Only about one-third of U.S. C-sections are medically justified, according to Declercq, the Boston University maternal health expert. A web of factors explains the rest, including hospital culture (C-section rates vary widely from one institution to the next); the convenience factor (C-sections can be scheduled); and indirect financial incentives. Because C-sections normally take much less time than vaginal deliveries, they are more cost effective for hospitals and providers.

Additionally, several studies point to the influence of “defensive medicine,” when doctors perform unnecessary procedures or treatments for fear of being blamed for not doing enough if something goes wrong.

A 2010 survey by the American Medical Association found that half of OB-GYNs had been sued before the age of 40 — a higher proportion than doctors in most other medical fields. In an industry survey in 2009, nearly 30 percent of OB-GYNs said their fear of lawsuits led them to operate more often than they otherwise would have done.

The fear that drives OB-GYNs to perform C-sections is that they’ll be sued for failing to do enough to protect the baby — not the mother. Lawsuits by mothers who suffered complications related to pregnancy and childbirth are rare, and — lawyers say — usually futile.

Even the first step — finding a lawyer — poses a formidable hurdle. In a medical malpractice suit, harm such as the loss of a uterus through an emergency hysterectomy would normally fall into the category of “pain and suffering.” About half of states have capped legal damages under that heading; in at least a dozen, including California, Colorado and Texas, the maximum is $350,000 or less. That’s rarely enough to entice lawyers who have to spend time and money up front to hire experts and investigate what happened.

Thus, to make a case truly attractive to a lawyer, plaintiffs must be able to prove they’ve suffered economic damages such as lost wages or long-term medical costs — an argument that’s all but impossible in the case of harm to reproductive organs, said Lucinda Finley, a University of Buffalo law professor who has researched the impact of tort law on women.

“What is the value of a uterus, unless a woman makes her living with it?” Finley asked. “What is the value of fertility for a woman of childbearing age and aspirations? Unfortunately our society says in many different ways and contexts that the value is minimal, which I think is extremely demeaning and devaluing of women.”

In contrast, a lawsuit over serious harm to a baby would likely yield far more: Parents might hope to collect economic damages to help pay to care for the baby into adulthood, and even provide for that baby’s potential lost wages.

Even women who suffer devastating long-term disability may face daunting legal challenges, as Rebecca Derohanian’s family has discovered. Derohanian, now 36, a native of Iran, was a vendor manager for Warner Brothers, with a hobby designing remarkably lifelike dolls. Her husband, Hungarian-born Zoltan Csizmadia, worked in information technology.

She became pregnant with her second child in 2014. Doctors discovered that her unborn daughter was small for her gestational age and recommended a C-section. Forty hours after the surgery at Cedars-Sinai Medical Center in Los Angeles, as Derohanian was preparing to go home, she complained of a severe headache; within 10 minutes, she screamed in agony and passed out, according to family members. She spent the next four months in a coma, transferred from hospital to hospital. In July 2015, as nurses were attending to her, Derohanian regained a semblance of consciousness. “She sneezed and said, ‘sorry,’ and we couldn’t believe what we heard,” her husband said.

But the excitement and hope soon faded. “It became apparent that some of the emotional regions of the brain were affected, so she wasn’t the same person really,” Csizmadia said. Physical and speech therapy only accomplished so much. She couldn’t walk or eat without assistance, so her family transferred her to a nursing home.

Csizmadia’s sister, Christine Roseland, an attorney, thought that going to court might help her brother cope with his wife’s medical bills, including hefty copays and deductibles, plus 20 percent of the costs of the nursing home.

Rebecca Derohanian and her husband, Zoltan Csizmadia, in an undated photograph. (Courtesy of Zoltan Csizmadi)

She felt a case could be made for lost wages, if only she could get a clear answer on what had gone wrong. Hospital officials told family members that they had conducted a case review, Roseland said. But Derohanian’s family was barred from discovering the results. Under a legal concept known as “peer review privilege,” the findings of hospital peer-review committees that examine medical errors cannot be used in litigation. Some version of this rule is in effect in all 50 states. The law’s goal is to encourage hospitals to learn from their mistakes without fear of being punished. But the result may be that families are left in the dark.

