Not of Woman Born (1990), by Renate Blumenfeld-Kosinski

Renate Blumenfeld-Kosinski published Not of Woman Born in 1990. The book is a historical account of the cesarean birth procedure, hereafter c-section, during the Renaissance in Europe. A c-section is a surgical procedure that medical professionals use to deliver a fetus through an incision in a pregnant person’s abdomen. During the medieval and Renaissance periods, midwives performed c-sections on pregnant women after they had died when there was a chance that the fetus was still alive. They did this so the midwife could get the baby baptized, enabling it to be buried in sacred ground after death. Not of Woman Born traces how the procedure evolved in the late fifteenth and sixteenth century to be more commonly performed by male surgeons, rather than midwives, to save both the mother and the fetus. Blumenfeld-Kosinski provides historical, religious, and cultural context for understanding how people viewed and practiced c-sections in Europe during medieval and Renaissance times, in contrast to how people view and rely on the widespread delivery procedure in modern times. 

Background and Context

At the time she published Not of Woman Born, Blumenfeld-Kosinski was an associate professor at Columbia University in New York City, New York. She received funding to write the book from the Columbia University Council for Research in the Humanities and the National Endowment for the Humanities, a federal agency dedicated to supporting research in the humanities, or subjects such as literature, history, and philosophy. Blumenfeld-Kosinski conducted the majority of her historical research for Not of Woman Born in European libraries, including the Bibliothèque de 1'Arsenal in Paris, France, and the Wellcome Library for the History of Medicine in London, England. In her early career, Blumenfeld received her bachelor’s degree in French at Rutgers University in Newark, New Jersey, and went on to get her doctoral degree in romance languages at Princeton University in Princeton, New Jersey. As a French literature specialist, she has written multiple books, including Not of Woman Born in 1990 and Reading Myth: Classical Mythology and Its Interpretations in Medieval French Literature, which explored classical French mythology, in 1997. As of 2024, she holds positions as the President of the Medieval Academy of America, an organization that promotes medieval studies and Distinguished Professor Emerita in the Department of French and Italian at the University of Pittsburgh in Pittsburgh, Pennsylvania.

Not of Woman Born addresses the impact that religious views of the c-section and societal ideas about birth had on the procedure during the medieval and Renaissance periods in Europe. The medieval period, or Middle Ages, lasted from the fifth century up until the fifteenth century, and during that time, the Catholic Church was the center of the community structure throughout much of Europe. After the medieval period, a cultural and historical movement occurred from the fourteenth through seventeenth centuries, known as the Renaissance. During the Renaissance, many individuals’ interests moved towards art, philosophy, and nature and away from religion. During the medieval period and the Renaissance, c-section procedures focused on saving the fetus, often at the expense of the pregnant person’s life.

As of 2024, physicians perform the procedure with the intention to preserve the life of both the pregnant person and fetus. According to the Cleveland Clinic, modern c-section procedures are an effective alternative delivery method for women, particularly when vaginal delivery is unsafe. Due to access to modern medical resources such as sterilization and anesthesia, which is the application of numbing gas or other pharmaceuticals to prevent pain during a procedure, c-sections can be safe and painless for the mother. Prior to a c-section, the mother receives anesthesia to numb any sensation of pain, but the mother remains conscious. During a c-section, a physician cuts through the mother’s abdominal tissue and into the uterus, where the fetus develops during pregnancy. The surgeon removes the neonate, as well as the umbilical cord, the tube connecting the fetus to the mother during pregnancy, and the placenta, the organ attached to the uterus during pregnancy that supplies the fetus with nutrients and oxygen. As of 2022, roughly 22 out of 100 babies in the US are born via c-section.

Book Roadmap

The book Not of Woman Born is split into four chapters. In the first, “Caesarean Birth in Medieval Thought,” Blumenfeld-Kosinski describes that midwives performed the earliest examples of c-sections in medieval-period literature, under the influence and guidance of the Catholic Church. In the second chapter called “Caesarean Birth in the Artistic Imagination,” the author provides examples of medieval art depicting the procedure and describes how the art showcased the shift of c-section delivery from midwives to male physicians. In the third chapter, “The Marginalization of Women in Obstetrics,” Blumenfeld-Kosinski explains that that shift occurred as a result of c-sections becoming a medical procedure, and men had access to medical education, while women did not. In the fourth chapter called “Saintly and Satanic Obstetricians,” the author highlights the duality of societal views on the c-section procedure. In that chapter, she explains how some stories from the medieval period and Renaissance displayed c-sections as miracles, while others, including ones about the birth of the antichrist, a demonic figure within Christianity, which was reportedly by c-section, portrayed c-sections as demonic. Blumenfeld-Kosinski describes how social views influenced c-sections and birth during the medieval period and Renaissance. 

