Cesarean sections became common in the United States during the 1970s and 1980s, when the rate climbed from about 5% of all deliveries to nearly 23%. But the surgery itself has a much longer history, and the path from deadly last resort to routine procedure took centuries of medical progress.
Centuries as a Last Resort
For most of recorded history, C-sections were performed only on women who were already dead or dying, usually as a desperate attempt to save the baby. The first written account of both mother and baby surviving comes from Switzerland in 1500, when a pig farmer named Jacob Nufer reportedly performed the operation on his wife. That story, while famous, was an extreme outlier. For the next several hundred years, the surgery almost always killed the mother through blood loss or infection.
It wasn’t until the nineteenth century that doctors began to believe they could perform the operation and keep the mother alive. The real breakthrough came in 1882, when German gynecologist Max Sänger proposed something that sounds obvious today: stitching the uterus closed after cutting it open. Before Sänger, surgeons left the uterine wound open, and hemorrhage killed many women on the operating table. His suturing technique quickly became standard practice and caused a dramatic drop in maternal deaths.
The Early Twentieth Century: Rare but Survivable
Even after Sänger’s technique spread, C-sections remained uncommon well into the 1900s. The surgery was reserved for emergencies where vaginal delivery would likely kill the mother or baby. Infection remained a serious threat until antibiotics became widely available in the 1940s, and general anesthesia still carried significant risks of its own. During this era, the physician Edwin Cragin coined the phrase “once a cesarean, always a cesarean,” reflecting the reality that women who survived one C-section were unlikely to safely deliver vaginally afterward. At the time, pelvic deformities from conditions like rickets were still common, drugs to speed up stalled labor didn’t exist, and the surgery itself was crude enough that a scarred uterus was considered permanently compromised.
The 1970s and 1980s: The Rapid Climb
The C-section rate in the United States sat at just 4.5% in 1965. By 1985, it had reached 22.7%, a fivefold increase in two decades. The sharpest jump happened between 1980 and 1985, when the rate rose more than six percentage points in just five years. Several forces drove this surge simultaneously.
Electronic fetal monitoring, developed in the 1920s but not widely used until the 1970s, became standard practice in labor wards. These machines continuously tracked the baby’s heart rate during contractions, and any sign of distress gave doctors a reason to move to surgery. The technology saved lives, but it also flagged many situations that might have resolved on their own, pushing more deliveries into the operating room.
Cragin’s old rule also played a major role. Because repeat C-sections were considered mandatory after a first one, each new cesarean created a near-guarantee of surgical delivery for every future pregnancy. This compounding effect drove a significant portion of the overall increase during these decades.
Malpractice pressure added another layer. Obstetricians in states with higher malpractice litigation rates performed more C-sections, a pattern researchers have interpreted as defensive medicine. A doctor facing a potential lawsuit had more legal protection if they had performed a C-section than if they had waited and something went wrong during vaginal delivery. One analysis estimated that reducing malpractice insurance premiums by $10,000 would result in roughly 6,000 fewer cesarean sections nationwide in a single year.
Where Rates Stand Today
Globally, about 21% of all babies are now born by C-section, based on data from 154 countries covering nearly 95% of the world’s births. That average masks enormous variation. In sub-Saharan Africa, the rate is just 5%, a level that suggests many women who need the surgery can’t access it. In Latin America and the Caribbean, the rate is 42.8%, more than four times what the World Health Organization considers ideal.
The WHO has maintained since 1985 that the optimal population-level C-section rate falls between 10% and 15%. Research supports a clear benefit as rates approach 10%: fewer mothers and babies die. Above that threshold, higher rates don’t improve survival. The United States currently sits well above the WHO recommendation, with roughly one in three births delivered by cesarean. The rate has been relatively stable since the mid-2000s after climbing steadily for four decades.
Why the Rate Stayed High
Once C-section rates rose in the 1970s and 1980s, they never came back down. Several factors locked the higher rate in place. Vaginal birth after cesarean, known as VBAC, gained popularity in the 1990s as a way to reverse the trend, but many hospitals later restricted or stopped offering it due to the small risk of uterine rupture and the malpractice exposure that came with it.
Scheduling also plays a role. A planned C-section is predictable for both the doctor and the patient, fitting neatly into a hospital’s workflow in a way that a 20-hour labor does not. Rising maternal age and higher rates of conditions like obesity and gestational diabetes have also increased the share of pregnancies where doctors recommend surgical delivery. The combination of medical, legal, and practical pressures means the procedure that was once a death sentence has become, for better or worse, one of the most common surgeries in the world.