Malpractice fears are believed to influence various aspects of obstetrical practice. They seem to have contributed in small part to the rising primary caesarean section rate, but have also played a considerable role in the downtrend in vaginal birth after caesarean statistics. The rising vaginal birth after caesarean section rate between 1981 and 1995 was interrupted by a spate of lawsuits associated with broadened indications for vaginal birth after caesarean section in conjunction with requirements for immediate clinician availability. These factors dramatically reduced the availability of hospitals and clinicians willing to offer vaginal birth after caesarean section. This reversal, however, has not diminished the demand for vaginal birth after caesarean section from various stakeholders in the name of patient autonomy, clinician beneficence and optimal care. Nevertheless, as long as stringent requirements remain for clinician attendance during vaginal birth after caesarean section, and as long as the spectre of preventable error and the lingering dread of lawsuits retain their hold on obstetrical practice, caesarean section trends are unlikely to change.
Introduction
In this chapter, we discuss the effect of liability concerns on the provision of obstetrical care, specifically related to the use of defensive ‘assurance’ practices, such as caesarean section, and ‘avoidance’ practices, such as refraining from attempted vaginal birth after prior caesarean delivery (VBAC), sometimes referred to as: trial of labor after cesarean (TOLAC). Although fear of a lawsuit influences many aspects of obstetrics, it probably contributes in a small way to the rising use of primary caesarean section. By contrast, such fears are likely to be the primary motivator of the diminished use and availability of VBAC. Attempts to increase the use of VBAC by focusing on the perceived shortcomings of the medical negligence tort system are unlikely to be fruitful. A more tangible solution to decreasing the rate of primary caesarean sections and increasing attempts at VBAC lies in the development of more rigorous definitions and guidelines, greater accountability, and a focus on obstetrical safety. From this perspective, much can be done to reduce obstetrical litigation and the dread of malpractice among practitioners. More importantly, it can improve care and enhance both outcomes and satisfaction.
Within recent decades, the caesarean section rate has risen dramatically worldwide. The rise has been driven in part by our reliance on electronic fetal monitoring, efforts to salvage small babies even at the margin of viability, fear of litigation, decreasing expertise in operative vaginal delivery, and by the appeal of elective caesarean to some obstetricians and women. The current high rate of caesarean delivery is unsustainable, in no small part because it is not meaningfully associated with any proportionate improvement in perinatal outcome or maternal mortality. Nevertheless, solutions to reverse the trend so as to control morbidity and reduce associated healthcare expenditures have proven elusive.
Obstetrical litigation experience
Obstetrical care accounts for a substantial segment of healthcare costs. Unique among medical specialties, obstetrics deals simultaneously with two individuals, and adverse outcomes for mother or fetus can lead to lifelong disability or death. Accordingly, obstetrical care poses unique liability issues and contributes a disproportionate share of claims and indemnity payouts. Although the frequency of all claims seems to be declining, the number of large verdicts has been increasing, and obstetricians continue to pay high premiums.
The primary objectives of the liability system are to deter preventable error and to compensate its victims. That is, we are supposed to learn from the adverse outcomes and reduce their risk in the future. It is generally agreed that, despite changing legal, legislative and insurance environments, the problems of obstetrical malpractice have proved difficult to solve. The discourse among stakeholders, including patients, reveals deep discontent, and is often defensive and unproductive. In its wake have emerged numerous attempts at tort reform, defensive modifications to clinical guidelines, and even increased uncertainty about the benefits of care.
Part of the problem lies with the fact that obstetricians, politicians and defense advocates characteristically overestimate the risk of lawsuit, and underestimate the true incidence of deficiencies in care or in medical record documentation.
An evaluation of 30,121 randomly selected records found that 1.5% of maternal hospitalisations involved adverse events; negligence was associated with 38.3%. About 0.6% of newborn hospitalisations involved adverse events, and negligence played a role in 25.8% of those. In another study, the complication rate during labour and delivery was 2.8%, with 27.7% of those attributed to negligence. Nearly 10% of adverse events were associated with serious disability. By extrapolating these findings to all USA hospital births in 1984, an estimated 23,118 complications were found to be caused by negligence among childbearing women, and 7262 among newborn babies. More recent studies have found remarkably similar results.
