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Betwixt The Sheets: The History of Sex, Scandal & Society
The Bloody History of the C-section
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- [00:00]
Kate Lister
Hi, I'm your host, Kate Lister. If you would like betwixt the sheets ad free and get early access. Sign up to History Hit with a History Hit subscription. You can also watch hundreds of original documentaries with top history presenters and enjoy a new release every single week. Sign up now by visiting historyhit.com subscribe.
- [00:27]
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- [02:17]
Kate Lister
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 book about other adults about adulty things and adulty wakering or age old 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. Drum roll please. The history of the C section. Yeah. So you can imagine what this one's gonna be like. And it's gonna get. 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 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 caesarean 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.
- [04:14]
Hannah Marsh
Why do you look funny? Mad. Oh, money. Of course you're supposed to rise when an adult speaks to you.
- [04:19]
Kate Lister
I make perfect copies of whatever my boss needs by just turning a knob.
- [04:23]
Hannah Marsh
And pushing a button. Yes, social courtesy does make a difference. Goodness. What beautiful dam.
- [04:35]
Kate Lister
Goodness.
- [04:36]
Hannah Marsh
There's nothing to do with the doing.
- [04:42]
Kate Lister
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 gonna find out. As well as how did the procedure evolve over time? How were women of color 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 Cesarean 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. Hello, and welcome to Betwixt the Sheets. It's only Hannah Marsh. How are you doing?
- [05:34]
Hannah Marsh
Oh, I'm well, thank you. Thank you so much for having me on. I'm I'm really excited to talking all things cesarean section.
- [05:42]
Kate Lister
Cesarean section. That's because your brain baby is about to be born, isn't it? We'll give it its full title thread, A Caesarean Story of Myth, Magic and Medicine released in June. How are you feeling about it?
- [05:56]
Hannah Marsh
I am feeling probably in equal parts terrified and incredibly excited, which is probably the same emotion that I was feeling before I birthed my son. Bias Caesarean 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.
- [06:19]
Kate Lister
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 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?
- [06:37]
Hannah Marsh
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. No birthing. Yeah, yeah, yeah, yeah, very much. I had an image in my head of what birth was going to be like and I thought I had 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.
- [07:13]
Kate Lister
I've wondered at 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. Does it ever go according to plan?
- [07:28]
Hannah Marsh
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 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.
- [07:54]
Kate Lister
This wasn't your plan, was it? This was not the plan, no.
- [07:58]
Hannah Marsh
So first of all, I was induced. I was. 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, 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 labor after which she'd still gouges 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 cesarean 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, 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 affirmat and meditations and 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 seem 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, 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, 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, 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 caesarean 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 world, I guess. Is the only way I can describe it. And this world was populated by godesses, 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 cesarean section, how we talk about it, what we think we know about it and how we judge it.
- [11:48]
Kate Lister
It's another thing that it seems to bring a lot of guilt to women, a lot of misplaced guilt. There's a lot of mum guilt from what. 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 a shame that you've not, like, earned your stripes somehow, if you've had a caesarean section. I've heard people say that before, but just in case anyone's listening to this, who. Who doesn't. Who's going see what. Sorry, let's just. Can we just explain what a caesarean actually is?
- [12:22]
Hannah Marsh
So this is how the NHS describes the cesarean 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.
- [12:36]
Kate Lister
Well, that sounds very neat, that's quite nice.
- [12:38]
Hannah Marsh
But, yeah, essentially it is a cup made in your tummy and womb. It is also a cup made through seven layers of tissue. So that is slicing through muscles and you into this organ, the uterus, that sits right at the core of your being. So it's major abdominal surgery.
- [12:56]
Kate Lister
It's huge. And it's a big, big operation.
- [12:58]
Hannah Marsh
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, make this way that. 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 if they find themselves, like I did, in a labor where that is just not happening.
- [13:33]
Kate Lister
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?
- [13:46]
Hannah Marsh
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, 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. For surgeons. You know, the uterus has got its own job, it's got its own purpose. 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. I've heard it described as surgeries bat noir 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 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.
- [14:54]
Kate Lister
Having to stitch it back up again.
- [14:55]
Hannah Marsh
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 sections safer. But actually, before silver sutures were available, which are one, antibacterial and two, dissolved within the body silk was more usually used. And that was not really appropriate for stitching up the uterus because of course that had to be removed and can't remove it when it's kind of right in there. 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 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.
- [16:02]
Kate Lister
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?
- [16:18]
Hannah Marsh
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 cesarean 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, 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 rites. 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, or there was also a piece of. There was also a law. It was existing Roman law, but there was a change made under Julius Caesar that resulted in it being known as the le cesarea. 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 caesaria changes to that law. There's also speculation that it could come from the Latin kadere, which means to cut. So nothing to do with Caesar, actually. And also children who were born in that way were known as soisones. There's a few different possibilities, but probably not the man himself.
- [18:32]
Kate Lister
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 they've had an extraordinary birth, therefore they must be an extraordinary person. But Julius Caesar not born by Caesarean section.
- [19:00]
Hannah Marsh
No, but there was, and you raised 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 fortitude comes from. So maybe that's kind of threading its way through his origin story as well.
