NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Institute of Medicine (US) Committee to Study Medical Professional Liability and the Delivery of Obstetrical Care; Rostow VP, Bulger RJ, editors. Medical Professional Liability and the Delivery of Obstetrical Care: Volume II: An Interdisciplinary Review. Washington (DC): National Academies Press (US); 1989.

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Medical Professional Liability and the Delivery of Obstetrical Care: Volume II: An Interdisciplinary Review.

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2Is the Rising Rage of Cesarean Sections a Result of More Defensive Medicine?

Benjamin P. Sachs, M.D., M.P.H.

In the United States today, almost 1 in 4 infants is delivered by cesarean section. The marked rise in the rate of use of this procedure over the last decade has coincided with a changing medical-legal environment. In this chapter I address the question of whether there is a relationship between the medical-legal climate and the rising rate of cesarean sections. To address this difficult question, I review the epidemiology of cesarean sections, discuss the causes for the rise in the rate, and examine the possible relationship of that rise to the practice of defensive medicine.

Historical Perspective

Cesarean deliveries were rarely performed in the United States and Europe prior to the end of the nineteenth century.1 The first reported cesarean section by a physician in the United States was performed in 1827 by John Lambert Richmond.2 Initially, cesarean sections resulted in high maternal morbidity and mortality because surgeons believed that the uterus should be left unsutured. American physicians—in particular, Frank E. Polin, from Springfield, Kentucky—were at the forefront of demonstrating the importance of suturing the uterus following a cesarean delivery.3 In 1868 Brickell published the first American report of the use of sutures.4

The safety of the surgery was further improved by the recognition that timeliness was important. Harris and Sanger demonstrated that an early cesarean section would improve maternal outcome.5, 6 The first to recommend a vertical incision through the lower uterine segment was Osiander of Goettingen in 1805.7 Kara of Heidelberg described a low transverse incision in 1881, and Kronig furthered the work of Kara by recommending a uterovesicle peritoneal reflection.8

In 1933 a White House Conference on Child Health and Protection was held.9 In New York at that time the state maternal mortality committee reported an incidence of cesarean section delivery of 2.2 percent. The maternal loss from cesarean section was reported to range from 4.2 to 16.1 percent, with one-fifth of all maternal deaths occurring among women who underwent a cesarean section. However, this report stressed that the high mortality was due as much to preexisting conditions as to the procedure itself.10

Epidemiology of Cesarean Sections

There has been a dramatic rise in the rate of cesarean delivery, from less than 5 percent before 1965 to 24.1 percent in 1986.11 The primary cesarean section rate appears to be leveling off at 17.4 percent, having risen from 4.2 percent in 1970.12 If the current rate of increase continues, by the year 2000 the total cesarean section rate will be 40 percent; for women aged 35 years and older, it may reach 50 percent.13

A National Institutes of Health (NIH) task force examined the reasons for the increase in the cesarean section rate between 1970 and 1978 (Table 1).14 It reported that 30 percent of the rise was due to a diagnosis of dystocia, 25 to 30 percent to repeat cesarean sections, 10 to 25 percent to breech presentation, and 10 to 15 percent to fetal distress. The further rise that occurred between 1980 and 1985 was recently examined, with the following findings: 48 percent of the increase was due to a previous cesarean section, 5 percent to breech infants, 29 percent to dystocia, 16 percent to fetal distress, and 2 percent to other factors.15 The major difference between the two analyses is a lower incidence of breech infants and a higher incidence of repeat cesarean sections in the later analysis.

TABLE 1. Contribution of Major Indications to the Increase in Rates of Cesarean Section, 1970-1978 and 1980-1985.


Contribution of Major Indications to the Increase in Rates of Cesarean Section, 1970-1978 and 1980-1985.

Demographic Factors

A number of demographic factors influence the frequency of cesarean section deliveries. These include the following.

Maternal Age

Women aged 30 years and older have a two-to threefold higher cesarean section rate.16, 17 The reason is unclear, but it has been suggested that it is due to a higher incidence of dysfunctional labor and therefore more sedation. As more women delay childbirth, the issue of the high cesarean section rate for the older first-time mother becomes more significant.

Prenatal Care

There is no clear relationship between the presence or absence of prenatal care and the cesarean section rate.18 In any such analysis there are many confounding variables, such as socioeconomic factors, race, parity, and so on.