Reviews of the quality of obstetrical care reveal that substandard care accounts for a significant percentage and sometimes most cases with adverse outcomes. Between 1993 and 2000, the Norwegian Board of Health investigated 70 claims of obstetrical misconduct. They found culpability on the part of the clinician, midwife or hospital in 97%. In Sweden, Berglund et al. scrutinised 472 records of women alleging negligence. Of these, almost 40% were considered to suffer from severe asphyxia caused by negligent conduct of labour. Results from the USA suggest that adverse obstetrical events are not infrequent and that most such events and outcomes are preventable.
There is always room for improvement, As is the case in other high-risk endeavours, the recognition of error is one of the first steps on the road to enhanced care and the creation of ‘high reliability’ maternity care units. Most malpractice seems to be unrelated to the incompetence of an individual provider, but to systemic problems that overwhelm competent people working in a highly imperfect and complex environment.
To benefit from these cases will require uniform definitions of ‘near miss’ and standardised, systematic evaluations by individuals not involved in the care. This approach has been undertaken by the American Society of Anesthesiologists with extraordinary reductions in adverse outcomes and liability premiums. To achieve similar goals and emulate high reliability maternity services, hospitals and professional organisations will have to take better care of patients and compile more reliable obstetrical data. Certainly, various approaches, including error reporting, development of prediction scores and checklists, crew resource management training and simulation training to improve clinical skills have advocates and appeal. Whether they will improve outcomes and diminish litigation will require further trials.
If we do not accept that lawsuits and unfavourable outcomes often derive from clinical practices outside applicable standards, we will probably inhibit progress in improving outcomes and dealing forthrightly with allegations of negligence. Studies of the culpability of the practitioner and the preventability of the adverse outcome provide some prescriptive value. Clark et al. found that 80% of VBAC-related claims and most shoulder dystocia cases would have been prevented had recommended practice and documentation patterns been followed. They concluded that more than one-half of hospital litigation costs might be avoided if obstetrical practice included delivery in a facility with 24-h in-house obstetric coverage, adherence to published high-risk medication protocols, a conservative approach to VBAC, and use of a comprehensive, standardised procedure notes in cases of shoulder dystocia. Berglund and Norman found flaws in neonatal resuscitation after severe asphyxia in cases of alleged negligence, as well as in those where no negligence was claimed. In the latter group, they found unsatisfactory documentation in 45% of records as well as a similar incidence of delayed resuscitation.
Available data indicate that the rate of claims filed in cases of negligent obstetrical injury is only about 2%, and less than one-half of these result in indemnity payments. Thus, negligent injury occurs far more frequently than any claim, payout or trial. Furthermore, most obstetrical lawsuits that are brought in the USA and elsewhere are unlikely to be frivolous: they are time-consuming, expensive to pursue and, in about one-half the cases, result in no payment.
Objective data related to culpability and preventability in malpractice claims tend to be viewed with considerable suspicion by care providers who believe that the legal system is unfair, that it favours the plaintiff, gives compensation for trivial accusations, and sympathetically rewards seriously injured newborn babies, even when the standard of care has been met. Consistent with this view, many in the medical community adhere to the notion that obstetrical care is a rare cause of fetal neurological injury. This belies recent clinical and neuroradiological studies that found that most neonatal encephalopathy is of perinatal not prenatal origin. Furthermore, the long-term consequences of intrapartum care are likely underestimated.
These sobering statistics notwithstanding, the statements that ‘it has never been safer to have a baby and never more dangerous to be an obstetrician’, that ‘no proven intrapartum policy can reduce the risk of injury’ or that ‘experts claim that timely cesarean section can prevent neurological injury to pursue meritless liability claims’ distract the obstetrician from the achievable goal of improving care. Furthermore, such rhetoric cultivates and reinforces the notion that the obstetrician is the victim of a system of tort law that allows greedy, ruthless plaintiff’s attorneys to destroy the specialty of obstetrics. When these ubiquitous notions are grafted onto the pain of fluctuating, capricious, sometimes exorbitant malpractice premiums, to fears of insurability and hospital accreditation, and to helplessness from poor support in the face of adverse events (see below), it is not difficult to grasp why obstetricians feel battered and abused by the legal system. In this environment, it is difficult to ascertain fully the effect of fear of malpractice litigation on the caesarean rate or to be optimistic about the implementation of reforms.
Obstetrical litigation experience
Obstetrical care accounts for a substantial segment of healthcare costs. Unique among medical specialties, obstetrics deals simultaneously with two individuals, and adverse outcomes for mother or fetus can lead to lifelong disability or death. Accordingly, obstetrical care poses unique liability issues and contributes a disproportionate share of claims and indemnity payouts. Although the frequency of all claims seems to be declining, the number of large verdicts has been increasing, and obstetricians continue to pay high premiums.
