe. In some countries, it is so safe as to be regarded as kind of routine, even as the so-called easy option. So, yeah, we are lucky enough to enjoy really high degrees of safety, but it absolutely is not without risk. And those risks are not distributed equally.

So there are risks to the mother, but there are also risks to the infants. Some of them are quite well talked about, you know, because the baby's not going down the birth canal, it's not picking up the vaginal gut flora. And because the lungs are not being, the amniotic fluid is not squeezed from the lungs, there are associated higher risks of asthma, associated higher risks of obesity, diabetes.

So it's not without risk. And of course, it's major surgery and no surgery is without risk for the mother. But beyond that, then the risks are not really born equally geographically. So, you know, there are countries where the C-section rate is extraordinarily high. There are also countries where the C-section rate is extraordinarily low. And that is because there are parts of the world where women simply don't have safe access to

to this life-saving operation. And yeah, the level of care you receive will also really vary depending on, sometimes that's a bit of a postcode lottery, but sometimes, you know, in a private healthcare system, it's going to vary depending on what kind of care you can afford.

Unfortunately, it's also going to vary on the colour of your skin because we have healthcare systems through which misogyny and racial bias is threaded. And we haven't really dealt with that. And that shows up in the discrepancies and figures. I mean, in...

In both the UK and the US, black women are more likely to experience an emergency C-section than their white counterparts. And separately, they are also more likely to die in childbirth or immediately afterwards. I mean, we see this in other parts of the world as well. We see racial discrepancy in Australia and New Zealand. This is a story that we don't

tell in a lot of places. And so, yes, it is a safe procedure. And in some places, it's very routine. It's not without risk. And those risks are not borne equally. So as a final question, then, why do you think we still have a stigma around a C-section? There was a whole controversy a few years ago when women could elect to have a C-section because they didn't want to give birth vaginally, quite frankly. They just didn't want to. Fuck off.

And that attracted this whole, almost like they were cheating, they were taking the easy way out. And I've always thought that is just horribly unfair. Why do you think we still have that stigma? What is that? Misogyny. We want women to suffer in childbirth. That's biblical, right? Yeah, that's one thread. You know, pain and suffering in childbirth, the transgression of Eve and her punishment is...

But it's like, it's really easy to jump on the idea of shaming women. And I mean, you see it in some of the mythical stories that there's one that I...

It's the first one that I kind of thread these myths through this book. And one of them is the birth of Asclepius, the ancient Greek kind of father of surgery, as he's sometimes known. And his emblem, the staff with the snake coiled around it, like even now, that's the symbol of the WHO. So it's really associated with like

mainstream patriarchal medical knowledge. His father was Apollo, the god, and his mother was a princess, Karonis. And she became pregnant by Apollo because that happened quite a lot in ancient Greece. And then she, I don't know, like maybe she fell in love with this other man. Apollo had kind of disappeared off. Unbeknown to her, he had left a white crow to spy on her. But, you know, what she thought, I don't know, like maybe she...

fell in love with this other man, Iskis. Maybe she just realised she was incredibly vulnerable, pregnant and abandoned, and so she chose to seek some sort of protection through marriage. Either way, she marries a mortal man named Iskis, and the crow flies to Apollo. Apollo is enraged with jealousy, and he orders his sister, Artemis, the hunter, also the goddess of childbirth, not in this case, who...

Quickly arrives at Coronis' door, kills her with her arrow that never misses its target and burns her body on fire. And suddenly Apollo is kind of seized, maybe with some sense of regret. And he leaps into the flames. He delivers his son, Asclepius, via Caesarian section. And this child becomes celebrated for his bravery.

and inherited surgical knowledge and mastery. That kind of has its own repercussions in another story. But this figure of this woman who is shamed for her choices and for her body and for these things that kind of happened to her, she's doing the best she can within a system that's quite stacked against her. But her role is one of shame and of punishment. And I think that really resonates for me now. You mentioned earlier that sense of shame that...

many women will feel after having a cesarean section when our bodies don't behave in the way that we think or hope they're going to, they don't meet our expectations, they don't meet society's expectations and we feel shame for that and I think that

laces its way down. So when labels like Too Posh to Push are coined, when Victoria Beckham has a caesarean section to birth her son, and this is like gold to the newspapers, like they can't resist Posh Spice, you know, it becomes Too Posh to Push. And then,

And it conjures up this image of a woman who is like vacuous and too busy to like give birth the messy way. Like she wants ease and convenience. She's going to birth in this way that's easy and quick and can be...

scheduled in on her, put in her diary. And even this kind of association of glamour or celebrity or ease that we sometimes see with the cesarean section now, it all for me kind of riffs on that same idea of shaming women for their choices, kind of willful misinterpretation of some of those figures as well, because it's actually not super easy to get an elective cesarean section. And you know, there are women who've spoken out about the impact of that on them. That's

That whole too push to push thing, a lot of the media really willfully misinterpreted the idea of an elective C-section with a maternal choice cesarean section, which is not the same thing. So an elective cesarean section just means that it's not an emergency cesarean section. There's many medical reasons why.

your baby might be breech, you might be having multiples, you might have placenta previa. That's not the same as a... that's not a woman choosing to have a caesarean section, that's a medically advised caesarean section. But the media picks up these figures and puts them forward as maternal, that women are choosing this. And yeah, I don't know, for me, it's misogyny, pure and simple. It's a tool with which to shame women.

It's a tool with which to judge them. And we love a phrase that does it so pithily. Hannah, you have been wonderful to talk to. Thank you so much for spending time with us. If people want to know more about you and your work and your new book, where can they find you?

I'm on Instagram at Hannah Marsh Writes. I'd love to see you there. And otherwise, my book Threads will be out in June. It's published by Leap, which is an imprint of Bonnier. And yeah, it will be out in June. So if you read it, then yeah, please come and have a chat with me because I'd love to hear what you think about it. Thank you so much for coming by. You've been marvellous. Thank you, Kate.

Thank you for listening and thank you so much to Hannah for joining us. And if you like what you heard, don't forget to like, review and follow along wherever it is that you get your podcasts. If you'd like us to explore a subject or maybe you just wanted to say hello, then you can email us at betwixt at historyhit.com. We've got episodes on Victorian sex work and Tudor and Stuart aphrodisiacs all coming your way. This podcast was edited by Tom DeLarge and produced by Stuart Beckwith. The senior producer was Charlotte Long.

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