- [19:47]
Kate Lister
They say the same thing about babies that are born in the sack as well. 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 Nelson was born like that as well. So it's strange how we get these legends about birth cropping up.
- [20:05]
Hannah Marsh
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.
- [20:25]
Kate Lister
So.
- [20:25]
Hannah Marsh
Yeah, I wonder if that association still.
- [20:28]
Kate Lister
No, but you can see how it would have done in the past. Can't you?
- [20:34]
Hannah Marsh
Absolutely.
- [20:35]
Kate Lister
So, Julius Caesar? No. Do we have accounts of people undergo, even if they don't survive? Do we have medical accounts of what happened?
- [20:45]
Hannah Marsh
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 lexaria. 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, sorry, cut out. So that's really explicit. That's definite. Like, that's clear. Yeah, 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 the story because this is the story of Jakob Neufahr, who was a Swiss pig gelder. So one more used to kind of working with the reproductive systems of. He lived very rurally in Switzerland, and his wife Elizabeth was due to give birth to their daughter. She went into labor and she labored for three days. She was seen by 13 midwives. None of them could coax the baby out. And so eventually Jakob 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 probably actually his profession gave him a bit of a knowledge of anatomy that maybe even a doctor would not have had at that point.
- [22:53]
Kate Lister
Now that I wonder as well whether.
- [22:55]
Hannah Marsh
He knows something about pain as well and how to manage pain in animals. You know, if you watch a vet now, they'll, they'll. 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, it's extraordinary.
- [23:17]
Kate Lister
That is extraordinary, actually. That's completely bonkers. But well done, Mrs. Newfa, quite frankly.
- [23:24]
Hannah Marsh
Yeah, absolutely. She must have been made of pretty strong stuff because apparently she went on to birth five more children vaginally, including.
- [23:32]
Kate Lister
Holy.
- [23:33]
Hannah Marsh
So that was not the end for her. She was there.
- [23:37]
Kate Lister
Extraordinary.
- [23:39]
Hannah Marsh
Yeah, Mrs. Elizabeth was definitely made of pretty strong stuff.
- [23:50]
Kate Lister
I'll be back with Hannah after this short break.
- [24:09]
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- [26:38]
Kate Lister
There's another story that you cover. Is it Isabella Della Volupe?
- [26:42]
Hannah Marsh
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. And this was kind of interesting for me. You know, caesarean sections are part of birth. This is in the 1600s when this 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 were happening posthumously technically, but we don't have firsthand details.
- [27:23]
Kate Lister
You need a doctor to write it down, don't you?
- [27:25]
Hannah Marsh
Basically, yeah. So we have. We have the story of Jakob Nufa, because a doctor went around looking for stories and it was a secondhand account, you know, and he wrote it down. So we have it as a. As an account, but it's not a firsthand hand witness account. 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 Della Volpe, the mother in this story, who had sadly died shortly before she was due to give birth to her daughter. 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. 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 physician, they begged him to deliver her so that this child could be baptized, so that its soul could be saved. Obviously, this 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 arrived on the doorstep very quickly, and the barber surgeon is Instructed on the cesarean section, a baby is born and she's quickly baptized. 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. 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 baptized if she wasn't alive. So she was reportedly pulled out alive, she was baptized 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 home, that inheritance would stand to go to her husband through their joint issue. 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 the. 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 that 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 baptize who would have the baby gifts, the startlingly precise information, who.
- [32:00]
Kate Lister
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?
- [32:15]
Hannah Marsh
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 Don 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. 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, men also become involved. And we see this shift where it begins to be professional male hands that hold the knife. 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 becoming a specialism.
- [34:50]
Kate Lister
So when do we start to get a sort of a professionalism around? Well, as much as they could do caesarean sex, 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. Yeah, Gynecology becomes its own kind of institution, doesn't it?
- [35:09]
Hannah Marsh
Absolutely. So we do see men in the bathroom before then you have this, this character called the man midwife. And in his early form he's here, he's still pretty rare in the 1700s and. Yeah, but then in the 1800s we see this shift. So I don't know, it's kind of interesting because we, we have this enormous societal shift in the form of the eight, the kind of prolonged age of enlightenment where we see such huge shifts in the way that women in 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 male. And at the same time, yeah, we're, we're seeing this specialization 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 oils. And they were kind of more rough and ready within the community, quite almost quite like like manual labor kind of 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 specialization begin to happen. And yeah, this is really the dawn of obstetrics and gynecology. And it would be a long time actually, like obstetrics and gynecology would be like a bit maverick, a bit left field. Like 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 sat. 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 bathroom, 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 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, you know, 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. It's. There are good things that happen. One of the things that is just quite interesting to point out is that like this comes at the expense of female midwives. So at this point, female midwives, 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 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 practicing a lot, like being within their communities. You know, some of these midwives are attending 300 births a year.
- [40:14]
Kate Lister
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 demonized as that roundabout that this time.
- [40:27]
Hannah Marsh
Yeah. Kind of derided as quackery, superstitious, possibly occult.
- [40:33]
Kate Lister
The wise woman.