The primary objectives of the liability system are to deter preventable error and to compensate its victims. That is, we are supposed to learn from the adverse outcomes and reduce their risk in the future. It is generally agreed that, despite changing legal, legislative and insurance environments, the problems of obstetrical malpractice have proved difficult to solve. The discourse among stakeholders, including patients, reveals deep discontent, and is often defensive and unproductive. In its wake have emerged numerous attempts at tort reform, defensive modifications to clinical guidelines, and even increased uncertainty about the benefits of care.
Part of the problem lies with the fact that obstetricians, politicians and defense advocates characteristically overestimate the risk of lawsuit, and underestimate the true incidence of deficiencies in care or in medical record documentation.
An evaluation of 30,121 randomly selected records found that 1.5% of maternal hospitalisations involved adverse events; negligence was associated with 38.3%. About 0.6% of newborn hospitalisations involved adverse events, and negligence played a role in 25.8% of those. In another study, the complication rate during labour and delivery was 2.8%, with 27.7% of those attributed to negligence. Nearly 10% of adverse events were associated with serious disability. By extrapolating these findings to all USA hospital births in 1984, an estimated 23,118 complications were found to be caused by negligence among childbearing women, and 7262 among newborn babies. More recent studies have found remarkably similar results.
Reviews of the quality of obstetrical care reveal that substandard care accounts for a significant percentage and sometimes most cases with adverse outcomes. Between 1993 and 2000, the Norwegian Board of Health investigated 70 claims of obstetrical misconduct. They found culpability on the part of the clinician, midwife or hospital in 97%. In Sweden, Berglund et al. scrutinised 472 records of women alleging negligence. Of these, almost 40% were considered to suffer from severe asphyxia caused by negligent conduct of labour. Results from the USA suggest that adverse obstetrical events are not infrequent and that most such events and outcomes are preventable.
There is always room for improvement, As is the case in other high-risk endeavours, the recognition of error is one of the first steps on the road to enhanced care and the creation of ‘high reliability’ maternity care units. Most malpractice seems to be unrelated to the incompetence of an individual provider, but to systemic problems that overwhelm competent people working in a highly imperfect and complex environment.
To benefit from these cases will require uniform definitions of ‘near miss’ and standardised, systematic evaluations by individuals not involved in the care. This approach has been undertaken by the American Society of Anesthesiologists with extraordinary reductions in adverse outcomes and liability premiums. To achieve similar goals and emulate high reliability maternity services, hospitals and professional organisations will have to take better care of patients and compile more reliable obstetrical data. Certainly, various approaches, including error reporting, development of prediction scores and checklists, crew resource management training and simulation training to improve clinical skills have advocates and appeal. Whether they will improve outcomes and diminish litigation will require further trials.
If we do not accept that lawsuits and unfavourable outcomes often derive from clinical practices outside applicable standards, we will probably inhibit progress in improving outcomes and dealing forthrightly with allegations of negligence. Studies of the culpability of the practitioner and the preventability of the adverse outcome provide some prescriptive value. Clark et al. found that 80% of VBAC-related claims and most shoulder dystocia cases would have been prevented had recommended practice and documentation patterns been followed. They concluded that more than one-half of hospital litigation costs might be avoided if obstetrical practice included delivery in a facility with 24-h in-house obstetric coverage, adherence to published high-risk medication protocols, a conservative approach to VBAC, and use of a comprehensive, standardised procedure notes in cases of shoulder dystocia. Berglund and Norman found flaws in neonatal resuscitation after severe asphyxia in cases of alleged negligence, as well as in those where no negligence was claimed. In the latter group, they found unsatisfactory documentation in 45% of records as well as a similar incidence of delayed resuscitation.
Available data indicate that the rate of claims filed in cases of negligent obstetrical injury is only about 2%, and less than one-half of these result in indemnity payments. Thus, negligent injury occurs far more frequently than any claim, payout or trial. Furthermore, most obstetrical lawsuits that are brought in the USA and elsewhere are unlikely to be frivolous: they are time-consuming, expensive to pursue and, in about one-half the cases, result in no payment.
