On C-sections, preparing for the unexpected, and knowing that 'the way you birth your baby doesn’t mean anything about you as a mother'

A discussion around Invisible Labor, with author Rachel Somerstein

Thank you to all my new subscribers - and welcome to The Village! I’m Kate – an essayist and mother fascinated by the ways we create community in our lives, inspired by those who do it well, and convinced that thriving communities are what makes for a joyful world.

Today’s interview is with Rachel Somerstein, a writer and thinker I deeply admire, whose critically acclaimed book Invisible Labor: The Untold Story of the Cesarean Section is out now. The work details the history of the procedure, and its rise within the medically complex world of American childbirth.

For Somerstein, this is a personal story. The birth of her first child went terribly wrong when she needed an emergency C-section - an event made horrific when the anesthesia did not work. This trauma made a lasting impact on Somerstein, who began researching the history of the procedure and its use in childbirth. The result is a gripping read, at once heartbreaking and hopeful, on how women’s agency in birth has historically been ignored - and what can be done moving forward.

We spoke over email about her work, her experiences, and the researchers whose insights continue to shift the realm of the possible for families welcoming new children into the world.

KL: You wrote this book in the aftermath of your own traumatic, horrific birth experience. What was one of the things that made researching and writing this work so important to you?

RS: When I was recovering from the birth in 2016, I wanted to read everything I could about C-sections, but there wasn’t that much I could find. And I mean that across the board: there was a paucity of books about people’s experiences; what C-section recovery really looks like; explanations for why C-sections constitute 1 in 3 births in the U.S. (a statistic that floored me when I first learned it); in-depth looks at their history. Much of what I read about them underestimated them—how tough they are on mothers, how they can shape the rest of your reproductive life. And many resources—books, TV, movies—failed to mention them at all.

I wanted to fill that gap.  To write the book that I and other people in my position—shocked at having needed a cesarean and trying to get our heads around what had happened—needed to read. I also wanted to write a book about survival, about overcoming a traumatic birth.

It was also really important to me to explore why we’ve said comparatively little about cesareans, despite how common they are. What does that say about the U.S.? What does it reveal about the culture in which we birth?

KL: For people considering parenthood or approaching labor, what are some of the things you wish you’d known prior to your own hospital experience?

RS: On the pragmatic side: I wish that I had learned about what happens in a C-section. When I was pregnant, I skipped over those parts of the books I read because I assumed I wasn’t going to have one. Bad idea! I wouldn’t have been as frightened during labor and leading up to the birth if I’d known what to expect. In many ways I was naïve and unrealistic. By virtue of numbers alone—1 in 3 births in the U.S. is a C-section—surgical birth was a real possibility.

That goes for recovery, too. I had prepared so much for a vaginal birth that I’d ordered a sitz bath, had doused menstrual pads with witch hazel and put them in the freezer. But the first time I learned about what a C-section recovery is like was when I was living it: in bed, unable to sit up unassisted, needing to ask my husband to lift me so I could go to the bathroom. I still would have been shocked at my condition even if I’d been better prepared—I mean, I’d walked into the hospital on my own, and was in terrible shape just a few days later. But I would have known that it’s totally normal, after a C-section, and that I would get better.

I also wish I had known that the way you birth your baby doesn’t mean anything about you as a mother. For awhile I felt as though there was something lesser about me because I’d had a cesarean—that my mode of birth said something bad about my character. It’s ridiculous—birth is birth, an incredible, exhausting, all-consuming feat no matter how the baby makes it out. But I had all of these stigmas about cesareans that have nothing to do with the actual operation. Instead, as I learned—and as I write about—they reflect the history of cesareans and the associations we have with unmedicated vaginal birth.

Last, I also would have wanted to know the different C-section rates of the hospitals where I considered having my baby. I went on reputation alone, and chose what I believed to be the “crunchier” hospital that would support vaginal birth. Its C-section rate is nearly the same as the hospital nearby with a reputation for being super-medicalized. In fact, the providers I saw at that medicalized hospital, for my second birth, had superior skills for attending vaginal birth. I write about that in the book too—how my second labor was a lot like the first, and how, in different hands, I might not have needed a C-section the first time.

KL: The book investigates both the history of the C-section, including the horrors of its early use on enslaved women, and the modern-day ethics, impacts, and implications of the procedure. What was your research process like for the work? Were there things you didn’t expect to uncover?

