A third of US women now get C-sections — and the world's leading health organization says that's way too many

Here's a doozy of a birth story: In an 1830 issue of the Western Journal of Medical and Physical Sciences, Dr. John L. Richmond describes an impromptu surgery he performed in rural Ohio. Richmond had made his way through a storm to a "bleak home, with its dirt floor and gaping crevices in the logs that constituted walls." He found a woman who had been in labor for hours, but each contraction was followed by "general convulsions" and "alarming faintings." He dosed her with laudanum and sulphuric ether, which helped with the "fits," but he could not figure out why her labor wasn't progressing.

Richmond told the woman, the midwives who had been attending her prior to his arrival, and the friends and family watching and worrying that only a cesarean section would give the patient and the baby any chance to survive. "Feeling a deep and solemn sense of my responsibility, with only a case of common pocket instruments," Richmond made the incision. "The woman's friends," Jacqueline Wolf writes in her absorbing new book, 'Cesarean Section: An American History of Risk, Technology, and Consequence,' "helped by holding blankets in front of candles to prevent the howling wind from leaving the surgical scene in total darkness."

Richmond couldn't pull the baby out through his incision and ended up fishing around in the woman's uterus, looking for the feet. "The mother begged him to stop," Wolf writes. "She couldn't endure the pain." The doctor referred to the medical ethics of that time and place, and made a horrifying decision. "Reminding himself that 'a childless mother is better [off] than a motherless child,' " Wolf writes, "Richmond altered course and proceeded to remove the fetus, in pieces, from the wound in the mother's abdomen." The mother survived and went back to work 24 days after the surgery. "After she healed, Richmond examined her thoroughly and discovered an abnormally shallow vagina with no discernable cervical opening," Wolf reports. Richmond's story is the first published account of a C-section performed in the United States.

C-sections remained extremely rare throughout the 19 th century. Even after the mid-20 th-century advent of antibiotics and blood transfusions, which rendered the surgery much safer, the national rate of C-sections remained low. Then, the procedure exploded. Between 1965 and 1987, it rose 455 percent. Today, despite the work of the birth-reform movement of the '70s and '80s, 1 in 3 babies are still delivered by C-section. That's twice the recommendation set by the World Health Organization, which states that a 10-15 percent rate is the ideal, since a rate higher than that has been assessed to have no effect on mortality rates, even as it pushes up medical costs and increases other risks for both mother and baby. Wolf's book explains how we got here, taking a long, historically informed view of a modern problem. It's an activist text, committed to the proposition that our C-section rate is dangerously high, but it's also plainly excellent in its account of how medical and cultural factors combined to get us to this point.

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Nineteenth-century medical texts "counseled physicians to refrain from interfering with the birth process." Births were mostly attended by midwives. When a doctor had to come in, like Richmond, they worked under the assumption that it was more important to save the woman's life than the baby's. As a pregnant woman is prone to hemorrhage, the surgery was perceived as far too dangerous to undertake lightly. It was a last resort, only after drastic interventions that could include the use of forceps or the execution of a craniotomy, in which the doctor would collapse a baby's skull in order to extract it from the woman and save her life. The section of Wolf's book that covers craniotomy is very difficult to read, but as an illustration of how medical priorities around women and babies have changed over the past two centuries, its vividness is unrivaled.

Given that many doctors shied from C-sections because of the value they placed on the mother's life, it makes a terrible kind of sense that many 19 th-century cesarean patients were enslaved women, whose owners, performing their own calculations as to the relative value of woman and baby, gave consent to the surgery. Wolf cites an 1863 case in Arkansas in which the slave owner asked the doctor to remove the patient's ovaries after a second cesarean, to prevent her from getting pregnant again: "The child survived the birth; the mother died 10 days later of peritonitis." Another slaveholder celebrated a successful cesarean by setting the baby, named "Cesarinne," free.

Wolf's chapter on the 19 th-century record draws from the data left behind by Robert P. Harris, a Philadelphia physician who became a medical statistician. Harris took an interest in the C-section surgery and solicited accounts from doctors who had performed them. "His accounts appear to be inviolable," Wolf writes. "After receiving the initial description of a surgery, he followed up by contacting witnesses and the patient, if she had survived, for corroboration." A majority of the cases Harris documented were black patients; 20 percent of surgeries occurred in cases where the women were (in his description) "dwarfs."

Though curious about the surgery's possibilities, Harris was no cesarean booster. He found a 52 percent death rate in his records. He also collected stories of situations in which women had been "gored by cattle and forced to deliver their babies through the gaping wound," as Wolf memorably explains. He found nine, and noted that of those situations, the rate of survival of the women and children involved actually exceeded that of the C-sections performed in New York state before the late 1880s. "There is a far better showing for the cow-horn than the knife," he observed.