Objective data related to culpability and preventability in malpractice claims tend to be viewed with considerable suspicion by care providers who believe that the legal system is unfair, that it favours the plaintiff, gives compensation for trivial accusations, and sympathetically rewards seriously injured newborn babies, even when the standard of care has been met. Consistent with this view, many in the medical community adhere to the notion that obstetrical care is a rare cause of fetal neurological injury. This belies recent clinical and neuroradiological studies that found that most neonatal encephalopathy is of perinatal not prenatal origin. Furthermore, the long-term consequences of intrapartum care are likely underestimated.
These sobering statistics notwithstanding, the statements that ‘it has never been safer to have a baby and never more dangerous to be an obstetrician’, that ‘no proven intrapartum policy can reduce the risk of injury’ or that ‘experts claim that timely cesarean section can prevent neurological injury to pursue meritless liability claims’ distract the obstetrician from the achievable goal of improving care. Furthermore, such rhetoric cultivates and reinforces the notion that the obstetrician is the victim of a system of tort law that allows greedy, ruthless plaintiff’s attorneys to destroy the specialty of obstetrics. When these ubiquitous notions are grafted onto the pain of fluctuating, capricious, sometimes exorbitant malpractice premiums, to fears of insurability and hospital accreditation, and to helplessness from poor support in the face of adverse events (see below), it is not difficult to grasp why obstetricians feel battered and abused by the legal system. In this environment, it is difficult to ascertain fully the effect of fear of malpractice litigation on the caesarean rate or to be optimistic about the implementation of reforms.
Malpractice and caesarean delivery
Defensive medicine may be defined as ‘the use of diagnostic procedures/testing or treatments undertaken explicitly for the purpose of averting malpractice suits.’ Trends in caesarean section, VBAC, and operative vaginal delivery are consistent with medical conduct designed to reduce exposure to malpractice litigation. It is understandable that the obstetrician would conclude that caesarean section would reduce the risk of lawsuit. Virtually every suit involving intrapartum care alleges that an earlier more timely delivery would have changed the outcome. Unnecessary caesarean sections, however, increase the costs of care, expose patients to significant risks of harm in this and future pregnancies, and are a major public health concern.
A study of the relation between malpractice premiums and obstetrical care in a cohort of 890,266 women across the US in 2006 found that an average state malpractice premium of over $100,000 was associated with a higher caesarean delivery rate and a lower incidence of VBAC, and instrumental delivery when compared with states in which the premium was less than $50,000. The authors concluded that fear of litigation had a marked effect on obstetric practice when premiums were high. Other investigators have similarly found that the perceived risk of malpractice litigation was a clear determinant of obstetricians’ choice of caesarean delivery in various clinical scenarios, and that a correlation exists between the caesarean rate and malpractice insurance costs. The size of this effect on practice patterns is difficult to quantify. Studies in Florida, USA, suggest that clinicians who have had a significant indemnity payment on their behalf responded by a modest change in their caesarean rates.
Further evidence that the liability environment influences route of delivery came from a US study of births between 1991 and 2003. Higher malpractice premiums were associated with higher rates of primary and repeat caesarean section and decreased VBAC rates. By the authors’ calculations, a reduction of $50,000 in premiums would have resulted in about 1600 more VBACs, 6000 fewer caesarean sections, and 3600 fewer primary caesarean sections nationwide. They, and others who have analysed birth data, concluded that the liability environment influenced the route of delivery to a small extent.
Thus, both national and state-level studies from the USA, in which the relationship between malpractice pressure and caesarean section was examined, generally found at most a small, positive relationship between fear of litigation and the increasing caesarean rate.
A theoretical basis at least exists for the notion that a high caesarean section rate is associated with decreased risks of adverse outcome and malpractice lawsuits. A thought experiment considered the effect of near-universal elective caesarean. If all 3 million women at 39 weeks’ gestation in the US elected caesarean delivery, it would reduce the incidence of permanent brachial plexus palsy, fetal trauma, stillbirth and neonatal encephalopathy. Such practice would theoretically prevent 6000 fetal deaths annually and would reduce by 83% the number of newborns with moderate or severe neonatal hypoxic encephalopathy.
Caesarean delivery, however, does not avoid all fetal adversity. Injuries normally associated with vaginal delivery, including Erb palsy, subgaleal haemorrhage and fetal skull fracture from vacuum-assisted extraction, have all been reported at caesarean section. More importantly, it is unclear what additional maternal misfortune would result from a high caesarean rate. Evidence shows that the rising caesarean section rate in the USA has been associated with increased maternal mortality and higher rates of haemorrhage, infection and infertility.