RS: I talked to so many people with different perspectives on birth: nurses, midwives, physicians, ethicists, economists, lawyers, demographers, sociologists, doulas, historians, policymakers. And, of course, dozens and dozens of mothers who’d had cesareans—some of whom were also experts in the fields I just mentioned. These sources helped me to understand the history of birth and how to think about motherhood intersectionally—that is, to bring in race, and class, and disability when I learned about experiences of pregnancy, C-sections, and access to providers in the past and the present.

I also read lots of archival materials, including obstetric and midwifery textbooks and medical journals. I read what other historians have written about obstetrics and birth in the U.S., particularly Jacqueline Wolf’s Cesarean Section and Deirdre Cooper Owens’s Medical Bondage. And I read about the history of birth from the perspectives of sociologists, specifically Barbara Katz Rothman, who treat birth as a site to investigate what people’s experiences of it reveal about the positions—and comparative power—of women, doctors, midwives, and technology. Whose knowledge is prized? Whose is dismissed? How has that changed over time? What does that reveal about these people’s values to society? C-sections are an excellent place from which to ask those questions.

I didn’t expect that this research would bring me to the history of midwifery. But you can’t talk about C-sections if you don’t talk about the decline of midwives or about the medicalization of birth. So along the way, I learned that in the US, midwives historically were Black, Indigenous, or immigrants, and that these groups were pushed out of the profession—something that still shapes birth today, shapes who has access to midwifery. I was also surprised to learn about the relationship between C-sections and eugenics—that is, this idea, in the late 19^th and early 20^th centuries, that the people who were most likely to need a cesarean weren’t fit to be mothers, and should be sterilized during the operation.

KL: What are the hopes you have for the future of C-sections and steps toward reproductive justice?

RS: I hope that we can continue to move toward greater recognition that reproductive justice must be the framework through which we discuss all aspects of pregnancy, reproduction, and parenting. That is, we can’t speak about access to abortion, and access to midwifery, as if they’re issues that affect different people. The person who wants to terminate a pregnancy is the same person who, at another time in her life, wants to see a midwife, or needs an IUD, or wants to have access to a vaginal birth after cesarean section. You can see that clearly with one of the delegates to the DNC, Kate Cox. She was denied an abortion in Texas—the pregnancy wasn’t viable—and had to travel to another state to get one. She is now pregnant again and due in January. She wanted both pregnancies, and had different needs for each one.

As for C-sections in particular, I hope that we can start to respect them for the life-changing and invasive and sometimes life-saving operation that they are. I write about this in the book, but we don’t accord them sufficient respect. One sociologist I talked with, Keisha Goode, said that we treat them as if they’re putting on a band-aid. A C-section cuts and parts through seven layers of tissue; it’s anything but easy.

KL: Whose work in reproductive justice and care have you found especially inspiring?

RS: So many people. I’m especially inspired by some of the academics I mentioned, because they are doing research that lays important foundations for theories and histories of reproductive justice. They also share their work, publicly and in academic channels, to get the ideas of reproductive justice into the public culture.

Also, so many midwives are doing incredible work in this area. They attend births; teach student midwives; and often hold leadership positions in organizations working to make birth safer and more joyful for everyone. To name a few: Helena A. Grant, a certified nurse-midwife who attended births in the hospital in New York for many years, and is now senior advisor of Midwifery Initiatives at New York City’s Department of Health and Mental Hygiene; Jamarah Amani, a licensed midwife in Miami, and the founder of the Southern Birth Justice Network; and P. Mimi Niles, a practicing midwife and assistant professor at NYU who is researching the ways that midwives can be more thoroughly integrated throughout the US medical system—something that, as worldwide authorities including the WHO and the editorial board of the Lancet have stated, will make pregnancy and birth safer for everyone, no matter how your baby makes it to this side of the veil.

Thank you so much, Rachel, for your words and your work, and thank you for reading. What are some of the things you wish you’d known going into the experience of childbirth? What might better prepare us to face the unknown and to prepare for recovery? I’d love to know your thoughts in the comments below.

Pick up your copy of Invisible Labor: The Untold Story of the Cesarean Section and check out my this & other recommended titles on parenthood + craft at my Bookshop here.

About Kate Lewis

Kate Lewis is an essayist and poet whose work appears in The New York Times, The Washington Post, Good Housekeeping, Men’s Health, Romper, The Good Trade, Literary Mama, River Teeth’s Beautiful Things, and elsewhere. She lives outside Washington, D.C. with her husband, their two young children, and a mischief-making dog. Her work has been nominated for Best of the Net and supported by the Perry Morgan Fellowship from Old Dominion University. At Substack, she writes The Village, conversations on craft and community. Find her online @katehasthoughts.