In a country with one of the highest C-section rates, technology, habits and fear of risks all block the path to a natural delivery.
Dannette Lund had 2½-year-old Ruth Ann by Caesarean section but wanted a natural birth for her second child. Repeat C-sections have become standard for women who have had one, but Lund fought the trend and delivered Ellie naturally.
Dannette Lund wanted to have her second baby the natural way, but she had to flout all the best medical advice to do it.
Because she had delivered her first child by Caesarean section, a hospital birth would almost certainly mean surgery again. Home birth? Her midwife refused, saying it was too risky. A birth center outside a hospital? She'd have to shell out $7,000 because her insurance wouldn't cover it.
"I felt like I had no options," said Lund, 36, who lives near Waconia. "I was so frustrated."
Lund and other women have discovered that birth in America is rarely the natural event they long to experience. Even though it's neither an illness nor an injury, childbirth is the nation's leading reason for hospitalization. It accounts for six of the 15 most commonly performed hospital procedures and $80 billion a year in hospital charges -- much of it paid by taxpayers through Medicaid. Last year, almost one-third of American babies were delivered by Caesarean section, twice the rate recommended by the World Health Organization.
Childbirth, in turn, is a microcosm of American health care, a system built around expensive, high-tech procedures. Americans spend at least 50 percent more on health care than countries such as Germany and Japan. Researchers at the Dartmouth School of Medicine estimate one-third of medical care in this country, about $700 billion a year, could be curtailed without reducing quality.
Although modern medicine has improved the health and quality of life of millions of people, many say the system has trouble distinguishing between effective and ineffective medical interventions, especially when all the incentives line up to push doctors to do more, not less.
"There is a huge opportunity here that we have to explore," said Dr. Neil Baker, an authority on medical cost and quality at the Institute for Healthcare Improvement in Boston.
With health care consuming more than $1 in $7 out of the economy, reducing health care costs, starting with birth, is paramount to the nation's financial health, economists say.
In the Twin Cities, a handful of doctors and hospitals is starting to rethink the assumptions about maternity care. But as Lund discovered, thwarting the forces that lead to expensive, medically intensive birth is next to impossible.
"It is sad," said Dr. Alan Peaceman, an obstetrician and childbirth researcher at Northwestern University in Chicago. "Many of us believe that this is not in the best interests of women. We are not convinced that babies are safer or healthier."
A one-way street
Lund wanted a natural childbirth with her first daughter, three years ago. It's something only women can do, she said, and "it's something I wanted to experience."
But the week she was due, a fetal stress test hinted at a problem. She went to the hospital. As soon as the doctor walked in "she wanted to do a C-section," Lund said.
Lund and her husband resisted the idea for five hours, she said. In the meantime, the medical staff at Ridgeview Medical Center in Waconia broke her water, tracked her baby's heartbeat with two different monitors and accelerated her contractions with drugs.
Everyone said they had the baby's health in mind, "but that's the line they give to everyone who is wheeled into surgery," Lund said. "It wasn't persuasive."
But eventually she could see for herself on the fetal heart monitor that her baby was under stress, and she agreed to a C-section. "It was really difficult for me, emotionally and physically," Lund said.
It's impossible to say, of course, what would have happened to Lund and her baby without the surgery. Medical advances have improved outcomes for Americans all across the health care spectrum, and birth is no exception, with maternal and infant death rates falling sharply since the early 20th century.
But some say the pendulum has swung too far. The share of babies born before 37 weeks has jumped sharply since 1990, partly because doctors induce labor more often. C-sections have increased by more than 50 percent in the past decade and are now the most commonly performed surgery in the country.
Experts say that widely used technologies such as ultrasounds and fetal monitoring start birthing mothers down a road of one medical intervention after another -- inductions that lead to drugs that accelerate labor that lead to anesthesia for pain control. Routinely, it culminates in the most intensive and expensive intervention of all, a C-section.
Black and white?
The trend has many causes: patients' preference, doctors' schedules, economic incentives and malpractice suits.
The chain of events often begins with inducing labor, by either breaking the amniotic sac or administering drugs, instead of waiting for birth to start on its own. Inductions allow patients and doctors to control the timing and circumstances of delivery.
"People are more concerned about their input into their childbirth than any other part of medical life," said Dr. Stan Davis, an obstetrician who is studying quality in maternity care for Fairview Health Care.
Sometimes, as in Lund's case, the doctor suspects a problem. But often, it's convenience: a patient who is sick and tired of being pregnant or whose husband will be out of town on her due date.
"Moms always ask, 'When can I get induced?'" said Terri Loscheider, the head maternity nurse at Ridgeview.
Only that's not good for babies or mothers. Babies born even a week or two before their due date are more likely to suffer complications, such as respiratory distress and longer hospitalizations, and to die within the first year of life, according to the Centers for Disease Control and Prevention.
For mothers, inductions lead to more painful births, blood loss, anesthesia and C-sections.
"There is little that is black and white in medicine," said Dr. Penny Wheeler, medical director for Allina Hospitals & Clinics and an obstetrician. "This one is."
