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

Everyone agrees that the cesarean section rate in the US is too high. Critics claim that it is high because doctors make money from C-sections (false, most obstetricians get paid the same amount regardless of how the baby is delivered) or because it is more convenient for obstetricians (false, nothing is more convenient than every patient having an uncomplicated vaginal delivery). No one seems to realize that 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.

In our legal system, 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 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.

Obviously every single C-section with a medical indication should be done. Moreover, 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 and early ovarian cancer does not cause symptoms. We could prevent virtually all ovarian cancer. How? We could remove every woman’s ovaries at the age of 40.

We don’t do that, and there are many reasons why. First, it would almost certainly lead to more deaths than it would prevent. Second, the law of diminishing returns applies to removing ovaries. As the rate of removal gets higher, the chance that you are actually doing some good gets smaller. Third, women understand that ovarian cancer is generally a random occurrence; it certainly is not the doctor’s fault. Therefore, the overwhelming majority of women who are diagnosed with ovarian cancer do not sue claiming 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 occurrence; women believe that a bad obstetric outcome must be someone’s fault. Therefore, they will sue if there is anything wrong with a baby 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.

Virtually every American obstetrician is sued. Most are sued several times. An obstetrician must assume that she will be sued for every bad outcome, and therefore, she must take whatever steps she can to preserve a legal defense. Of course, the only acceptable legal defense is a C-section.

Obstetricians win most lawsuits. The cases were without merit to begin with. We might conclude 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.

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 suits without merit, 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?

We determine where we draw the line in direct response to patient expectations. 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 large numbers of lawsuits without merit, the C-section rate would drop in response to their acknowledgement that a perfect baby is not guaranteed.
There are too many C-sections being done in the US countries because American women demand a very high C-section rate, while simultaneously insisting that they want a low C-section rate. To those complaining I say: If you want to lower the C-section rate, start by looking in the mirror!


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