Detailed Content

In the first chapter “Caesarean Births in Medieval Thought,” Blumenfeld-Kosinski describes that before c-section delivery was common, women typically gave birth naturally in the medieval period with the assistance of midwives. Blumenfeld-Kosinski writes that during the Middle Ages, people largely saw it as improper for men to be present when women gave birth, unless it was the royal family. Therefore, midwives commonly assisted women with the birthing process instead of men, but medical knowledge of childbirth at that time was limited. She states that following delivery of the infant, midwives had the task of cutting the umbilical cord with a sharp object, such as glass or reed. Then, she details that the midwives swaddled the newborn and attended to the health of the mother and infant. Due to limited medical knowledge, many births resulted in still born fetuses or infants dying shortly after birth. Blumenfeld-Kosinski states that despite the risks associated with birth, natural delivery with the aid of midwives remained the most common form of delivery throughout the time period, even following the introduction of the c-section.

Next, the author goes on to discuss how the Roman Catholic Church began to permit midwives to perform c-sections under specific circumstances in hopes of baptizing the fetus. Blumenfeld-Kosinski explains that during that time, the Roman Catholic Church permitted members of the clergy such as monks and nuns to act as physicians, and nuns could take on the role of midwifery in their communities. She states that by the twelfth century, the Roman Catholic Church forbade its clergy to perform any procedures or surgeries involving the shedding of blood because the Church viewed it as sinful, leaving c-section procedures to midwives. She notes that the Church allowed midwifes to perform c-sections if there was a possibility that the fetus was alive after the mother had died. The Church did this because they wanted the fetus to be baptized into the Church to save its soul, according to their religious interpretation.

Blumenfeld-Kosinski goes on to discuss how the Church tasked midwives with the responsibility of deciding whether a c-section should be performed, thus determining the religious salvation of the fetus and the mother’s life. She writes that if a baptized mother died, and a midwife presumed the fetus dead inside the mother, the midwife could bury both the mother and the fetus in sacred ground. On the other hand, she states that if the midwife removed the fetus while it was dead, the baptized mother could be buried in sacred ground while the fetus, which could not be baptized, had to be buried outside the cemetery. Blumenfeld-Kosinski then details that after the midwife removed the fetus, if the fetus was alive, the midwife could find a priest to baptize it, therefore saving it in the eyes of the Church. She also writes that midwives decided whether to save the life of the mother or child, if delivery came to that decision. She states that midwives had to determine if a dying mother was beyond help and, thus, if they should perform a c-section to potentially save the life of the fetus at the cost of losing the mother, or to continue helping the mother in hopes that she might survive and potentially lose the fetus. The author explains that the Church advised midwives to save the child only when the mother did not have possibility of being saved. By the beginning of the Renaissance, it was common practice for midwives to perform c-sections on dead or dying women for the sake of the salvation of the fetus.

Blumenfeld-Kosinski continues by explaining how physicians and medical students began developing methods of cauterization, dissection, and autopsies, which allowed them to understand human anatomy, particularly that of pregnant females, in the thirteenth century. She details that prior to the thirteenth century, researchers did not perform human dissections due to social taboos around opening the human body. Instead, medical researchers performed dissections on animals and cadavers to learn about anatomy, which led to misconceptions about the human body, such as misunderstanding the location of certain organs. Blumenfeld-Kosinski explains that in the thirteenth century, physicians working in France and Italy wrote surgical treatises that contained new medical information on how to treat and cauterize wounds, which allowed surgeons to perform procedures more safely. She states that dissections and autopsies became a common medical practice at that time, and for the first time, scholars began to understand human anatomy and bodily processes. The author explains that physicians followed protocols to perform dissections on human cadavers in the thirteenth century, which allowed the stigma around performing surgery to dissolve. After dissection of the human body became more accepted, medical writers included dissection procedures in the texts they published during the early fourteenth century.

Blumenfeld-Kosinski concludes the first chapter by discussing how physicians published new medical information about childbirth and c-sections in the fourteenth and fifteenth centuries, which led c-section practices to transfer from the purview of midwives to male surgeons. She discusses the advancements of various physicians, including Guy de Chauliac and François Rousset. She writes that in the fourteenth century, Guy de Chauliac, a surgeon in France, wrote a medical treatise titled Grande chirurgie (Major Surgery). Blumenfeld-Kosinski writes that the text mentioned the c-section procedure and stated that if the woman dies, the midwife should remove the fetus if it is still alive, while also holding the mouth of the mother open, according to tradition. Blumenfeld-Kosinski remarks that Chauliac’s attention to c-sections reflects the growing interest of male surgeons in childbirth, which was previously an area reserved for females. In 1581, François Rousset, another French physician, published Traitté Nouveau de Phystérotomotkie, ou enfantement Caesarien (New Treatise of Caesarian Childhood). According to Blumenfeld-Kosinski, Rousset’s work was one of the first to suggest performing c-sections on living women. She explains that he suggested the reasons why a physician may need to perform a c-section, such as a large fetus positioned feet-first or the presence of twins in the womb, which may prevent a woman from giving birth naturally or cause undue distress for the pregnant mother. Blumenfeld-Kosinski argues that works like Chauliac’s and Rousset’s reflect a shift from midwives previously performing c-sections for the salvation of a fetus to male surgeons performing c-sections to aid the mother in delivery without losing her life.