- [40:34]
Hannah Marsh
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 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.
- [41:27]
Kate Lister
Last resort. Nobody wants to perform them. And if they are being performed, the mother is usually deceased at that point.
- [41:33]
Hannah Marsh
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. 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 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 baby's head was. 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. They were. It was a pretty bleak situation that an obstetrician faced. But sometimes even the pelvis was so small or misshapen or there just wasn't even space to carry those options out. So a cesarean 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 cesarean 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.
- [43:05]
Kate Lister
I'll be back with Hannah after the short break.
- [43:24]
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- [44:55]
Kate Lister
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, does it? 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.
- [45:18]
Hannah Marsh
Maybe we should not go straight from autopsies to delivering babies.
- [45:23]
Kate Lister
It's awful.
- [45:24]
Hannah Marsh
Yeah, it's shocking.
- [45:26]
Kate Lister
When does it start to become like, I know that you've got the account of the pig gelder, but like when, like in medical. Yeah, that's a fluke. When do you start to get that? Doctors and physicians, they've kicked the midwives out. Bastards. But when do you start to get like that? This is actually something that's viable.
- [45:43]
Hannah Marsh
It could be done in the 19th century. There are three moments that really change things. The first one is, yeah, anesthetic. That is huge. 1846, Robert Liston operates, 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 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 cesarean 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 unsuchured, 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 Poro 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, we're not going to have any more children. 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 U.S. ah, yes. Who is known for his extremely controversial and racist experiments.
- [48:16]
Kate Lister
We can just say shithead, can't we? Just shithead experiments.
- [48:18]
Hannah Marsh
He's just an asshole. 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 over that 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 experimented so freely upon their bodies. And this is a myth that exists, exists now that echoes down through the ages and harms black women.
- [49:08]
Kate Lister
It's a lot of experimenting that went on to get us where we are, isn't there on the bodies, hugely enslaved women, poor women as well, were experimented on. Just. It's a grim, grim history.
- [49:19]
Hannah Marsh
There is inequity in birth now, and it is racial and it is social. And the color 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 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, you know, we benefit from today. And the legacy of the success of the caesarean section really owes a great debt to those women and the extraordinary suffering that they must have endured.
- [50:17]
Kate Lister
Was it Dr. Sims that pioneered a C section then?
- [50:21]
Hannah Marsh
So, no, he didn't. He didn't. But he did pioneer silver as silver sutures. 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. But miraculously, it 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 kind of suturing the uterus, and that is huge. So that silver suturing and Sanger's techniques, Joseph Lister and his work around germ theory and antiseptic and the earlier discovery of anesthetic 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.
- [51:25]
Kate Lister
Really, Is it a safe operation today?
- [51:29]
Hannah Marsh
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 safest 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, 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. 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 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 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 color 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 both the UK and the us, yes, 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 tell in a lot of places. And so yes, it is a safe procedure and in some places it's very routine, but it's not without risk and those risks are not born equally.
- [53:49]
Kate Lister
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, wasn't there 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. Why do you think we still have that stigma? What is that?
- [54:16]
Hannah Marsh
Misogyny?
- [54:17]
Kate Lister
We want women to suffer in childbirth. That's biblical, right?
- [54:21]
Hannah Marsh
Yeah, that is. That's one. That's one thread. You know, pain and suffering in childbirth, the transgression of Eve and her punishment is one. 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 mainstream patriarchal medical knowledge. His father was Apollo, the God, and his mother was a princess, Korones. And she became pregnant by Apollo. Cause 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 unbeknownst to her, 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, Ischis. Maybe she just realized 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's door, kills her with her arrow that never misses its target, and burns her body on pyre. 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 Caesarean section. And this child becomes celebrated for his learned 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 happen to her, she's Doing the best she can within a system that's quite stacked against her. But. But her role is one of shame and of punishment. And I think that really resonates for me. Now, you mentioned it 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 thread 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. This is like gold to the newspapers. Like, they can't resist Posh Spice, you know, it becomes too posh to push, 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 gonna birth in this way that's easy and convenient, 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 whole too posh to push thing. A lot of the media really willfully misinterpreted the idea of an elective C section with a maternal choice caesarean 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. Your baby might be breech, you might be having multiples, you might have placenta previa. That's not the same as. That's not a woman choosing to have a cesarean section. That's a medical advised cesarean 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.
- [58:45]
Kate Lister
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?
- [58:55]
Hannah Marsh
I'm on Instagram. Hannah Marshwrites I'd love to see you there. And otherwise my book thread 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.
- [59:13]
Kate Lister
Thank you so much for coming by. You've been marvelous.
- [59:16]
Hannah Marsh
Thank you Kate.
- [59:22]
Kate Lister
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 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@betwixtistoryhit.com We've got episodes on Victorian Sex work and Tudor and Stuart Aphrodisiacs or all coming your way. This podcast was edited by Tom Delaghi and produced by Stuart Beckwith. The senior producer was Charlotte Long. Join me again Betwixt the Sheets the History of Sex Scandal in Society, a podcast by History Hit. This podcast contains music from epidemic sound.
- [60:07]
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