Maternal Demographics

Maternal demographics include marital status, education, and ethnic background. Again, it is unclear from the literature whether these factors affect the rate of cesarean delivery. 19, 20

Hospital Teaching Status

Teaching hospitals are often large facilities that are set in cities and that serve high-risk populations. Furthermore, they often have special-care nurseries. Logically, teaching hospitals should have higher cesarean section rates than other hospitals; a 1981 Massachusetts study, however, found that the cesarean section rate for first births varied only from 0 to 31.4 percent, with an average of 18.5 percent.21

Only 1 of the 10 hospitals with the highest rates had a neonatal intensive care unit.

Private or Clinic Care

In four Brooklyn hospitals that accounted for 65,647 deliveries between 1977 and 1982, it was found that private physicians performed significantly more cesarean sections than house officers and attending physicians.22 Diagnoses of dystocia, malpresentation, or fetal distress were more likely to be made by private physicians. Private patients' infants had lower mortality rates, but they also had a significantly higher incidence of low Apgar scores and birth injuries than the infants of clinic patients.

Hospital Ownership

There is no clear relationship between hospital ownership and the cesarean delivery rate.23 If there were, then the often-cited economic incentives could be held responsible for the high cesarean section rate. In an analysis of data from hospitals in 1981 Placek and colleagues showed that the highest cesarean section rates were in proprietary hospitals, followed by nonprofit hospitals, and then government hospitals.24 In contrast, a New York City study found nonprofit hospitals and proprietary hospitals to have similar rates.25

Insurance Coverage

A recent study showed higher cesarean section rates for patients with Blue Cross-Blue Shield or other private insurance.26 The lowest rates were seen in self-paying patients and Medicaid patients. These findings were true both in 1980 and 1986.

Comparison of National Cesarean Section Rates

There has been a marked rise in the frequency of cesarean deliveries in Europe and in Australia and New Zealand (Table 2), but the highest rates are found in the United States.27 National differences are related to differences in obstetrical practice with regard to complications in pregnancy and delivery and the frequency of vaginal deliveries following a cesarean section. The practice of repeat cesarean sections was undoubtedly a major contributor to the higher rate in the United States. Also of interest is the higher incidence of the diagnosis of fetal distress in the United States, compared with the other countries.

TABLE 2. Cesarean Section Rates (as percentage) in Selected Countries, 1970-1973 and 1981-1983.


Cesarean Section Rates (as percentage) in Selected Countries, 1970-1973 and 1981-1983.

Electronic Fetal Monitoring

The technical ability to monitor the fetus continuously during birth was developed in the 1960s. Originally intended for the management of high-risk obstetrical cases, electronic fetal monitoring (EFM) has become almost routine for deliveries in the United States—despite a number of recent reports that routine fetal monitoring does not improve the outcome in low-risk obstetrical patients.28, 29 The widespread use of EFM has lead to a marked increase in the cesarean section rate, for a number of reasons.


The predictive value of electronic fetal monitoring is poor.30 With increased use of EFM for low-risk patients, the predictive value will be even lower, resulting in an increased cesarean section rate.


A method of further evaluating the pattern of the fetal heart rate is to measure the pH of blood samples from the fetus's scalp. However, this procedure is available only in a minority of obstetrical services in the United States.


In the current medical-legal environment, in my opinion, fetal heart rate tracings are likely to be overread, leading to more cesarean deliveries.


The objective of fetal monitoring is to detect a fetus that is in distress, with the objective of performing either a forceps or a cesarean delivery. Thus, fetal monitoring by itself will increase the rate of intervention.


Although difficult to prove, it is thought that there is a higher incidence of dystocia among women who have continuous electronic fetal monitoring, the reason being that they are unable to walk. They are therefore less able to tolerate labor and require more sedation.


Dystocia is a catchall phrase that includes failure to progress in labor and cephalopelvic disproportion. There has not been a marked rise in the birthweight of U.S. infants between 1980 and 1985; therefore, a change in clinical practice must have caused the rise in this diagnosis, which led to a 29 percent increase in cesarean deliveries during this period.31 This area has not been thoroughly studied; from personal experience, however, I would judge that because of the current medical-legal climate, there has been a decrease in midforceps deliveries. The other explanation may be the widespread use of fetal monitoring and its relationship to dystocia, as discussed earlier.

