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Chapter Six Operating in a Culture of Risk A Fraught Environment for Obstetricians Twenty years ­ after the introduction of the electronic fetal monitor, the influence of the birth reform movement had waned. Fallout from the movement nonetheless persisted; well into the 1980s, obstetricians complained of working in a fraught environment. Expected to accede to the contradictory demands of individual patients, consumer groups, insurance companies, the ­ legal system, federal agencies, and their own professional organ­ izations, they also ­ were forced to contend with the risk culture created, in part, by the electronic fetal monitor.1 Thomas Sartwelle, an American trial ­lawyer specializing in birth injury, blames the monitor for what he terms a “phenomenon previously unseen in medicine’s long history . . . ​defensive medicine.” He contends that the seemingly irrefutable rec­ ord of fetal distress provided by monitor strips was responsible for the excessive damage awards issued by juries beginning in the mid-1980s. The judgments, he writes, “not only substantially altered medical practice but medical ethics as well. Physicians’ response to the rising claims was abandonment of the venerable ‘first do no harm’ princi­ ple, replacing it with the expedient self-­ serving ethics of ‘do what­ ever is necessary to keep trial ­ lawyers at bay.’”2 Although Sartwelle defines the rising number of cesareans as “harm,” most physicians have not. An array of forces had converged by the mid-1980s to create a medical culture focused on the alleviation of risk during birth, however slight that risk might be. The forces included reluctance to sanction vaginal births ­after a previous cesarean (VBACs), a series of medical malpractice crisis points, the 154  Cesarean Section weaknesses of American healthcare financing, changes in the training of obstetric residents, and the counterintuitive effect of the dramatic increase in female obstetricians. In the cloistered world of obstetrics, ­ these influences transformed doctors’ perception of, and be­ hav­ iors surrounding, cesarean section and vaginal birth. As a result, a medical procedure that was once dreaded and rare would become , by the early twenty-­ first ­ century, the most frequently performed surgery in the United States.3 The Federal Government Weighs In Initially, the public health community expressed the gravest discomfort with the spike in cesareans. The National Institutes of Health (NIH) called the rising rate “a ­ matter of concern,” while the Department of Health, Education, and Welfare (HEW) called for “controlled clinical ­ trials” to assess the efficacy and safety of cesarean versus vaginal birth. The concern was significant enough that both federal agencies, the HEW in 1979 and the NIH in 1981, issued reports examining the ­ causes of the increase in cesareans and providing suggestions to alleviate the rise.4 Between 1968, when the National Center for Health Statistics first began gathering data on cesareans, and 1977, the nation’s cesarean rate ­ rose 156 ­ percent, even as the birth rate declined 12 ­ percent. The HEW report noted that the increase did not appear to benefit ­either individuals or the healthcare system—­cesarean sections saw a complication rate of at least 33 ­ percent and a financial cost three times that of vaginal birth. As part of her data-­ gathering, Helen Marieskind, author of the HEW study, interviewed 100 obstetricians, granting interviews only to physicians willing to provide comprehensive data about their practices and patients. Noting that representatives from assorted interest groups ­ were “pretty hot ­ under the collar” about the cesarean rate, Marieskind sought facts, not anecdotal evidence or emotional claims. She devoted the bulk of the HEW report to a systematic examination of the ­ factors contributing to the rise. While most physicians she interviewed cited their fear of a lawsuit as the reason for their growing propensity to perform a cesarean, she could find ­ little basis for their claim. Only a tiny minority of the doctors she interviewed had been sued or knew anyone who had been sued. She found instead that more significant contributors to the increase ­ were American physicians’ unwillingness to allow vaginal births ­ after a previous cesarean, changes in the training of obstetric residents, the unsubstantiated conviction that cesarean section saw outcomes that ­ were superior to vaginal birth, a willingness to accept vague justifications for cesare- Operating in a Culture of Risk   155 ans, and a declining fertility rate that amplified the notion “­ every baby counts.” She also noted that obstetricians had begun to look to cesarean section as a solution for ­every prob­lem they encountered during ­labor, even as they dismissed the notions that vaginal birth benefited neonates and posed fewer risks to ­ mothers. She...


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