Vaginal birth after caesarean section: quo vadis?
Trends
The dictum, ‘once a caesarean, always a caesarean’ first appeared in about 1915 and has governed obstetrical practice for most of the intervening century. The dictum has been intermittently challenged and reinforced since the 1960’s. In 1981, when the US caesarean rate was about 23%, one-third owing to repeat caesarean section, the VBAC rate was about 3%. At that time, a concerted effort was made to increase the use of VBAC, an approach championed vigorously by a National Institutes of Health consensus development conference, women’s advocacy groups, many health professionals and their organizations, and by health insurance companies.
The risks of uterine rupture after a prior low segment transverse uterine incision (usually cited as about 0.5–1.0%) were considered low and acceptable. Many ruptures were not calamitous, and were associated with good maternal and neonatal outcomes, and some ruptures even occurred before labour. Another driver of the VBAC trend was the presumption that vaginal delivery is less costly than elective repeat caesarean section, and that a policy encouraging VBAC would reduce the economic burden on the healthcare system. In response, VBAC rates increased almost 10-fold, from about 3% in 1980 to a peak in the mid-1990s, when 28.3% of women who had undergone a previous caesarean section underwent vaginal birth. This peak was short-lived, and fell as precipitously as it had risen. By 2004, the VBAC rate had fallen to 9.2%, and has remained about constant since. Recently, we have again seen a concerted effort to reverse the trend away from VBAC.
It is commonly thought that the abandonment of a trial of labour after 1995 as an obstetric strategy for women who had undergone a prior caesarean was a response to the emergence of critical reviews, or to new research that revised previous risk estimates, or to a rethinking of the known risks and benefits of VBAC, or even to the imposition of more restrictive criteria for the conduct of VBAC. Although each of these positions has some validity, more reasonably, it is the fear of litigation that may well have been the primary driver of the reduced use of VBAC.
Contemporaneous articles during the run-up to the VBAC rate, for example, identified no new class of risk (other than the increased chance of uterine rupture with use of prostaglandins for cervical ripening during VBAC attempts). No evidence has emerged to suggest that VBAC complications were more severe than previously thought. The frequency of rupture reported in most studies in the 1990s, when VBAC use peaked, was about 1%, roughly the same as in the 1960s. Absent the use of prostaglandins, the complication rates among those attempting VBAC, whether it succeeds or fails, and whether or not the uterus ruptures were similar before the run up and after the downturn. Differences in success, failure and rupture rates probably relate more to selection criteria, the definition of failure, the willingness to use oxytocin, and the way labour is managed than to any fundamental difference in the overall risk of the procedure. Even articles dealing with uterine rupture during this time maintained the reasonableness of continuing to attempt VBAC, but emphasised the need to refine criteria for patient selection to minimise the chance of rupture.
Efforts to reduce the caesarean rate
The widespread efforts to promote VBAC between the early 1980s and mid 1990s created a ‘prize’ mentality for diminishing the caesarean rate, a goal promulgated by hospitals, professional organisations and insurers. This mindset had not meaningfully calculated the risks and costs of near-universal attempts at VBAC or the effect on malpractice.
Physicians [were] pressured into allowing a trial of labor even when they consider[ed] it unwise or a patient does not want it. In fact, some insurance carriers have now mandated… a trial of labor (American College of Obstericians and Gynecologists [ACOG] Newsletter September 1989).
We are unaware of any medical, ethical or economic justification for a policy of universal or near-universal VBAC or of any published estimate of its benefits and risks. Some understanding of the possible consequences of such an initiative comes from an article in the Los Angeles Times in January 1998 entitled ‘Los Angeles County c-section rule took heavy human toll’. The article linked deaths and birth injuries to an expanded policy toward attempting VBAC, which led to $24 million in damage awards to settle claims in 49 cases of uterine rupture.
In the context of the zealous promotion of strategies to reduce the caesarean section rate, and the willingness of healthcare personnel to pursue such policies aggressively, the following case took place in Wisconsin, USA.
A multipara with two previous caesarean sections agreed to attempt VBAC. On three separate occasions during a long labour, the woman requested a caesarean. Each request was denied. On one occasion, her obstetrician summoned a consultant who concurred that the trial of labour should continue. The uterus ruptured, with devastating results. The newborn baby suffered spastic quadriplegia.
