Mere Medicine

Reflections on C-section survival, miscarriage death, and the limits of medicine in the face of the law

I apologize for the long break between posts! I spent the end of 2024 researching & writing a short story/accidental fan fiction about ABBA and OpenAI¹, but I’m back on the placental mammal beat now. Thanks for reading.

A cropped cover image of “The Story of Human Birth” by Dr. Alan Frank Guttmacher (1947).

The Cesarean section is the most common surgical operation in the world, accounting for 1 in 14 surgeries. Globally, about 21% percent of women give birth this way. And in emergency situations, the operation can be critical for preserving the health of both mother and baby.

While it can be a life saver now², for most of its early history, the C-section was a deadly procedure. It was so lethal that it was mostly performed on women who were dead or dying, the surgery a last-ditch effort to save the baby.

That’s why it’s highly unlikely that Roman emperor Julius Cesar entered the world this way.³ His mother, Aurelia, survived his birth!

Records indicate that not a single woman in Paris survived the operation from 1786 - 1876. And In the mid-19^th century, the mortality rate of the procedure in the United State was 85%.⁴

The C-section situation was so dire that American physician Dr. Robert P. Harris argued that it was safer for a pregnant woman to deliver via a wound caused by a bull goring than go under the knife – and had the data to back it up!

In 1887, the American Journal of Obstetrics published his study Cattle-Horn Lacerations of the Abdomen and Uterus in Pregnant Women which shared the cases of nine pregnant women who delivered their child after they were bored by bovines with the 12 women who were recorded to have underwent C-sections in New York before the late 1880s. Five of the women who were gored survived. Only a single woman survived a C-section.

This outcome led Harris to write the following about Shakespeare’s Macduff, a character in Macbeth who was born by C-section: "If Macduff told the truth, he is much more likely to have been delivered by a horn or sword than by the knife of a surgeon.”⁵

The survivability of the C-section started to improve starting in 1876 with the development of the Porro operation, in which the uterus was removed after delivering the baby. But it had the big downside of sterilizing the patient. The physician Max Sanger offered a marked improvement on the Porro operation in 1882. It involved — get this — leaving the uterus in place but sewing up the uterine incision, not just the abdominal one!⁶

The Sanger operation drastically improved C-section outcomes by reducing the risk of internal hemorrhage. It also set the stage for further improvements that made the C-section a widespread and safe procedure.

These medical advancements have made C-sections not just survivable, but ubiquitous. You certainly know people who have had them, or who have been born by them, or both. You might be one of them!

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Much of the C-section history recounted above is mentioned in the book “The Story of Human Birth” by Dr. Alan Frank Guttmacher, MD.⁷

The book was published during a time when Americans moving from home births to hospitals. In 1937, when the first edition of the book was published, about 37% of births occurred in hospitals. By the second 1947 edition ( the version I read), that percentage had almost doubled to 68%. Today the rate is almost 99%.

The history and innovations recounted by Guttmacher illustrate why hospitals have become the preferred place to give birth (and why they were avoided in times past ⁸).

Although I’m critical of many aspects of pregnancy medicalization —especially how ultrasound images and sounds have helped create the entity of the “public fetus” — reading about these advancements made me feel a sense of relief.

The modern C-section — along with anesthesia, antibiotics, and medical/surgical abortions — have completely changed the stakes of being pregnant and giving birth. When issues arise, doctors can treat them!⁹

This whole situation brings to mind a billboard that I frequently pass for St. David’s Healthcare that displays that same essential message 24/7.

It reads: High-risk pregnancy care. The best is here.

The thing is, that billboard is in Texas. To be true it would need to come with a giant asterisk and fine print: subject to approval by the Texas attorney general.

The best is here.*

The realities of human reproduction — which stem from our status as placental mammals — can make pregnancy and birth a risky time. As the saga of the C-section recounted above shows, revolutions in care can happen with sustained medical attention. But the C-section is just one of a host of medical procedures that have improved the stakes of pregnancy and delivery for women.

When treatment entails anything that has to do with abortion, Texas laws are making that care less certain — even when it’s desperately needed.

Doctors know what to do. The legal landscape is stopping them from acting.

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I’ve written before about how antiabortion laws have ripple effects that affect the care of pregnant women in general. Recent, reporting provides an unflinching look at what that really means.

Just last week, ProPublica published a story about soaring cases of sepsis among Texas women experiencing pregnancy loss in the second trimester. Since 2021, when Texas banned abortion, cases of the life-threatening infection have increased by 50%. The increase is associated with delayed medical treatment for miscarriage.

Not surprisingly, the condition was most pronounced in women whose fetus may have still had a heartbeat when they came in for treatment.

In Texas, the presence of a fetal heartbeat means that a woman must risk “death or substantial impairment of a major bodily function” before a pregnancy can be legally terminated. It doesn’t matter if other medical indicators show that the pregnancy is doomed, whether due to miscarriage or severe fetal abnormality.

But the case of Porsha Ngumezi shows that even when there’s no fetal heartbeat to be found, care can still be denied.

As ProPublica reported last fall, Ngumezi was a 35-year-old Houston woman who died in June of 2023 because she did not receive an emergency D&C to treat heavy bleeding during a miscarriage. A D&C is a surgical procedure that suctions out the contents of the uterus, and that can help stem uterine bleeding in the process.

