Just How Old Is C-Section Birth?

An 18th-century Hungarian woman made history this week—her mummified remains preserve the earliest direct evidence of C-section. Sadly, neither she nor her full-term son survived. Which raises the question: Just how old is C-section birth, and when did women and babies start surviving it?

CHILDBIRTH AS EVOLUTIONARY COMPROMISE

Basically since humans started walking upright, childbirth has been difficult for women. The brains of our hominin ancestors got larger and larger, with the result that today’s average newborn has a head 102 percent the size of its mother’s bony pelvis. Yes, you read that right—our babies’ heads are actually larger than our skeletal anatomy.

Obviously, an evolutionary compromise was worked out, so that humans could have large-brained babies and still walk upright. Babies’ skulls bones can slide around and overlap to help them get out. The fetus also goes through a sort of dance when it’s born, wiggling and turning with the help of contractions to make its way through the bony pelvis. And, perhaps most importantly, towards the end of pregnancy, a hormone is released that weakens the cartilage of the joints of the pelvis, letting it widen just enough for the baby to come out.

But we humans also rely on culture for our existence, and the same is often true for birth. The caesarean section—which includes the Latin root word for cut—involves extraction of a baby through a cut into the mother’s uterus. Although the practice dates back thousands of years, women didn’t survive it until comparatively recently.

HISTORICAL RECORDS OF C-SECTIONS

Ancient Roman relief carving of a midwife attending a woman giving birth. Wikimedia Commons // CC BY 4.0

There is some argument among scholars that C-sections were performed in Egypt around 3000 BCE, but the earliest clear documentation in ancient texts comes from early Rome. The second king, Numa Pompilius (c. 700 BCE) passed a law called the Lex Regia, later renamed the Lex Caesarea and reported in Justinian’s Digest (11.8.2). This law forbade burying a pregnant woman until her offspring had been excised from her body. The reason stated for the law was that there was a small chance the baby would survive, but it is unclear if the law was religious in nature or whether it simply aimed to increase the population of tax-paying citizens. A similar reference to post-mortem delivery comes from Sage Sustra, a practitioner of Hindu medicine around 600 BCE. But in neither case is it clear how often—if ever—this was carried out.

This means that the first person who was born by C-section is also hotly debated. Julius Caesar is often held up as the most famous example, with the assumption that his cognomen—third name or nickname—resulted from his style of birth. Sadly, it seems that the Roman author Pliny either made this up or was referring to a very distant ancestor of the Julii clan. Since women didn’t survive C-sections in ancient Rome, Caesar’s mother Aurelia, who lived well into her 60s, did not deliver him in that way.

Historical records of famous people born by C-section actually go back further than Caesar, though. Some scholars claim [PDF] that the earliest documented C-section produced the orator Gorgias in the 5th century BCE, but the historical evidence is murky. Although Pliny was wrong about Caesar, in his Historia Naturalis (VII.ix) he wrote that the celebrated Roman general Scipio Africanus was born in this manner in 236 BCE. If either of these cases is correct, there is evidence of viable offspring from C-sections nearly 2500 years ago. But these procedures were certainly only done when the mother died or was about to die in childbirth.

It wasn’t until the 1500s that doctors began to expect women to survive the procedure. French physician François Rousset broke with medical tradition at the time and advocated performing C-sections on living women. In practice, though, it was still only performed as a last-ditch effort to save the newborn. Certainly some women survived C-sections from the 16th to 19th centuries, but it was still a very risky procedure that could easily lead to complications like endometritis or other infection. C-sections didn’t become common until the 1940s, following advances in antibiotics that made them survivable.

ARCHAEOLOGY OF CHILDBIRTH AND C-SECTIONS

Medieval caesarian on a deceased woman. Wikimedia Commons // CC BY 4.0

The infant mortality rate was very high in antiquity, as were rates of mothers dying in childbirth. Consequently, you might expect that archaeologists have found loads of mother-fetus burials. But very few exist. In fact, the number of pregnant female burials in the published archaeological literature from around the world is only about two dozen.

There are several potential reasons for this lack of evidence. First, archaeological methods got significantly more scientific in the 1970s, so more recent excavations are better at finding tiny fetal bones. Second, the mother could outlive the fetus, and the newborn could outlive the mother. Death at different times will not be obvious archaeologically as evidence of childbirth-related complications. Even when the mother and baby both die before birth, though, this may not be evident because of a phenomenon called “coffin birth”—when the gases that build up within a corpse cause post-mortem “birth” of the fetus. And finally, cultural practices could be to blame for our lack of evidence—application of the Roman Lex Caesarea, for example, could result in a woman buried by herself and a viable newborn who grows up and dies much later.

Unfortunately for archaeologists, C-sections usually involve soft tissue only, so it is unlikely that we will ever find direct ancient evidence of it in a skeleton. There are two possible ways to see physical evidence of ancient C-sections. One is cut marks on the pelvis made around the time of the mother’s death by a surgeon. (Normally, C-sections don’t involve cut bones, but symphysiotomies—cutting through the front of the pelvis—can be done with or without accompanying C-sections to aid in delivering a baby.) The second is a mummy with an incision into the uterus and other physical changes associated with pregnancy and labor. At the International Conference on Comparative Mummy Studies earlier in April, the first-ever direct evidence of an early C-section was presented. The case study, presented by anthropologist Ildikó Szikossy of the Hungarian Natural History Museum, involves a woman named Terézia Borsodi, who died in December 1794 during the birth of her sixth child. While historical records suggest that the baby boy was delivered alive, Terézia’s mummy shows she was likely already dead when the C-section was performed. The baby also did not survive, and they were buried together.

CHILDBIRTH IS BIOLOGICAL AND CULTURAL

Successful Caesarean section performed by indigenous healers in Kahura, Uganda (1879). Wikimedia Commons // Public Domain

Childbirth is both a biological and a cultural process, today and in the past. But while biological variation is consistent across all human populations, the cultural processes that can facilitate childbirth are quite varied. A quick glance at the rates of elective C-section around the world demonstrates this easily. So archaeologically, we should also expect to see variation in the lives, deaths, and burials of women and infants.

Archaeologists use skeletons, historical records, medical artifacts, and other clues from burials to reconstruct childbirth practices and interventions in the past. New advances in microscopic analysis of the bones of ancient fetuses are also revealing whether or not the baby was alive or stillborn. As the archaeological record gets better, and as excavation, recording, and analysis techniques advance, we should soon have better methods for understanding this key time in the lives of mothers and infants, and for figuring out when the earliest C-sections occurred.