Breech Presentation

Between 1980 and 1985, 5 percent of the increase in the cesarean section rate was related to breech presentations.32 The incidence of an infant presenting by the breech at term is approximately 3 percent. Most clinical studies have shown that certain types of breech infants can safely be delivered vaginally. For others, such as a complete breech or a footling breech, the risk of a vaginal delivery is increased, albeit by a small amount. Despite there being acceptable guidelines for the vaginal delivery of breech infants, in many institutions today all infants who present by the breech are delivered by cesarean section. The question is clearly, why? Again, my impression is that the medical-legal environment is responsible. With so few vaginal breech deliveries, there is less opportunity to educate residents; we have therefore an increasing pool of physicians with little or no experience in performing such deliveries.

Repeat Cesarean Sections

Repeat cesarean sections were responsible for 48 percent of the increase in the cesarean section rate between 1980 and 1985.33 The dictum ''once a cesarean section, always a cesarean" was originally put forward by E. B. Cragin, chairman of the Department of Obstetrics and Gynecology at Columbia University College of Physicians and Surgeons at the beginning of the twentieth century.34 At that time the frequency of uterine rupture was higher than it is today because many more patients had had a classical cesarean section. In contrast, most patients today have a low transverse incision, which has been shown in many studies to allow for safe vaginal delivery in a subsequent pregnancy.35 In a review of vaginal deliveries following prior cesarean sections the incidence of uterine rupture was 0.7 percent; the incidence of perinatal death (fetal and infant) was 0.93 per 1,000 births.36 Two of the three perinatal deaths in this study involved patients who had had a prior classical uterine incision. Of note was the fact that two-thirds of the patients in this series of 4,729 patients cared for in 11 institutions underwent successful trials of labor.

The American College of Obstetricians and Gynecologists (ACOG) has put forward the following guidelines for patients undergoing a trial of labor.37 Labor is indicated for all patients except those who have repeated contraindications to a vaginal delivery. There should be a single infant presenting by the vertex and weighing not more than 4,000 grams. The mother should have had only one prior low transverse incision, with no extension, and the type of incision should be confirmed by a written operative report. Labor is indicated even for women whose previous cesarean section was for dystocia. Technical support should be available in hospital, including skilled nurses, a staff obstetrician, a pediatrician, and an anesthesiologist. Furthermore, an adequate blood bank with compatible blood should be available and staffed 24 hours a day. Electronic fetal monitoring is advisable intrapartum. Finally, there should be immediate access to an operating room.

Given the preponderance of evidence that a trial of labor is safe, why are so many patients undergoing elective, repeat cesarean sections? The reasons might include convenience for both the physician and the patient, although in some cases (e.g., a small community hospital), given the ACOG guidelines, a more substantive reason might be the inability to provide sufficient support for a woman undergoing labor. As described, the risks are very small; nevertheless, in the current medical-legal environment a trial of labor that does not go well and for which the guidelines have not been met would be held against the attending physician and institution. This explanation, I believe, accounts for only a small fraction of the large number of repeat cesarean sections.

Risks Associated with Cesarean Section

If the medical-legal environment is driving up the cesarean section rate, is it at the expense of the mother? The maternal mortality rate is defined as the number of maternal deaths during pregnancy and within a set time postpartum per 100,000 live births.38 For deaths directly related to the cesarean section, the rate in five American and two European studies ranged from 0 to 60.7 per 100,000 cesarean sections.39, 40 The mean was 27 deaths per 100,000 cesarean sections (with a 95 percent confidence limit, ± 15.1). It is difficult to compare these seven studies as two were hospital based, three were statewide reviews, and two dealt with national statistics. Nevertheless, from these data it would appear that the risk of cesarean section did differ by country and, in the United States, by region.

A more recent study, carried out under the aegis of the Committee on Maternal Welfare of the Commonwealth of Massachusetts, found that between 1954 and 1985 there were 886 maternal deaths in Massachusetts.41 The maternal mortality rate fell from 50 deaths per 100,000 live births (1954-1957) to 10 (1982-1985). During this same time the cesarean section rate rose dramatically, from 13.9 percent in 1976 to 21.8 percent in 1984. There were 121,217 cesarean sections with 27 deaths, giving a mortality rate of 22.2 per 100,000 cesarean sections. However, only 7 of these deaths were directly related to the operative procedure, giving a mortality rate of 5.8.

