Alicia Ault

May 20, 2016

WASHINGTON, DC — A reluctance to offer women trials of labor or vaginal birth after cesarean delivery is likely related to concerns about malpractice, and one obstetrician is calling for a national injury compensation fund that ostensibly would remove the threat of litigation from the equation.

No-fault alternatives for settling injury claims have been established in other areas for this reason, said James Palmer, MD, assistant professor of obstetrics and gynecology at Morsani College of Medicine at the University of South Florida in Tampa.

The federal government's National Vaccine Injury Compensation Program provides compensation to people injured by vaccines, and Florida's Neonatal Injury Compensation Association provides benefits to children who have sustained brain or spinal cord injury caused by oxygen deprivation or mechanical injury during labor, delivery, or the immediate postdelivery period.

"It does seem like an interesting idea," said Rita Driggers, MD, assistant professor of gynecology and obstetrics at the Johns Hopkins University School of Medicine in Baltimore.

"Anything that could decrease malpractice and make people more likely to attempt labor or vaginal birth after cesarean" would be welcomed, she told Medscape Medical News. And she pointed out that those strategies could help reduce overall rates of cesarean delivery.

"The only thing that has had measurable impact on decreasing total cesarean delivery rates has been the use of trial of labor after cesarean and vaginal birth after cesarean," Dr Palmer said during his presentation here at the American Congress of Obstetricians and Gynecologists (ACOG) 2016 Annual Clinical Meeting.

Both strategies were recommended in 1980 as reasonable options after previous cesarean delivery by a National Institutes of Health consensus development panel, when the rate of vaginal birth after cesarean delivery was around 3%. By the mid-1990s, that rate had risen to 28.3%.

But rates have not really budged since, said Dr Driggers, who is a member of the ACOG Committee on Scientific Program. "Part of it is the litigious environment now; it really makes people afraid," she said.

A survey of ACOG fellows conducted in Florida in 2014 by Dr Palmer confirmed the litigation fear. Of the 204 respondents, 58% offered trial of labor or vaginal birth after cesarean delivery to their patients. Of the 42% of respondents who did not offer it, the overwhelming concern, related to malpractice, was cited by 42%. Other reasons given were personal experience and the fact that the practice did not allow it.

Sixty-five percent of those who did not offer either of the strategies took home calls, which might have contributed to a lack of interest in or motivation for laboring with a patient for extended periods, Dr Palmer explained.

Some obstetricians and gynecologists might not have the time or ability to leave a practice for an in-house labor, Dr Driggers pointed out, but financial incentives or the laborist model could help increase interest. "You can continue to see patients in the clinic, so you aren't losing revenue by doing that," she said.

Florida Fund as a Model

The compensation fund in Florida was created as a way to keep obstetricians and gynecologists frustrated by the rising cost of malpractice insurance from leaving the state en masse, Dr Palmer told Medscape Medical News. The Virginia Birth-Related Neurological Injury Compensation Program is a similar program.

Obstetricians and gynecologists in Florida who elect to participate in the fund are required to contribute $5000 per year. Those who opt out still contribute through a $100 fee that accompanies licensure.

"If you participate, then all your patients participate," Dr Palmer explained. However, if a patient wants to opt out, the practice is obligated to help her find another clinician within a reasonable amount of time. Dr Palmer said he has had two patients receive compensation from the fund.

The program is helpful, but he said he and his colleagues are confident in their decision to provide vaginal birth and trial of labor after cesarean delivery, regardless. They have access to in-house anesthesia and clinicians at the University of South Florida, which allows them to shift to cesarean delivery if necessary. And they use the vaginal birth after cesarean calculator to determine good candidates and counsel patients (Obstet Gynecol. 2007;109:806-812).

"The risk of maternal death is higher with elective repeat cesarean delivery," he reported. And, for the right candidate, both strategies are safe for the baby.

But, he added, they also offer the strategies because "we feel it's important to allow women the choice."

Dr Palmer and Dr Driggers have disclosed no relevant financial relationships.

American Congress of Obstetricians and Gynecologists (ACOG) 2016 Annual Clinical Meeting: Presented May 14, 2016.

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