A Perfect Storm

A perfect storm is approaching, one where pregnant women at the moment of giving birth cannot find a doctor in America. A study of pregnancies in Washington State, published in the August 2, 2002, issue of the medical journal Obstetrics & Gynecology, shows that women giving birth without doctors are almost twice as likely to have their babies die. Lately, skyrocketing medical malpractice premiums have been driving doctors out of business. This is a campaign issue because John Edwards led the litigation charge that drove up the premiums. But the issue is bigger than politics. It needs to be addressed now, because the lives of many children are at stake.Recently, obstetricians with patients whose children have developed cerebral palsy have come under withering legal attacks for delivering babies through natural childbirth instead of Caesarean section. While these attacks have subsequently been proven to have no statistical validity, many obstetricians suffered enormous damages from these spurious lawsuits. And these claims raised the bar for malpractice awards against obstetricians in general. One patient was recently awarded $95 million.The money to pay these claims does not come from the moon. Insurance companies pay them, adjust rates, and doctors pass them on to patients as higher costs. Now, average annual malpractice premiums for obstetricians have risen to $135,000 a year. As a result, between 1999 through 2002 14% of all obstetricians retired, according to the American College of Obstetricians and Gynecologists. It says that only 66% of seats in obstetrics classes are filled by American citizens intending to stay here.Inevitably, the rapid retirement by obstetricians will continue because they rely on medical students to help at the hospital. A typical obstetrician has 200 patients in a year. Each pregnant woman should have 10 visits, and when she comes to the hospital to deliver, she is there on average for 10 hours. If the hospital fails to replace its interns, no one can help the doctor. If the doctor leaves a patient alone during labor, it is malpractice. But 200 patients require 2,000 office visits to properly monitor those babies. Since the doctor cannot be in two places at once, he reduces the number of patients he attends, and as he does that, his income may not support his massive malpractice premiums.For example, Macon County, Mo., lost its last obstetrician when she left to start a practice that would allow her to afford her malpractice premiums. Many of her patients were on Medicaid. Women going into labor in Macon County now drive one or two hours to get to doctors in neighboring counties. Some will wind up giving birth in their car. This lack of obstetricians is occurring throughout the country. The American College of Obstetricians and Gynecologists has identified 23 crisis, or “red alert” states, including New York, New Jersey, Connecticut, Ohio, Pennsylvania, Texas, Illinois, Virginia, Florida, Georgia, Nevada, Missouri, Arkansas, West Virginia, Missouri, Mississippi, Maryland, Utah, Alabama, Arizona, and Washington.More ominous is the American College of Obstetricians and Gynecologists’s statistic that the obstetricians who were surveyed delivered 9% fewer babies in the same period. The pipeline for doctors cannot be quickly filled. It takes 14 years to graduate a new obstetrician. At present rates of retirement, one can anticipate that over the next eight years, our nation will have 40% fewer obstetricians than we had as recently as the 1990s.What is the impact of these retirements on our population? The study of women in Washington concluded that neonatal death rate was nearly double when a birth occurred at home without the benefit of a doctor or a hospital. A 40% drop in obstetricians would suggest 25% of all babies being born without the benefit of an obstetrician if the relationship from the American College of Obstetricians and Gynecologists survey held between retirements and fewer attended deliveries.Each year there are roughly 4 million births in America. In 2002, the infant mortality rate nationwide increased to 7.0 per thousand in 2002 from 6.8 per thousand in 2001. It was the first increase since the 1950s. Each one-tenth percentage point change in infant mortality represents an additional 4,000 lost babies, with a disproportionate impact on minorities. In New York City, the infant mortality rate increased to 6.5 deaths per 1,000 babies in 2003 from 6.0 deaths per 1,000 babies born in 2002.These are babies that parents wanted. Common sense and statistics tell us lack of available doctors is a factor in these numbers.The study showed the pregnant women were in greater distress as well. Against the population of pregnant women in America, many women will perish who would have lived if they had obstetricians. There are trade-offs between Caesarean and natural childbirths reasonable professionals should make. There are risks with surgery and anesthesia. But the malpractice storm has shattered the doctor-patient relationship. With every patient, a doctor must first ask, “how can I avoid litigation?” instead of, “what is the absolute best course of action?” Driven by malpractice considerations, Caesareans have grown to 26% of all births last year from 5% of all births in 1970.For mothers-to-be with complications, the easiest way for a doctor to avoid litigation is to refuse them as patients altogether.Without doctors, many more babies will die. What was once a choice between having a Caesarean and a natural childbirth, both with an attending doctor, will now become, for many woman, a choice between making a run to a far away hospital with the risk of giving birth in the car, or staying at home without the benefit of a doctor at all. Tort reform sounds abstract when discussed in presidential campaigns. But a perfect storm is coming.

A Perfect Storm

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