Derohanian’s doctors at Cedars-Sinai told her family that she had suffered a subdural hematoma, a traumatic brain bleed that rarely occurs in childbirth. But the medical team never provided a clear explanation of how or why. “If it were your mom, your sister or your wife, would you be OK with that answer? Would that be enough for you to move on?” Roseland asked. “I think for a lot of people, it wouldn’t be.”

A hospital spokeswoman declined comment, citing patient confidentiality.

Roseland interviewed more than a dozen lawyers before finding one who would file a suit, which is now pending in Los Angeles County Superior Court. Jason Argos was among those who turned her down. The malpractice attorney spent nearly \$4,000 on experts to review Derohanian’s medical records, but their conclusion — that the brain bleed was likely related to a problem with Derohanian’s anesthesia — wasn’t clear-cut enough to be worth the gamble.

“Rebecca’s case is hands-down the most tragic one to ever to come across my desk,” Argos said. “I hated to walk away from it.”

Had Derohanian died, Argos said, it probably would have been easier to determine whether someone was to blame. The hospital would have had to do an autopsy or let the family hire a forensic pathologist for that purpose. Yet when a woman nearly dies, doctors are under no formal obligation — beyond providing medical records — to tell patients and their families what occurred. “It’s almost impossible to get answers or hold anyone accountable,” Csizmadia said. Derohanian, he said, “has almost been forgotten.”

Samantha Blackwell considered a lawsuit over her coma and hysterectomy. She and her mother “interviewed every lawyer between Columbus and Cleveland,” she said. Yet no attorney would take the case. They all said more or less the same thing: Finding someone to blame for Blackwell’s injuries would be too hard. Her doctors, they told Blackwell, “could’ve said it was just a series of unfortunate events.”

Kasia Bogdanska, special to ProPublica

These complications, many of them preventable, impose a financial burden on women, their families, and the health care system. Kristen Terlizzi’s care for her placenta accreta case in 2014 cost almost $1.2 million, which was covered by her private insurance. Blackwell’s medical bills topped $400,000, a cost borne largely by her mother’s insurance. Still, she and her husband weren’t completely spared. Blackwell was unable to work for six months, and the couple is fighting a $30,000 charge from the private helicopter company that flew Blackwell between hospitals.

Several maternal health experts told ProPublica that no researcher or agency has yet calculated the total cost of severe maternal morbidity. Yet the available data suggests it amounts to billions of dollars every year. The cost alone of caring for mothers with preeclampsia exceeds $1 billion annually, according to a September 2017 report in the American Journal of Obstetrics & Gynecology. In 2011, Medi-Cal, California’s Medicaid program, paid more than $210 million to treat maternal hemorrhage and hypertensive disorders, both among the leading conditions associated with childbirth complications.

In 2014, the average cost of a hysterectomy related to complications of childbirth was more than $95,000, according to information provided by the Agency for Healthcare Research and Quality, part of the U.S. Department of Health and Human Services. That could translate into hundreds of millions of dollars a year for all emergency hysterectomies.

None of these estimates begins to include the other very real costs borne by women and families — psychological trauma and treatment, lost wages and long-term health effects. Whatever the exact price tag, the impact on women of life-threatening complications from childbirth “is financially, emotionally, medically, spiritually life-changing,” said Miranda Klassen, a maternal health advocate who almost died in 2008 from an amniotic fluid embolism — the entry of amniotic fluid into the bloodstream, triggering heart and lung failure.

“The pain and suffering is exponential. It’s not just the moms, it’s the spouses, it’s the parents, it’s the children, it’s the larger family and community … It completely turns your world upside down.”

NPR special correspondent Renee Montagne contributed to this report.

Adriana Gallardo contributed reporting.