Tuesday, July 11, 2006

Why is the C-section rate so high?

Although the rising C-section rate has not produced the predicted increase in maternal mortality, it certainly accounts for plenty of morbidity, not to mention increasing medical costs. So who or what is at fault?

It is certainly a multi-factorial problem. It involves anesthesiologists and the types of epidurals they give. It involves the demands of patients and it involves the fear of legal action. If I had to point to the most important factor, though, I would say it is the attitude of patients. You might think that this has nothing to do with homebirth, but it is related in a way. The homebirth movement is prey to this attitude and actually promotes it. What am I referring to? I am talking about the widespread and erroneous belief that childbirth is not dangerous.

Obstetricians have been so successful that most people do not realize that childbirth has an inherently high neonatal and maternal mortality. Modern obstetrics managed to drop the neonatal mortality rate over 90% and the maternal mortality rate over 99% in the last 100 years. It is the direct application of medical technology, including C-sections, anesthesia, antibiotics, blood banking and neonatalogy that accounts for the current very low mortality rates. Take that away, and the mortality rates would skyrocket again.

At this point, many people (and homebirth advocates are among them) believe that childbirth has no risks for healthy women and their babies. Since most women are sure that nothing could or should go wrong, they are angry and horrified when something does go wrong. Then, of course, they sue.

A recent paper in the New England Journal of Medicine concluded that approximately 40% of malpractice suits are frivolous. That means that they have no basis in fact. There was never any evidence that anything was done wrong medically. Even when you consider the suits that have some basis in medical fact, the overwhelming majority return verdicts in favor of doctors. That's because, ultimately, the jury does not believe that the patient can show that the doctor did anything wrong.

Considering the fact that doctors win most of the time, you might think that lawsuits might be considered an inconvenience. Far from it! The average malpractice suit takes years to make its way through the legal system, involves multiple depositions and other demands, and it usually experienced by doctors as anguishing, even if they win. Most doctors will do a great deal to avoid being sued.

Almost all obstetricians are sued. Some are sued more than once. The best defense against a lawsuit for neonatal death or disability is an early C-section, the earlier the better. At this moment in time, a C-section is the legal equivalent of "doing everything that could be done". If an obstetrician has not done a C-section (even if a C-section would not have helped), he or she is in a virtually defenseless position.

The obvious result of this is that the threshhold for performing a C-section has dropped dramatically. The baby is breech: do a C-section even though the vast majority of breech babies can safely be delivered vaginally. Signs of potential fetal distress: do a C-section, even though the fetal monitor is a relatively crude measure of fetal well-being. I could make a very long list of situations in which a C-section is probably not necessary, but is done anyway so that the obstetrician is perceived as "doing everything that could be done.

How can this be fixed? As I said before, it is a multi-factorial problem, so it will take a multi-factorial solution. Nonetheless, in my judgment, one of the most important steps in the process is to institute no-fault compensation for parents of babies who die or are injured during birth. The main advantage of this system is that parents will not have to prove that a particular person injured the baby, only that the baby was injured. The parents and the baby will not have to give 1/3 of any compensation they receive to a lawyer. Neither will they have to wait for the money. Morally, it is a much fairer system. Disabled babies who are disabled through no one's fault are no less disabled than babies who are victims of malpractice. Their parents are no less stretched, financially and emotionally, than the parents of babies who were victims of malpractice. Shouldn't they also receive financial help to meet the need of their child?

A no-fault system will free doctors to make decisions based on medical factors, not legal factors. In my judgment, that would produce a dramatic drop in the C-section rate. Instituting a no-fault compensation system requires legislation, though, and there is not much chance of it happening soon.

In the meantime, patients can help lower the C-section rate by accepting realistic expectations. Childbirth is inherently dangerous to baby and mother. If you have a healthy baby, it is often because of the medical technology available and the judgment of the obstetrician. If you don't have a healthy baby, it is not necessarily anyone's fault, because there is an irreducible level of neonatal mortality. Once people appreciate the inherent danger, they will be less likely to sue, and the C-section rate can begin to drop.


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