Access to ob-gyn care has been diminished. This means less
prenatal care as doctors decrease high-risk obstetrics (30 percent), reduce
deliveries (14 percent), and stop obstetrics altogether (8 percent)--avoidance behaviors reported by 63 percent
of ACOG members who responded to a 2009 survey. Access to preventive care is also diminished
as fewer gynecologic surgeons are available to treat women with pelvic pain,
infertility, or cancer.
In Southeastern Pennsylvania,19 hospital maternity units have closed since 1997 due to medical liability
concerns and costs. In Philadelphia,
only the city's six teaching hospitals continue to deliver babies. Statewide, there
has been a net loss of 43 hospital ob units over the last several years. Yet
safe hospital deliveries and increased availability of prenatal care are among
the very factors that contributed to a greater than 90 percent reduction
in national infant and maternal mortality during the twentieth century.
Assurance behaviors, another element of defensive medicine, result in additional
laboratory and imaging studies and consultations. Both increase
health-care costs and may subject patients to the risks of false-positive test results. Liability costs, including defensive medicine, are by
one estimate $56 billion, or 2.4 percent of the nation's annual health-care tab.
Reliable justice would help improve the physician-patient
relationship and medical care overall. Two grievous birth outcomes in
particular--neurologic impairment, including cerebral palsy, and shoulder
dystocia--can have a devastating effect on a patient and her family, as well
as on an ob-gyn's relationship with her patient, her own family, and her
profession. Neither of these outcomes is likely related to the obstetrician's actions or inaction. But
multi-million-dollar jury awards often follow.
Despite dramatic improvements in maternal and neonatal
morbidity and mortality, the rate of cerebral palsy remains unchanged.
Epidemiologic studies show that less than 10 percent of cases can be attributed to
events occurring during labor and delivery. Yet the costs of caring for and
educating these children are substantial, and malpractice lawsuits are often
the only source of financing, regardless of an absence of fault.
Shoulder dystocia constitutes an obstetric emergency. A
newborn can suffer permanent injury to the brachial plexus--nerves supplying
the infant's arm--when the baby's head delivers but the shoulders remain
trapped in the mother's pelvis. More critically, the umbilical cord is
compressed and the baby is deprived of oxygen. The obstetrician has only minutes
to deliver the baby before it suffers brain damage or dies. Before intervention, the brachial plexus is already stretched; appropriate maneuvers to
free the baby necessarily further stretch it. About 88 percent
of brachial plexus injuries result in only transient impairment of the baby's
arm, but unavoidable permanent injury afflicts the remainder.