A landmark verdict on an unnecessary cesarean.

Cesarean section is America's most frequently performed major surgery. Currently, the cesarean rate appears to be levelling off at about 24% of all births. Ten years ago, it was considered too high at only 15%. (By way of comparison, some obstetric and midwifery practices have a cesarean rate in the low single digits, with no added risk to mothers and babies).

Cesarean section can be a lifesaving operation (i.e. if there is a prolapsed umbilical cord, active genital herpes, true cephalpelvic disproportion, or a placental problem). But when it is done unnecessarily, it is ma or surgery that carries two to four times greater risk for the mother and baby than vaginal birth. There's a greater risk to the pocketbook, too. According to the Wall Street Journal, "reducing cesarean births would save the U.S. $1 billion" per year. The Centers for Disease Control called 349,000 cesareans performed in 1991 "unnecessary."

In February, 1991, Consumer Reports listed three main reasons unnecessary cesareans are performed: "Some are done partly because it's more convenient for the medical team to operate than to wait out a long labor. Some may be done partly because obstetricians usually earn more from surgery than from routine deliveries.(1) And many are done because obstetricians fear a malpractice suit should something go wrong in the delivery." If it is true that convenience is a factor, than the increasing use of certified nurse midwives, improvements in training of doctors and nurses, and consumer education should help bring the cesarean rate down. Indeed, this may already be starting to happen. It it is true that finances are a factor, then health care reform should include a change in the policy of greater insurance reimbursement for cesareans.

It is true that malpractice worries are a factor, according to a 1993 report in the Journal of the American Medical Association. Doctors fear malpractice litigation if something goes wrong and the doctor hasn't done everything possible. For every doctor sued because a cesarean might have prevented an unfortunate outcome, more cesareans are performed unneccessarily. This is called "defensive medicine" and it means that doctors perform many more tests and procedures than they would without the fear of lawsuits.

Mother's Suit Sets New Precedent

A landmark case here in Massachusetts might turn that around, at least part way. In June 1993, a mother of four was awarded $1.5 million because her unnecessary, coerced cesarean caused serious medical complications.

According to the Midwife Advocate, Mary Meador was planning a vaginal birth after cesarean in 1985. Her doctor scheduled her for a cesarean as he was planning to go on vacation. She says that when she protested, he responded with "dire images of her uterus blowing up like a hydrogen bomb." An on-call doctor did the cesarean despite Mary's protests and the fact that she was dilated to 6 cm with no problems.

The surgery triggered a rare, previously inert genetic disease called hollow visceral myopathy, which produces intestinal obstructions. Mary endured several more operations, including removal of part of her intestines. She spent two years in the hospital and in bed. Besides her physical discomfort, she was unable to care for her children, and she was deeply traumatized by her betrayal by health professionals. As a nurse, she had admired and emulated physicians.

Dr. Leo Sorger, an obstetrician known for his loyalty to midwifery-style ;are, testified on Mary's behalf Dr. Harold Bursztajn, a forensic psychiatrist, testified that she suffered from Post Traumatic Stress Disorder.

The case was not tried on the issue of informed consent for technical reasons. The Midwife Advocate says, "the jury apparently concluded that the physicians' misrepresentation if the risk of VBAC constituted medical malpractice... Childbirth activists everywhere can now use this precedent to increase the legal, professional, and public pressure against unnecessary cesareans as well as against coercive treatment of any kind."

Now that doctors can be sued whether they do a cesarean or not, what will happen? Will perceptions change about the advantages of aggressive intervention? Will obstetricians be forced to give up and leave their practices? Will protocols change so that doctors can practice medicine as they see fit, and mothers can be assure that each cesarean is a necessary one?

(1) "National statistics show that a married woman over 35 who lives in the Northeast, enjoys a high socioeconomic status, delivers in a large proprietary hospital, and is insured by Blue Cross stands the greatest chance of having a cesarean birth." Consumer Reports, February 1991.