But it's not just patient preference that drives the trend toward surgical births. Doctors like to control their schedules as well, Peaceman said.
"There is nothing more convenient to a physician than scheduling an operation at 7:30 in the morning and being back in the office by 8:15," Peaceman said.
Financial incentives line up, too. Minnesota hospitals charge on average about $8,000 for a normal vaginal birth and $16,000 for an uncomplicated C-section.
But the biggest factor driving medical interventions, from ultrasounds to fetal monitoring to surgery, the experts say, is the fear that the baby or mother will suffer a tragic outcome during a vaginal birth. The risk of those events is extremely low, but the emotional consequences -- and legal risks -- are enormous.
That's one reason why obstetricians have some of highest malpractice insurance rates among specialists, and births that go wrong often draw the highest jury awards. Just last January, a jury in Willmar awarded $23 million to a toddler who in 2007 was severely handicapped for life as a result of being deprived of oxygen during a vaginal birth.
"No one ever gets sued for having done a C-section too soon," Peaceman said. "Never."
Neil Baker says doctors almost always believe they are making the right choice for their patients. Generally, he said, physicians don't know if they are overusing a procedure, and it tends to happen when there is a lot of uncertainty and not much science. So doctors rely on what they were taught and what their colleagues do, which leads to wide variations across the state and the country.
No one knows what the proper C-section rate should be, especially given the trends of rising obesity, larger infants, older mothers and multiple births, all of which can make a C-section advisable.
But C-sections are also rising among women who should be able to have a normal, vaginal birth.
In part that's because many women don't know the surgery's risks: infection, excessive bleeding, emergency hysterectomy and the likelihood of future C-sections.
The medicalization of birth might be justified if the United States had better outcomes than other advanced countries. But it doesn't. Its infant and maternal mortality rates are significantly higher than those in most European countries.
In the past two years some hospitals and leading medical organizations have started to fight these trends.
Fairview, Allina Hospitals & Clinics and other hospitals are starting to draw a gestational line in the sand: no unnecessary inductions before 39 weeks. In 2008 Fairview Southdale in Edina imposed a rule requiring doctors to ask the head of obstetrics for permission to do elective early inductions. Within months, they dropped from 15 percent of all births to just 2 percent.
But reducing C-sections may be more difficult.
"There is nobody advocating for lower C-section rates," Peaceman said. "It's not insurance companies. Not doctors and not women."
Except, perhaps, for women like Lund.
Last year, when she became pregnant for the second time, she knew she was likely to have a C-section again. The surgery has become standard for women like her because there is a small chance that a prior C-section scar will rupture during contractions.
But Lund was determined to avoid it. First, she did her research and concluded the risk was acceptable -- less than half a percent. "It's not as risky as the things we do every day," she said.
Just giving birth entails risk, Peaceman noted -- about a 1-in-1,000 chance that something tragic will happen in a hospital birth. That compares with 1 in 500 for a vaginal birth after a C-section. But most parents aren't like Lund, he said: "Most don't see that as a low number."
Lund's doctor didn't either. "She said, 'If something went wrong, a doctor could lose everything,'" Lund recalled. "I thought, 'Wow, there it is, right out there. That's her perspective.'"
(Lund's doctor declined to be interviewed for this story.)
Lund's hospital, Ridgeview in Waconia, will consider a vaginal birth after a C-section. Many hospitals won't because of stringent national medical guidelines for the procedure.
But there's been some push-back on that, too. In March an expert panel at the National Institutes of Health recommended that leading medical groups reassess those guidelines, making it easier for women with prior C-sections to have a natural childbirth.
The panel pointed out that there are serious risks to repeat C-sections as well -- risks that are not so widely known among patients. For example, pregnant women who have had prior C-sections are at much higher risk for developing a dangerous condition in which the placenta becomes deeply imbedded in scar tissue. It can lead to hemorrhaging during birth and emergency hysterectomies.
Though still uncommon, the frequency of that condition has increased tenfold in the past 50 years, largely as a result of more C-sections.
After weighing her options, Lund asked a midwife to deliver her baby at home, but the midwife said it was too risky. She called a St. Louis Park birthing center run by midwives. Although such centers are common in some states, they are new to Minnesota, and Lund's health plan wouldn't pay.
By that point she was 30 weeks pregnant and out of options, she said.
Lund, an attorney and trained litigator, is the first to admit she is not typical of most pregnant women. She's comfortable with confrontation and decided to take matters into her own hands.
Three months ago her labor started at 1:30 a.m. She and her husband waited. And waited. They counted the minutes between contractions, then waited some more. Finally, when she was far enough, she hoped, that it would be too late for a C-section, she went to the hospital.
As soon as she arrived, her water broke. Her cervix was 9 1/2 centimeters dilated. She was ready to deliver her daughter.
"I said: 'Yay, there is nothing they can do to me now,'" Lund said.
Josephine Marcotty • 612-673-7394 Staff writer Glenn Howatt contributed to this story.
Coming Thursday: How one St. Paul hospital kept C-section rates low.