A subtle pressure
Of course, only a minute fraction of the c-sections performed in this country are court ordered. Far more women undergo the procedure at the recommendation of their doctor. The most common reason a woman is encouraged to have a c-section is if she previously delivered a child this way. These "repeat c-sections" have become so common that they now account for nearly 410,000 births annually in the United States, about 10 percent of births each year.
And it doesn't seem that this number will be getting any lower, as an increasing number of hospitals that formerly permitted women to try for vaginal birth after cesarean (VBAC) now prohibit the practice, making a return trip to the O.R. mandatory for moms-to-be with a previous surgical delivery. Because it's getting harder and harder to find medical centers that allow VBAC, the rate has plunged by nearly two-thirds, from 27.5 percent in 1995 to 10.6 percent in 2003.
Ask doctors what's behind the ban, and you'll hear the same answer: fear of lawsuits. Trying for a VBAC carries with it a 1 percent risk of uterine rupture. This dangerous complication is an emergency that requires surgical repair -- or, in some cases, a hysterectomy -- to stop potentially life-threatening blood loss. "Medical liability is a huge problem for obstetricians, because people are losing their practices over malpractice claims," reports medical ethicist Anne Lyerly, M.D., assistant professor of obstetrics and gynecology at Duke University in Durham, North Carolina. "So it's understandable that a lot of us practice defensive medicine by avoiding risky deliveries that might have adverse outcomes." A 2004 American College of Obstetricians and Gynecologists (ACOG) survey bears this out, since 15 percent of its members say they've stopped doing VBACs to protect themselves from malpractice claims, and another 14 percent no longer deliver babies at all for the same reason.
In 1999, ACOG responded to concerns about VBAC risks with new practice guidelines, saying that the delivery should only be provided at hospitals equipped to do an immediate c-section if anything went wrong, instead of within 30 minutes' notice, as was previously required.
That's fine for big medical centers that have anesthesiologists and surgeons on duty 24/7, like the one where Dr. Minkoff delivers babies, but not for smaller hospitals. "Often, they can't afford to have doctors standing by in case a woman who arrives in early labor needs surgery later on, so in many parts of the country, especially rural areas, pregnant patients can't find anywhere to have a VBAC," he explains.