When Ngumezi was miscarrying, doctors couldn’t detect a fetus, let alone a fetal heartbeat on the ultrasound. All that was visible was a “sac-like structure.” Yet instead of receiving the D&C she needed — a procedure that usually takes 30 minutes or less to perform — she bled for hours under observation in the hospital before her vitals crashed.

Since a D&C is sometimes used to perform elective abortions, Texas doctors are wary about using it to treat women, the story reports. The mere association of the procedure with abortion stopped Ngumezi from receiving the safe, straightforward care that she needed.

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In Guttmacher’s book, at the start of the chapter on obstetrical operations, the doctor makes a frank observation about a major shift in values he has observed around fetal life.

He writes: Until recently, except to a certain religious minority, the life and the health of each mother was inestimable more important than that of her child; today the pendulum has veered a long way toward dead-center.

Guttmacher thinks the reason for the shift comes primarily down to two related things: the improvement of the child mortality rate and families having fewer children.

Before our current age of antibiotics and vaccines, about 462 out of every 1,000 children died before their fifth birthday. With these numbers, a death of a child may have been a tragedy, but it wasn’t necessarily unexpected. As improvements in public health and hygiene have changed theses stakes, it’s led to the fetus gaining ground. In short: Children are expected to survive.¹⁰

In my opinion, this has led anything associated with fetal demise — whether elective or therapeutic — to become suspect, especially for people with antiabortion politics. Antiabortion laws arm that suspicion with punitive power.

Some people have written about how abortion bans tilt care toward prioritizing fetus over the woman, leading to a situation that law professor Caren Meyers Morrison describes as “fetal coverture”.

But I would say it's even worse than that. The case of Ngumezi shows that a fetus doesn’t have to be present for care to be denied. The mere idea of a fetus being potentially terminated is taking precedent over a pregnant woman in need of care.

It’s impossible to prioritize the public fetus living in the brains of antiabortion lawmakers or activists without harming actual patients in the process.

Still, antiabortion advocacy groups have reacted to the news of sick and dying pregnant patients by blaming doctors doctors for withholding care.

Earlier this month, Texas Alliance for Life published a press release noting that 135 medically necessary abortions have been performed in Texas since Roe was overturned in 2022. They hold up these abortions as proof that the current exceptions for the life and health of the pregnant woman are enough. Also this month, Gov. Greg Abbott told the Austin-American Statesman said that doctors who fail to “protect the life of the mother” are “actually violating their duty as a physician."

But the actual policies of the state tell a different story. They make medicine more difficult to practice, and pregnant patients more difficult to treat.

For example, the Texas Supreme Court declined to clarify what conditions constitutes a medical exception to the state’s abortion ban. The Texas attorney general sued the federal government when they sent a notice to hospitals saying that, under EMTALA, federal laws permit abortions if they’re needed to treat emergency medical conditions — leading to a state circuit court ruling that EMTALA does not apply to abortion care. And Republican Texas lawmakers have filed bills this legislative session to make mifopristone a controlled substance. The drug is used to induce first trimester abortions. But it’s also used to stem uterine bleeding after delivery. A controlled substance status would mean it would have to be kept under lock and key in hospitals. This has already happened in Louisiana, leading to concerns about caregivers being able to access it during medical emergencies.

Talk is cheap, and these calls against doctors primarily serve as shields for deflecting criticism of antiabortion laws that disempower medical providers from acting. But when facing a medical emergency, action is what saves lives.

1. I’m currently in the pitching stage. The story is pretty outside of my usual Substack writing wheelhouse, but it might end up here!

2. There’s also criticism from women and the medical community about its overuse.

3. Blame Pliny the Elder, a historian who lived more than a century after Cesar, for starting the rumor.

4. Both these stats are from The Story of Human Birth (1947).

5. Interestingly, Harris was a believer in the medical utility of the C-section! He just thought it was performed on women who were bad candidates for the operation. He blamed “meddlesome midwifery” for delaying C-sections until patients were too far gone. He thought that if the procedure was performed on patients who were in better health —healthy enough to care for livestock for instance — it would have an improved rate of survivability.

6. Before you slap your forehead too forcefully, doctors did have their reasons for not closing up the incision. There was 1) the risk of the sutures introducing infection and 2) the sutures coming loose and the wound re-opening when the uterine shrunk down from its pre-pregnancy size. Still, a short biography of Sanger still calls his innovation “embarrassingly obvious.”

7. If his name sounds familiar it’s probably due to the Guttmacher Institute for reproductive rights.

8. In short: hospitals were hotbeds for infection. Post-partum women were particularly susceptible to puerperal fever, which is caused by bacterial infection of the reproductive organs and was frequently spread from doctors to patients. In Guttmacher’s words, “until the second decade of the century it was mainly prostitutes and the very destitute who sought hospital deliveries.”

9. I know that’s a gross simplification in many cases. Many women have been harmed as result of unnecessary or overzealous application of medical procedures. I just want to recognize that we now have solutions to problems that didn’t exist in the past.

10. This expectation for survival brought on by medical improvements is also underpinning the anti-vaccine movement. People can become overly fixated on rare side-effects rather than the disease the vaccine prevents in the first place. We are now dealing with the largest measles outbreak in decades in Central Texas due to anti-vaccination negligence.