Richard Hyer

May 12, 2009

May 12, 2009 (Chicago, Illinois) — "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.

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. A common accusation is failure to perform cesarean in a timely manner, and concern has been voiced that obstetricians as a result are turning to cesarean delivery at any sign of complication.

According to the findings that Dr. Platz presented here at the ACOG 57th Annual Clinical Meeting, that fear is well founded.

In discussing the increase in total and primary cesarean delivery rates, Dr. Platz began by noting that it remains poorly understood. As a possible explanation, she cited maternal characteristics (including increasing maternal age, obesity, the number of multiple gestations, and declining rates of vaginal birth after cesarean) and physician practice patterns.

Dr. Platz said that her results also reflect results from the ACOG's 1985 survey, which examined changes in obstetrical and gynecological practice behavior that were thought to affect the rate of cesarean delivery. These changes included an increased number of referrals, consultations, tests, and diagnostic procedures.

It has been suggested that medical-legal pressures are a factor in the rise in cesarean deliveries. A number of studies have borne this out. Localio and colleagues (JAMA. 1993;269:366-673) found a positive association between medical malpractice claims risk and the rate of cesarean delivery. Murthy and colleagues (Obstet Gynecol. 2007;110:1264-1269) found an association between professional liability premiums and rate of cesarean delivery — for every $10,000 increase in insurance premium there was a 15% increase in the rate of cesarean sdelivery.

Dr. Platz's study was designed to establish whether state-specific cesarean delivery rates differed by medical liability climate. This cross-sectional observational study reviewed cesarean delivery rates and malpractice activity measures.

The states were classified by an ACOG formula, and demographic and population data were obtained from the US census and the National Center for Health Statistics. Malpractice activity variables were obtained from the National Practitioner Databank. The study used ACOG classifications for malpractice.

The Kolmogorov–Smirnov test was used to measure normal distribution, and bivariable associations were analyzed with Pearson's correlation coefficients. A multivariable linear regression model was performed using a stepwise regression (mixed effects and interactions model) to include all variables and variants, Dr. Platz explained.

She noted that variables associated with higher cesarean delivery rates included ACOG's Red-Alert states, payout reports, obesity, the percentage of African American women, smoking, and poverty. Red-Alert states have a cesarean delivery rate of 29.9% and are deemed to be in crisis. States with a rate of 28.1% are defined as having a crisis brewing, and those with a rate of 27.2% or less are not considered in crisis.

Commenting on the results to Medscape Ob/Gyn & Women's Health was Kurt L. Barnhart, MD, MSCE, member of ACOG's Committee on Scientific Program. Dr. Barnhart is director of women's health research at the University of Pennsylvania in Bryn Mawr, and served as director, with Janice L. Bacon, MD, of the Papers on Clinical and Basic Investigation.

"First of all, I applaud the abstract, that it quantifies a perceived problem," Dr. Barnhart said. "We all anticipated that defensive medicine might be a reaction to litigation, and this paper demonstrates that that is indeed the case," Dr. Barnhart said.

"What one does about it is a little bit more difficult. But with objective evidence . . . that fear of liability is causing C-sections, we can address the problem by reducing liability, thereby reducing C-sections," Dr. Barnhart explained. "So instead of just telling physicians not to do C-sections, this identifies [the need] to remove the risk, and then they'll do fewer C-sections.

"So don't just blame the doctor for doing a C-section, recognize that there's probably a reason that [he or she is] doing it. And that fear of litigation is the reason," Dr. Barnhart concluded.

The study was funded by the Medical University of South Carolina. Dr. Platz has disclosed no relevant financial relationships.

American College of Obstetricians and Gynecologists (ACOG) 57th Annual Clinical Meeting: Papers on Current Clinical and Basic Investigation. Presented May 5, 2009.


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