A number of studies have attempted to examine the relative risks of a cesarean section and a vaginal delivery.42, 43 These reports, however, compared all cesarean section-related deaths with all other maternal deaths, thus overestimating the risk of a cesarean section. Between 1976 and 1984 in Massachusetts, as noted earlier, maternal mortality directly related to a cesarean section was 5.8 per 100,000 procedures.44 In contrast, during the same period there were 57 deaths associated with vaginal delivery, excluding ectopic pregnancies, septic abortions, and nonmaternal deaths. This calculates to a rate of 10.8 deaths per 100,000 vaginal deliveries. Thus, one can conclude that, in Massachusetts in the 1980s, a cesarean section is at least as safe as a vaginal delivery for the mother with respect to mortality. It should be stressed, however, that all studies have shown that a cesarean section is a far more morbid procedure for the mother, with morbidity including increased incidence of infection, longer hospitalization, and problems of bonding with the infant, as well as rarer complications, including hysterectomy and bowel trauma.

The relative safety of cesarean sections clearly must play a part in the decision making in individual cases. If the obstetrician is concerned about the risk, albeit a small one, of increased perinatal morbidity and mortality, he or she will resort to a cesarean section earlier because of the reassurance of the relative safety of the procedure.

Has the Increased Rate of Cesarean Sections Lowered Perinatal Mortality?

Is there a cause-and-effect relationship between the dramatic rise in the number of cesarean sections performed in the United States over the last decade and the simultaneous decline in neonatal mortality? The analysis of a potential relationship is confounded by a number of issues, the major one being the widespread introduction of neonatal intensive care units and improved neonatal care. The National Maternity Hospital in Dublin has reported a similar decline in perinatal mortality, despite a stable cesarean section rate of approximately 5 percent. A recent article comparing the perinatal outcome in patients delivered at Parkland Memorial Hospital in Dallas and at the National Maternity Hospital in Dublin reported that there was a higher rate of perinatal morbidity in Dublin, presumably as a result of the lower cesarean section rate.45 Yet when this comparison is extended over more years, there is no longer a difference in either perinatal mortality or morbidity, despite cesarean delivery rate at Parkland Memorial Hospital that is six times higher than the rate at the National Maternity Hospital in Dublin. It is of interest to note that in this Dublin hospital almost 20 percent of the patients delivered infants who weighed more than 4,000 grams.

The contrary point of view was put forth by Williams and Chen in a study in California in which they showed that there was a reduction in perinatal mortality in infants weighing less than 2,000 grams as a result of the advent of neonatal intensive care units and an increase in the cesarean delivery rate.46 I examined the effects of cesarean section on neonatal mortality rates for breech and low-birthweight vertex infants in Georgia between 1974 and 1978.47 For 229,241 singleton deliveries, cesarean section improved the neonatal outcome for breech infants and high-risk low-birthweight infants presenting by the vertex.

Cost of Cesarean Sections

In 1984 health care costs represented 10.6 percent of the gross national product (GNP), with an expenditure of $387 billion. Health care costs are projected to approach 12 percent of the GNP by 1990, with expenditures of $660 billion. If we continue in this fashion, we can expect an expenditure of $1.9 trillion, representing 14 percent of the GNP, by the year 2000. In terms of percentage of GNP, the United States has the most expensive health care system in the world, but statistics for maternal and child health do not reflect this large expenditure. The United States has one of the highest infant mortality rates of all developed countries, with a large disparity in the rates among socioeconomic groups. The high infant mortality rate is largely secondary to a high incidence of prematurity, the rate of which has not changed in almost 20 years.

A cesarean section may improve the outcome for some premature infants but clearly does not affect the number of premature births. The very high cesarean delivery rate in the United States, driven by the medical-legal environment, adds considerably to the cost of health care; yet the recent rise in the rate has not been shown to have improved the outcome for either mother or infant. The difference in cost between an uncomplicated cesarean section and an uncomplicated vaginal delivery in Boston in 1988 was $4,000-$5,000. This figure assumes a global fee for obstetrical care; thus, the differential will be higher in instances in which the physicians bill for a cesarean versus a vaginal delivery. Furthermore, this figure will clearly vary from hospital to hospital and state to state; nevertheless, it emphasizes the importance of the fiscal issue. If the cesarean section rate could be reduced by 5 percent, it would represent a savings of between $700 and $900 million per annum.

