'Ooooooowwww ... I can't!"
Ashley Maas, laboring in a birthing tub, long blond hair tied back, has had enough.
Her midwife, Brielle Stoyke, submerges her arms elbow deep in the water and urges: "Just let this baby come. You're doing good."
"Oh my God, I'm gonna die!" Maas yells. "I want my baby!"
That's when Peyton Maas, 7 pounds and 5 ounces, slips into the water and into the world.
Peyton is one of 1,200 babies delivered at St. Joseph's Hospital in St. Paul each year. He also happens to be part of a startling statistic. St. Joe's performs fewer Caesarean sections, as a share of total births, than almost any other hospital in the country.
At St. Joe's just one in 10 babies is delivered surgically. Nationally, the average is one in three.
Because C-sections cost roughly twice as much as vaginal births, and because medical experts are beginning to ask if they're performed more often than necessary, the experience of St. Joe's is instructive at a time when many Americans wonder if they're paying too much for medical care -- or getting the wrong kind.
It's a debate that starts, fittingly, at the beginning of life.
Surge in C-sections
Since 1970, C-sections have surged from about 5 percent of all births nationally to 32 percent. In 2007, the latest year available, New Jersey topped the nation at 38 percent, with Utah at the other end of the spectrum at 22 percent.
Minnesota's rate is 26 percent.
There are many reasons for the jump: In the 1970s, fetal monitoring devices came into wide use. Doctors, worried about malpractice lawsuits, grew more likely to pick up a scalpel at the first sign of trouble.
Women are now also more likely to schedule C-sections for convenience or to avoid a lengthy labor.
In addition, a woman who has had one C-section is more likely to have another because doctors fear the scar from the first delivery might rupture during the second.
While there are sound medical reasons for the procedure -- the most common being "failure to progress" or breeched babies -- experts worry the procedure is now overused. Risks include an infected wound or uterus and higher blood loss.
The World Health Organization recommends a C-section rate of no more than 15 percent, half the current U.S. rate.
At St. Joe's, executives attribute the low use of C-sections to a reliance on midwives, who deliver 40 percent of the babies. Others agree.
Midwives are trained to "see labor as physiology," said Dr. Bruce Flamm, a spokesman for the American Congress of Obstetricians and Gynecologists and an obstetrician at Kaiser Permanente Medical Center in Riverside, Ca. "We OBs are trained to see labor as a disaster waiting to happen."
But there are also cultural and historical reasons for St. Joe's natural approach to birth.
St. Joe's is the oldest hospital in Minnesota. It started in a log church in St. Paul in 1853, and the first nurses were the Sisters of St. Joseph. At the time, most babies were born at home.
After World War II, more women began delivering at hospitals. St. Joe's had one of the busiest maternity wards in Minnesota, with 2,500 deliveries each year.
Then came the sexual revolution in the 1970s.
Because it was a Catholic hospital, doctors at St. Joe's would not prescribe birth control pills or perform tubal ligations or abortions. Twin Cities obstetricians began referring their patients to other hospitals; volumes at St. Joe's also fell as families moved to the suburbs.
It was a different era in maternity care.
"Nurses would be sitting at the desk and smoking cigarettes and talking about whatever," said Deb Monson, a young St. Joe's labor nurse at the time. "If a patient got too noisy, they shut the door."
For their part, doctors didn't like waiting around for a baby to show up. One doctor would give flowers to any nurse who called him just in time to deliver the baby -- and no sooner.
In the 1980s, Monson, then head nurse, met a midwife from St. Paul-Ramsey Hospital, now called Regions.
"That's exactly what I want to do," Monson thought. "Stay with the family through the whole labor [and not] have that 'clock mentality.'"
She went back to school and returned as St. Joe's first midwife in 1987. It took another year to change the hospital's bylaws so she could deliver a baby without the supervision of an obstetrician.
Soon, Monson says, even the obstetricians noticed that women who used midwives were less likely to end up with C-sections.
Minnesota's oldest hospital had found a new niche.
"It's their birth on our turf," said Karen McConville, clinical director of maternity care.
Today, the patients of midwives at St. Joe's fall roughly into two groups: recent immigrants who are used to midwives in their home countries and older, professional women.
Not everyone agrees that midwives make all the difference. "They might just be getting a lower risk pool," said Dr. Ron Less, an obstetrician who delivers babies at St. Joe's and other HealthEast hospitals. "If you gave all [their] patients to the OBs, I'm not sure you'd get more C-sections."
Whatever the case, for many pregnant women in the eastern Twin Cities who seek a natural birth experience, St. Joe's has become the place to go.
Kara Sime, 38, a first-time mother from St. Paul, arrived one recent Thursday morning, her contractions five minutes apart. By Friday morning, her labor still wasn't progressing. Exhausted, Sime asked for an epidural, a powerful painkiller, and got one. She also got Pitocin, a synthetic hormone to induce labor.
But there was a problem. Her baby was facing backward, increasing the diameter of the head going through the pelvis. Such cases usually require a C-section or a vacuum.
Instead, the midwife and nurse helped Sime onto all fours -- no small feat since her legs were numb from the epidural. With Sime's belly hanging down, the baby turned.
Three pushes later, Catherine Julia was born at 6 pounds 10 ounces.
"I don't have surgical skills," said the midwife, Melissa Hasler. "I'm motivated to get the baby out vaginally."
Chen May Yee • 612-673-7434 Chen May Yee researched part of this story while participating in a California Endowment Health Journalism fellowship, a program of the Annenberg School for Communication & Journalism at the University of Southern California.