A lawsuit was filed. In court, the defense prevailed; they successfully contended that the conduct of labour was appropriate and that the woman, once having signed the consent form permitting a trial of labour, was bound to that decision and those of her caregivers. The case was appealed before the Court of Appeals and ultimately the State Supreme Court. Their deliberations would have an extraordinary effect on obstetrical care far beyond Wisconsin. [Schreiber v. Physicians Insurance Company of Wisconsin 223 Wis. 2d 417 (1996)].
Both courts reversed the trial court’s defense verdict and held that the clinician had violated Wisconsin’s informed consent law by refusing to honor the woman’s request for caesarean when such a delivery was a viable treatment option. The courts said that the woman’s right to select treatment encompassed a right to change her mind; that once a woman withdraws consent for a procedure or when medical circumstances change, a clinician is obligated to conduct another informed consent discussion. This woman’s requests for a caesarean section constituted a withdrawal of consent. The courts explicitly rejected the notion that once a procedure has been initiated, the time for a decision and discussions relating to that decision have passed. The courts determined that the damages to the baby resulted from the clinician’s failure to honour the woman’s request.
In November, 1996, the same year that the above case was adjudicated, a letter was sent to all obstetricians covered by an insurer ( Appendix 1 ). The letter emphasized the risks of lawsuit inherent in trials of labor and encouraged its policyholders to use the elements in a model consent form.
The consent form, created by the clinician who had acted as the defense expert in the Wisconsin case described above, contained the provisions outlined in Appendix 2 . Among other things, the form essentially asked the patient to accept responsibility for adversity that might occur during a trial of labor.
Many patients found the form threatening and exceeding the bounds and the spirit of a proper informed consent. Patients who refused to sign, however desirous of attempting VBAC they might be, were denied the option.
Vaginal birth after prior caesarean delivery rebound
After the mid-1990s, articles, editorials and pronouncements of professional societies (similar to those appearing during the run-up of the VBAC rate) feeding on the fears of malpractice, shifted gears and questioned the safety of VBAC. By 1999, the ACOG acknowledged that VBAC was no longer ‘encouraged’; rather, it was now to be ‘offered’ if there were no contraindications. It also suggested that if VBAC were attempted, a clinician’s ‘immediate availability’ was required.
In 2001, Lydon-Rochelle et al. reported the risk of uterine rupture with various delivery modes among 20,000 women. Although the incidence of rupture during VBAC attempts was low, the occurrence of poor fetal outcome, including death, was increased compared with those with no rupture. An editorial accompanying the article, noting the similarity of these data to those from several meta-analyses, observed that ‘there is no reason to believe that improvements in clinical care can substantially reduce the risks of uterine rupture and perinatal mortality.’ When faced with the question, ‘what is the safest thing for my baby?’ the editorial answered ‘unequivocally, elective repeat cesarean section.’
Although the 1999 ACOG guidelines and others simply reflected a return to the 1982 standards and viewpoint, the particular requirement for immediate availability of the obstetrician resulted in diminished access to VBAC. Many facilities no longer offered the option. A survey of California obstetrical units in 2004 indicated 25% of hospitals had stopped offering VBAC, a finding similar to that of a National Institutes of Health report. The California survey reported that ‘the stated reasons for discontinuing VBAC included the recommendation of the hospital’s liability carrier and an inability to comply with ACOG’s 1999 recommendations… for the immediate availability of the physician.’
A survey of practice patterns published in 2005 indicated that most obstetricians were carrying out more caesarean deliveries than they had been 5 years earlier. The primary stated reasons for this were the risk of liability and ‘patient preference’. More than 25% of clinicians reported that they practised in hospitals that did not follow the ACOG guidelines on resources and immediate availability. Almost all (98.2%) respondents agreed that they knew the risks and benefits of VBAC, but only 61% reported feeling competent in determining which patients will be successful.
A postal survey of obstetricians from the Dallas Fort Worth area in the USA revealed that only about one-half (52%) offered VBAC to their patients. The remainder cited ‘maternal–fetal safety concerns’ associated with uterine rupture followed by medico-legal liability concerns as an explanation. Predictably, previous malpractice litigation was a factor associated with clinicians not providing VBAC. Thus, the rise in lawsuits that proved difficult to defend, and the defensive responses thereto, were the foreseeable consequences of a broadened, aggressive approach to reduce the caesarean section rate. Both clinicians and patients now had less interest in VBAC: clinicians and hospitals because of staffing requirements and the fear of lawsuit; and patients because it required finding an accommodating clinician and hospital and, sometimes, signing an odious informed consent form.

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