At a recent meeting of the American College of Obstetricians and Gynecologists, a paper was presented that shows a strong correlation between the rate of Cesarean sections and the problem of lawsuits.

“States classified as having a medical liability crisis or crisis brewing by ACOG [the American College of Obstetricians and Gynecologists] have significantly higher rates of cesarean delivery, and this may reflect a pattern of defensive medicine in response to the liability climate,” said Elizabeth A. Platz, MD, from the Medical University of South Carolina in Charleston.

Well, how bad is the problem?

Total cesarean and primary cesarean rates are currently as high as 30% of total births in the United States, up from 4.5% in 1965. In 2003, 76% of all American obstetricians reported at least 1 litigation event, with a median award of $2.3 million for medical negligence in childbirth.

There are some things you should know to put this all into perspective.

One: when you do a delivery, within minutes you literally can go from a simple delivery to an emergency where you might lose the mother and/or the child. This is where skill makes the difference in life and death.

But sometimes, all the skill in the world won’t prevent a stillborn child.

If you have a baby with Cerebral palsy or brain damage, often parents assume that the damage was caused by the doctors not doing a Cesarean section fast enough.This assumption has been encouraged by lawyers who urge families to sue for “damages”.

So physicians often feel impelled to do a Cesarean section for any sign of a problem, even though a lot of times “watchful waiting” or other interventions work just as well.

You see, the outcome may not be different, but the parents will feel that the doc did everything to save the baby, and so are less likely to sue.

In contrast, a conservative approach takes time and energy.

One cannot overestimate the emotional stress to physicians by such lawsuits.
Never mind that most cases of cerebral palsy have little to do with lack of oxygen to the baby at time of birth (“fetal anoxia”) but are caused by a baby sick from intrauterine problems, often caused by smoking, high blood pressure, diabetes, medications, or most commonly viral infections.

Never mind that Cesarean sections have their own risks for both mom and baby.

To do a Cesarean section safely, you need an anesthesiologist, an operating room, and nurses right there. Most larger hospitals have these available, but even then it may take ten or fifteen minutes to get everything ready.

True, a lot of problems are prevented by doing a C-section when you see fetal distress on the monitor.

Sometimes, especially with very long labor and a child who may be too delicate to survive prolonged labor (the most common reason for Cesarean section is prolonged labor due to a large baby: often called dystocia).

This is especially true in first babies, where mom’s tissues have never been stretched by previous childbirth; and sometimes the baby is simply too large to deliver at all.

So, sometimes an emergency C-section will save a life.There are also times that you might see signs of “fetal distress” on monitors, and have to deliver as soon as possible but don’t necessarily need emergency surgery. Giving oxygen, placing mom on her side, relieving her pain, and a forceps delivery should be done.

But how many abnormal patterns on modern monitors are caused by mother’s distress-from the discomfort in sitting with cords attached, as opposed to walking around an changing positions during labor?

A lot of cerebral palsy is caused by problems before delivery: especially viral infections. So when you see the pattern of “fetal distress” on the monitor, it is because the kid is already sick, and surgical intervention to speed up a delivery doesn’t make any difference.

But one cannot underestimate the devestation of a mentally handicapped child to a family.

Fifty years ago, families had several children, so if you had a severely brain damaged child, you put it into an “institution” and went on with your life.

This practice has, thank God, been eliminated, for most of these children do better in a loving home.

But nowadays, often families face the difficulties of raising a child, with limited community support and problems getting their care paid for by their insurance.

So they sue.

Like the lawsuits over vaccines cause autism, there are reasons: the need for money for the child’s treatment being the main one.

But the guilt of the parents is another: because too many people blame themselves if their child is not perfect. This is not logical: No religion nowadays teaches that God punishes parent for sin by harming their child. But the superstition remains, and it is easier to find a “bad guy” for the problem…So how often does a Cesarean section need to be done?

Well, our rate in Africa was five percent, to save the mom’s life. But sometimes we lost kids who would have elsewhere been saved.

But in the US, one way to estimate what the rate would be without the lawsuit worry that pressures a physician to jump to do a C-section is to find the rate in a population that can’t sue.

There is one: The Indian Health Service, being federal, makes it very difficult to sue, unless you can prove negligence.

Several studies show that the rate of Cesarean sections is much lower: about 7% ,

The authors suggest:

The community’s low rate of cesarean delivery is primarily the result of a decreased use of cesarean delivery for labor dystocia and an almost universal acceptance of trial of labor after cesarean delivery. Cultural attitudes toward childbirth, design of the perinatal system, and genetic factors also may explain the low rate of cesarean delivery.

But that low rate is also rising.

The Native American population has some differences: many clinics have care by midwives, who are usually Native Americans.

The average number of children per woman is higher than the general population.

And many Native Americans have gynecoid (round) pelvises, which means they can easily deliver even a huge baby, and would be good candidates for “trial of labor” after having a Cesarean section in an earlier pregnancy.

Yet there are higher risks among Native Americans too: Many teen-aged pregnancies, some without prenatal care. Older moms with diabetes or high blood pressure. And on some reservations, a high rate of obesity.

So with all the dubious talk of lowering health care cost, one way to help is to mandate insurance for disabled children, limiting lawsuits to cases where negligence is obvious.

Take away the need for defensive medicine and you will end up with more efficient medical care.

Another way might be to take a public health approach to having a baby: using midwives who can spend more time with mom to educate her and to stay with her during labor.

But until physicians aren’t pressured to order expensive tests and procedures such as Cesarean sections, partly by fear of being sued for missing a rare problem, the cost of medical care will continue to be excessive.


Nancy Reyes is a retired physician living in the Philippines. She worked for the IHS for ten years.

Her website is Finest Kind Clinic and Fishmarket, and she writes medical essays at HeyDoc xanga blog

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