Friday, April 04, 2008

How to lower the C-section rate: step 1, look in the mirror.

Yesterday someone wrote in to remind me that it is C-section awareness month, asking what could be done about the C-section rate, and implying that I could do something about it.

Here's what I wrote in response:

The rising C-section rate is a direct response to what PATIENTS demand, which is a perfect outcome and massive financial compensation if the outcome is not perfect. Efforts to lower the C-section rate have to start with patient expectation and demands.

The way the legal system currently operates, there is no possible justification for not doing a C-section when there is any element of doubt, no matter how tiny. Unless and until people stop penalizing doctors for not doing C-sections, they will continue to do them in ever increasing numbers. They really have no choice.

How can we modify patient expectations and demands? The most practical response would be to institute no fault compensation for a baby who dies or is permanently impaired. No fault compensation has the added advantage of being more ethical. The current system requires that getting help caring for a profoundly impaired child is completely dependent on being able to blame a medical provider for the impairment. Parents who care for impaired children who are impaired due to genetic problems (no one's fault) are forced to struggle without any assistance, while parents whose children may be less disabled receive lottery size awards as long as they can convince a jury that someone is at fault.

The bottom line is that you cannot say to obstetricians, "Give me a perfect baby or I will try to destroy you professionally and economically" and then express shock and dismay that obstetricians will perform C-sections in order to guarantee that you will have a perfect baby.

Liz 1, a long time participant on the blog, is disappointed and angry with my response, but I stand by it. Let me explain further:

Obviously I believe that every single C-section and induction with a medical indication should be done. Moreover, I am certainly well aware that what is unnecessary in hindsight is not knowable in advance. Nonetheless, a C-section rate of 32% cannot be MEDICALLY justified IF the normal parameters for medical justification are used. Unfortunately, the typical parameters are not used.

Let's look at another medical issue for comparison. Ovarian cancer is one of the most dangerous problems an OB-GYN is likely to encounter. Partly that is because early ovarian cancer does not cause symptoms. There is a way that we could prevent virtually all ovarian cancer. We could remove every woman's ovaries at the age of 40.

We don't do that, and there are many reasons why we don't do that. One reason is that it would almost certainly cause more deaths than it would prevent. Another reason is known as the law of diminishing returns. As the rate of removal gets higher, the benefits drop off. Simply put, as the rate of removal gets higher, the chance that you are actually doing some good gets smaller.

Another reason we don't remove every woman's ovaries is that women understand that ovarian cancer is generally a random occurance; that it certainly is not the doctor's fault; that women do not "naturally" live to be 80 without getting cancer; and that women are not "entitled" to a life free of ovarian cancer. That translates into the fact that the overwhelming majority of women who are diagnosed with ovarian cancer do not sue and claim that someone should have figured it out sooner.

The contrast with obstetrics could not be more glaring. Women DO NOT understand that hypoxic brain damage can be a random occurance; women DO believe that a bad obstetric outcome must be someone's fault; women Do NOT understand that bad outcomes occur "naturally; and women believe that they are entitled to have perfectly healthy children. Because of these erroneous beliefs, they will sue if there is anything wrong with a child and the ONLY effective legal defense for a doctor is to show that a C-section was performed, and was performed as soon as humanly possible.

Essentially every American obstetrician is sued for a bad baby. Most are sued several times. You MUST assume that you will be sued for every bad outcome, and therefore, you must take WHATEVER steps you can have a legal defense. As I pointed out above, the only acceptable legal defense is to have done a C-section.

Of course, obstetricians win most lawsuits. The cases were without merit to begin with. One way to look at the situation is that the system works because most doctors who did nothing wrong are found not liable. However, another way to look at the high proportion of physician victories is that it tells us the system is totally dysfunctional. Most lawsuits occur in the absence of any legal wrong, yet they are allowed to proceed anyway.

A malpractice suit is a very traumatic for a physician, win or lose. It is the suit itself that is most traumatic, not the outcome. A lawsuit represents literally YEARS of worry, since the legal system works so slowly here, not to mention lost work, lost wages, etc. etc.

Lawsuits do not file themselves; patients file them, and they are an expression of patient expectations. The large number of obstetric malpractice suits, and particularly the large number of meritless suits, are a direct expression of patient expectations. They expect a perfect baby and they believe they ought to punish any doctor who doesn't present them with a perfect baby.

As the C-section rate rises, the percentage of unnecessary C-sections rise and that is a bad thing. Logically speaking we are not going to recommend a C-section rate of 100% even though a C-section rate of 100% would guarantee that everything was done to ensure a perfect baby. So where do we draw the line?

My point is that where we draw the line is in direct response to PATIENT expectations, and is out of the control of doctors. When patients demand a perfect baby or else, THEY have essentially drawn the line at a 100% C-section rate and doctors are merely attempting to respond to that. If patients stopped filing massive numbers of meritless lawsuits, the C-section rate would drop in response to THEIR acknowledgement that a perfect baby is not guaranteed.

What is especially ironic is that women who choose homebirth and women who choose UC have an entirely different standard for midwives and for themselves than they have for doctors. Women who choose homebirth are essentially saying "I can't guarantee that I will have a healthy baby if I deliver at home, but it is worth it to me to risk my baby's life in order to avoid interventions I don't want", yet when they head to the hospital, they completely reverse that logic and essentially say, "The doctor must guarantee that I have a healthy baby if I deliver at the hospital."

The expectations of the hospital are so out of touch with reality that it beggars belief. Look at the MDC case that was the inspiration for this thread. The baby is fine, the woman is fine, and yet she wants to sue (and everyone is encouraging her to sue) because the doctor allegedly pulled on the cord and it hurt! The doctor didn't listen to her when she said no! Are these even remotely defensible reasons for a lawsuit. Absolutely not, but American women are so unreasonable that not only do they think they are entitled to a perfect baby, but they think they are entitled to a perfect "experience", even after they screw up and seek emergency attention to save their lives.

There are too many C-sections being done in the US (and other industrialized) countries because American women (and the women of other industrialized countries) DEMAND a very high C-section rate, while piously pretending that they want a low C-section rate. To all the anti C-section activists out there I say: If you want to lower the C-section rate, start by looking in the mirror!


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