After an emergency cesarean with her first baby, Ruby Wales was holding out for a vaginal birth with her second one.
With a toddler underfoot, the 33-year-old Mission Viejo woman wanted a faster recovery. But finding a physician to deliver her second child wasn't easy. Her first obstetrician turned her down flat. "She said, 'No -- no way,' " Wales recalled.
Once reserved for cases in which the life of the baby or mother was in danger, the cesarean is now routine. The most common operation in the U.S., it is performed in 31% of births, up from 4.5% in 1965.
With that surge has come an explosion in medical bills, an increase in complications -- and a reconsideration of the cesarean as a sometimes unnecessary risk.
It is a big reason childbirth often is held up in healthcare reform debates as an example of how the intensive and expensive U.S. brand of medicine has failed to deliver better results and may, in fact, be doing more harm than good.
"We're going in the wrong direction," said Dr. Roger A. Rosenblatt, a University of Washington professor of family medicine who has written about what he calls the "perinatal paradox," in which more intervention, such as cesareans, is linked with declining outcomes, such as neonatal intensive care admissions. Maternity care, he said, "is a microcosm of the entire medical enterprise."
As the No. 1 cause of hospital admissions, childbirth is a huge part of the nation's $2.4-trillion annual healthcare expenditure, accounting in hospital charges alone for more than $79 billion.
Because spending on the average uncomplicated cesarean for all patients runs about $4,500, nearly twice as much as a comparable vaginal birth, cesareans account for a disproportionate amount (45%) of delivery costs. (Among privately insured patients, uncomplicated cesareans run about $13,000.)
Pregnancy is the most expensive condition for both private insurers and Medicaid, according to a 2008 report by the Childbirth Connection, a New York think tank.
"The financial toll of maternity care on private [insurers]/employers and Medicaid/taxpayers is especially large," the report said. "Maternity care thus plays a considerable role in escalating healthcare costs, which increasingly threaten the financial stability of families, employers, and federal and state budgets."
The cesarean rate in the U.S. is higher than in most other developed nations. And in spite of a standing government goal of reducing such deliveries, the U.S. has set a new record every year for more than a decade.
