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Chapter Three Risk or Remedy? 1930s–1970 Even as obstetricians discussed the appropriate indications for a cesarean section , the operation remained so rare that the public was largely unaware that the surgery, let alone the contentious debate, existed. Only 2 to 2.5 ­ percent of births overall ended in a cesarean in the 1930s, 1940s, and early 1950s, and that number did not reflect how few cesareans ­were performed at most hospitals. Ranging from less than 0.5 ­ percent at many institutions to as much as 6 ­ percent at a few large, urban hospitals, a birth by cesarean continued to be an extraordinary event in the professional life of physicians and the personal experience of ­mothers. Given the small numbers, the surgery was simply not on the public’s radar.1 As late as the 1960s, physicians still belittled colleagues who performed cesareans with any regularity. J. P. Greenhill, the longtime editor of the Yearbook of Obstetrics and Gynecol­ogy and a protégé of both J. Whitridge Williams and Joseph B. DeLee, was typical. He intimated that only doctors who lacked sufficient training relied on cesareans: “In fact for many ­ there is but one way out of a difficult obstetric situation, suprapubic [i.e., cesarean] delivery.” In listing the “legitimate indications” for a cesarean, Greenhill used typographic emphasis to imply that, despite the surgery’s growing safety, too many “illegitimate” surgeries ­were being performed. The ability of an obstetrician to execute a difficult delivery “from below”—­ obstetricians’ chummy vernacular for vaginal birth—­ continued to be a source of professional pride.2 72  Cesarean Section If the scorn of colleagues failed to persuade a doctor to change his habits, the recommendations of hospitals and professional organ­ izations usually succeeded. In the 1950s, the Joint Commission on Accreditation of Hospitals advised in their “Standards for Hospital Accreditation” that obstetricians consult at least one colleague before performing a cesarean. Hospital administrators adhered to the suggestion so assiduously that when Francis Bayard Car­ ter, the chair of the Obstetrics Department at Duke University Hospital, failed to ensure that all obstetricians ­ under his supervision observed the recommendation, he received a stern letter from a hospital bureaucrat: “I noticed a total of 22 cesareans [for the year, out of about 1,500 births] but . . . ​­ there is a rec­ ord of only 13 consultations .” Lest Car­ ter underestimate the seriousness of the oversight, the administrator quoted directly from hospital accreditation standards: “Except in emergency, consultation with a member of the Consulting or of the Active medical staff ­ shall be required in all . . . ​ cesarean sections . . . ​ or other operations which may interrupt a known, suspected, or pos­ si­ ble pregnancy.” In this case, however, failure to document consultations rather than failure to conduct them was the likely error. Car­ ter, who was fastidious about keeping the cesarean section rate low at Duke, regularly advised colleagues working outside his institution to consult not one but two colleagues before performing a cesarean. He also believed oral communication alone was insufficient: “it is always good to have written signed consultations for Cesareans, repeat Cesareans ­ etc.”3 It was in this atmosphere, with obstetricians still wary of cesareans, that the public caught its first glimpse of the surgery, courtesy of the American press, particularly ­ women’s magazines. American ­ women’s magazines ­ were singularly influential immediately ­ after World War II, helping to redefine and inform consumerism , ­family life, and health. Indeed, ­those publications helped link the three. While ­ mothers had always been responsible for the health of their ­ children, with the help of their favorite magazines in the 1950s they became educated consumers of medical ser­ vices. Offering information about cesarean section was a small component of the educational effort. Thus, even as social and institutional pressures kept the rate low, the surgery was coming to public attention. As early as the 1930s, and in earnest by the 1960s, newspapers and magazines explained cesarean surgery, its ­ causes, and its effects. ­ These types of articles helped to establish a climate of heightened awareness and vigilance around childbirth—­the stirrings of a zeitgeist that would eventually, in ­ later de­ cades, foster ac­ cep­ tance of a much higher cesarean rate.4 Risk or Remedy?   73 Newspapers and Magazines Depict a Rare Surgery Given how rare the surgery was before World War II, ­ women had few opportunities to familiarize themselves directly with cesarean sections, or even vicariously through friends and relatives. What ­little the public did know usually came from outlandish depictions in newspapers. Through the...


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