In the second chapter, “Caesarean Birth in the Artistic Imagination,” Blumenfeld-Kosinski discusses that artistic representations of c-sections exist from the late thirteenth to sixteenth centuries and concludes that the art depicts the displacement of midwives for male surgeons in the role of childbirth over time. Many medical art pieces in the twelfth and thirteenth centuries depicted surgical illustrations, particularly dissections and bloodletting, which is removal of blood for medical purposes. The artistic representations of birth during the 1300s were most often either medical depictions or dramatized Christian art. She states that the artistic representations of childbirth were often inaccurate, such as a work in Chirurgi (Surgery), a Latin manuscript by Abulcasis, a surgeon from Spain, where he depicted twin delivery simultaneously with two heads emerging from the birth canal. As of 2024, it is medically known that twins are typically born a few minutes apart, not at the same time. The artists and illustrators were often not well versed in internal anatomy or medical procedures, which Blumenfeld-Kosinski states is evident in their works. Blumenfeld-Kosinski also discusses how throughout the medieval and Renaissance periods, many artists painted the c-section birth of Julius Caesar. Each artist painted the scene in slightly different ways such as the position of the mother and placement of incision. The author concludes that in the twelfth and thirteenth century, such portraits portrayed midwives performing c-sections, but later in the 1500s, the paintings portrayed male surgeons performing the procedure.

In the third chapter, “The Marginalization of Women in Obstetrics,” the author discusses that laws and education barriers facilitated the shift in childbirth and c-section delivery from female midwives to male physicians. Blumenfeld-Kosinski states that women controlled the infant delivery process because the Roman Catholic Church believed only women should be present for birth in the Middle Ages. However, in the thirteenth and fourteenth centuries, new medical facilities and medical education helped make medicine a more professional practice, which educated men about anatomy and procedures, and eventually pushed midwives out of performing c-sections, since laws prohibited women from studying medicine. According to the author, midwives were still present for births, but only as medical assistants for exams and small procedures. Blumenfeld-Kosinski explains that European men in high society were skeptical of women who practiced medicine, who at the time were almost exclusively midwives, due to the stigma associated with ideas of witchcraft that arose in the late fifteenth century. Blumenfeld-Kosinski argues that the fears about witchcraft were likely focused on women such as midwives to promote male social power and due to patriarchal fears that women were too established in the workforce. Midwives during this time were often single women, and the author claims that the witch hunts focused on these women due to the threat that social group posed for powerful groups of men.

In the fourth chapter “Saintly and Satanic Obstetricians,” Blumenfeld-Kosinski explores the duality of the views on c-section in medieval society by explaining the miraculous stories of saints saving women in childbirth as well as folklore surrounding the antichrist’s birth by c-section. She states that, during the fourteenth century, many people reported witnessing or having miraculous births, where saints, or Christian religious figures with supernatural power, would assist men in saving women and children by using c-sections. Blumenfeld-Kosinski argues that many of those reported cases were unrealistic based on the details. In the fifteenth century, images and descriptions of the birth of the antichrist began to emerge. She explains that many authors wrote different stories about the antichrist’s life, some of which show the midwives as demons assisting the devil in the birth of the antichrist.

Impact

As of 2024, Not of Woman Born has over 230 citations on Google Scholar. At present, medical professionals view c-sections as a safe medical procedure for delivering a fetus when the mother or fetus’s health are at risk. Not of Woman Born assesses how c-sections evolved between the Middle Ages and the Renaissance by analyzing medical texts, art, and folklore that mention the procedure across the fifth through sixteenth centuries. The extensive folklore surrounding the procedure and those who were born by c-section demonstrates that birth, and specifically birth by c-section, socially and politically influenced medieval and Renaissance society. The views and perspectives of the Renaissance on birth and c-sections described in Not of Woman Born contrast with the evolved and modern views on medicine and childbirth. Male or female physicians, known as obstetrician-gynecologists, typically perform c-sections in hospital settings. Midwives typically do not have the training required to perform a c-section, but they continue to provide support to women before, during, and after the childbirth process. Not of Woman Born remains one of the few sources providing a comprehensive history of c-sections from the Medieval and Renaissance periods.