Health Policy

A 1987 survey of practicing obstetricians by the American College of Obstetricians and Gynecologists found that 46 percent were performing routine fetal monitoring, 41 percent reported a change in their clinical practice because of the medical-legal environment, 33 percent cared for fewer or no high-risk patients at all, and 12 percent were no longer practicing obstetrics.48 The widespread use of routine EFM is a form of defensive medicine: it reflects the perception among many clinicians that fetal monitoring and a timely cesarean section can keep them out of court. There is some truth in this. A study by the Harvard Risk Management Foundation of 75 single claims between 1976 and 1988 found that the frequency of allegations was 24 percent for fetal distress and only 7 percent for improper cesarean sections.49

The most prominent cases with the largest settlements or awards revolve around the issues of cerebral palsy and mental retardation. The epidemiological evidence clearly shows that only a small percentage of the cases that result in cerebral palsy or mental retardation, or both, are secondary to intrapartum events and thus affected by fetal monitoring or a cesarean delivery.50, 51 Cerebral palsy is defined as "a chronic disability characterized by an aberrant control of movement and posture appearing early in life and not a result of recognized progressive disease." The incidence of cerebral palsy is approximately 2 per 1,000 school-age children. The common association is low weight at birth. The lower the birthweight, the higher the risk of cerebral palsy. In full-term infants with cerebral palsy, only 16 percent of the cases in one series were caused by perinatal events.52 The prevalence of severe mental retardation is 3-4 per 1,000 children of school age, with mild retardation found in 1-3 percent of children of school age. The most common cause of severe mental retardation is genetic, with only about 18 percent of cases the result of perinatal events.53 In both animal experimentation and epidemiological studies it has been shown that total asphyxia in fullterm infants leads to brain damage and in most cases to perinatal death. (Lack of oxygen that is sustained long enough to cause brain damage usually results in myocardial ischemia and renal damage as well.)

In obstetrical malpractice cases it is often alleged that an instance of cerebral palsy, mental retardation, or both was secondary to intrapartum events. The plaintiff alleges failure to perform a timely cesarean section or misinterpretation of the fetal heart rate tracing, or both, resulting in death or brain damage. This medical-legal concentration on the issues of fetal monitoring and cesarean section is the origin, in my opinion, of the perception among clinicians that they need to perform defensive medicine. It is not helped by the fact that interpretation of a fetal monitor tracing is more of an art than a science.54 The broader issue relating to the etiology of cerebral palsy and mental retardation is often ignored in this environment.

The Children's Defense Fund in Washington, D.C., has reported a decrease in the availability of obstetrical care, in part as a result of the medical-legal environment. Some contend that this is a financial issue, resulting from lower physician reimbursement for Medicaid patients. In Massachusetts, however, the Medicaid reimbursement rates are the same as those of many private insurance carriers, and there is still a shortage of obstetricians for Medicaid patients. Again, I think that this is fallout from the medical-legal environment, the perception among obstetricians being that Medicaid patients are at higher risk and more likely to sue. This perception may be related in part to the relationship between the physician and the patient: an unexpected bad outcome is more likely to result in a suit if the patient and physician have a poor relationship or no relationship at all. This situation is more frequently the case for Medicaid patients and patients with no insurance.


There is overwhelming evidence that part of the recent rise in the cesarean section rate in this country is the result of the medical-legal environment. Given the current siege mentality among clinicians, one wonders why the cesarean section rate is not higher. Arguments that the rise in the cesarean section rate is a result of defensive medicine include


the widespread use of fetal monitoring (because of the medicallegal environment, fetal monitoring is widely used, even though its poor predictive value for detecting perinatal asphyxia in low-risk patients results in more cesarean sections);55


the lower incidence of midforceps deliveries;56


abandonment of vaginal breech deliveries;57 and


physicians' perception that the majority of allegations in obstetrics suits involve the issues of fetal monitoring and failure to perform a timely cesarean section.

Arguments that the higher cesarean section rate is not a form of defensive medicine include


a rise in the cesarean section rate in countries that do not have the same tort system as the United States;58 and


dystocia and repeat cesarean sections as important reasons for the rise in the cesarean section rate—they are probably only in part a result of the medical-legal environment.59

The high cesarean section rate in the United States is a major public health problem, one that is having and will continue to have a major impact on health care delivery. If the $800 million that could be saved by reducing the cesarean section rate by 5 percent were spent instead on prenatal care and preventive programs, dramatic effects on maternal and child health would be seen. This shift, in my opinion, is very unlikely to occur, given the current medical-legal environment, which has resulted in a siege mentality among clinicians. If one also considers that less than 20 cents on the dollar paid for malpractice premiums is given to injured parties, our current tort system is clearly very expensive, inefficient, and, because of its adverse effects on the delivery of maternity care, dangerous.


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Speert. 1980; see note 1.
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Taffel et al. 1987; see note 15.
Watson et al. 1987; see note 27.
Taffel et al. 1987; see note 15.
Copyright © 1989 by the National Academy of Sciences.
Bookshelf ID: NBK218656


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