An Israeli look at elective cesareans

I’ve pointed out in the past that medical/scientific reporting in the lay press often leaves much to be desired, accuracy-wise. There are exceptions to this rule, however. I’ve found one of those exceptions to be Judy Siegel-Itzkowitz of the Jerusalem Post. I have no idea what credentials she posesses, but at least regarding the subjects I know enough about to judge, her writing has always been clear, fairly accurate and easy for an intelligent layperson to understand. All the more remarkable when you consider that she has several articles in every day’s paper, including a regular ‘Reader Rx’ column, where reader’s medical questions are matched up with, and answered by, Israeli and American medical experts.

Siegel-Itzkowitz recently wrote a very interesting article about the legal and medical aspects of patient-demand CS (the term used in the article is CDMR – Cesarean delivery by maternal request). There are several points of interest in the article best left for discussion in the comments; I will point out that this month’s Zman Harefu’ah (Medical Times), an Israeli Medical Association periodical for IMA members, had an article (in Hebrew) about the increase in medical malpractice suits. It seems that, in more ways that one, America really is coming here. And much of the increase is OB-related.

You don’t even need to be able to read Hebrew to understand the graph from the article, which represents the increase in the amounts paid out due to med-mal lawsuits, from 1995 to the present:

I suspect that CDMR is here to stay, and in certain circles, will become more fashionable.


23 Responses

  1. That is a really startling graph – but what does it tell you? Are these the number of lawsuits that are started? How many continue? How many are successful? Do you have a jury system, like America, or not, like the UK? Are these for stillbirths, severely damaged babies, dead mothers? Or unrealistic expectations of perfection? Lots of doctors, or the same doctors over and over? Some studies have found that the “compensation culture” is a bit of a myth, but it still persists. As the mother of a brain damaged daughter, I get a bit irritated by the idea that my first thought was “Oh goody. We can get rich.”

  2. Several things in this article set my alarm bells to ringing”

    1) “Cesareans may also postpone the psychological/hormonal bonding between newborn and mother, and have harmful psychological effects.”

    Oh really? I’d LOVE to see the evidence for that.

    2) “The right to autonomy over one’s body is very important here, but sometimes it can be pushed aside.”

    You either have the right or you don’t – you can’t just push it aside, at least withough due process or it’s not actually a right.

    3) “High-income women on the Upper West Side of Manhattan often give birth on schedule by cesarean on a Thursday and get back to work the following Monday. ”

    This just screams “urban legend”. In my own experience women in the US (in NY on the Upper West Side even) sometimes opt for a c-section because it means they get extra time off for materinty leave – more than the standard (and miserly) 6 weeks.

    This really isn’t an issue we should allow to be politicized. it should be between a woman and her doctor. There’s more to say but I’ll leave it at that.

    • I agree/trust your experiences re points #1 and #3. About #2, she was quoting a lawyer defending a doctor in a mock trial about elective CS – I think the point being made is that the woman’s right to submit her body to a CS for no obvious medical reason doesn’t trump the doctor’s right to refuse the CS (and presumably refer her to someone more accommodating) if he believes it to be to her and her baby’s detriment.

      • Re; point 2, I realized after the fact that I’d misinterpreted the statement – and then of course I couldn’t edit. I do though wonder about this point on bodily autonomy and a physician’s ability to refuse to carry out a procedure. I’m thinking in relation to abortion. There’s controversial because medical students are refusing to learn to how to perform and abortion because they say they would never do them.

        What would a woman do if she couldn’t find anyone who would accommodate her wishes – whether for a c-section, a vaginal birth, etc.? I find it worrisome. I think if I hadn’t been able to have a scheduled c-section with my first son (I’d lost 5 pregnancies previously) I think it is possible I’d have had a nervous breakdown. I was that terrified of losing another baby.

        • I think this would be more problematic (in the Israeli medical context, at least) if hospitals refused to allow CDMR on their premises, rather than individual doctors refusing to so them. As long as doctors have a place to do the CS and it’s not deemed a suable, unethical offense – I suspect there will be many OBs who’ll be more than happy to fill that particular void.

  3. I do not think patient elected primary C-section is a trend. I have only seen a handful in 16 years as an OB/NICU nurse. If the mother demands one after much counseling and education, then fine. Big wup.

    I personally have had a C-section for my first, and a VBAC with my second. I think it is crazy that anyone would WANT a C-section. Way more painful and longer recovery.

    • My first pregnancy was twins, and while they were vertex-vertex and my OB would have supported an attempt at vaginal birth, I chose to have a CS. This was partly because I was concerned about having an emergency CS for the second baby, but also partly because I was concerned about the prospect of a third- or fourth-degree tear.

      1 in 25 odds is pretty scary for a complication that will most likely affect you for years after giving birth. Many of the common CS complications, such as hemorrhage and wound hematoma, are relatively short-term by comparison. Admittedly, I made that decision assuming postpartum infection wasn’t a huge deal, and then had a postpartum infection which left permanent damage. On the other hand, I’m not, y’know, incontinent.

      I know a couple of women who had very bad vaginal deliveries and wish with all their hearts they’d had a CS. I had major complications in both of mine — a hemorrhage in my first, infection in my second — but I still wouldn’t trade them for what these women have gone through.

    • IME, the recovery from a CS was indeed longer, but the pain from the episiotomy/tear (I had both, the small tear was anterior and the epi done to prevent its extension) was much worse than the CS incision. I can see advantages and disadvantages to both ‘types’ of births, actually.

  4. On reading the article in question, it seems to me quite muddled, sliding from the general rise in CS to the ethics of CS for maternal choice only. The paragraph that says doctors don’t get sued for refusing makes little sense as it stands – and I doubt very much that all of those who sue for a bad outcome are successful. It points out that complications CAN follow a CS, glosses over the fact that some of them can also follow a vaginal birth.

    I am not a supporter of “Too posh to push” – nor am I vehemently against it. Councel women about the risks by all means – but trying to limit CS generally to some arbitrary ideal figure seems to me irrational.

  5. Siegel-Itzkowitz doesn’t have any special credentials beyond being the Jerusalem Post’s reporter on medical issues for some years.
    Our system here is very different from the US, or even from the UK. Antenatal care is done under the auspices of a doctor via the patient’s “Sick Fund” [HMO] but management of the labor is by the staff midwives of the hospital the patient chooses, in collaboration with the resident medical staff, so that a pregnant woman is usually taken care of by multiple care providers. Taking an MD for a private delivery is quite rare; the homebirth situation is rarer still. The hospital midwives are not as autonomous as in the UK, and not infrequently are overruled by the on-call doctor, who is more likely to want to go to CS than the midwife might be. Maternal and neonatal morbidity/mortality statistics are better than in the US, and I find that most women actually have to be dissuaded from excessive antenatal ultrasounds and monitors, but there is a growing expectation by women that ALL births will result in an absolutely perfect outcome.
    The picture is complicated by the fact that while there is a certain segment of the secular population which wants every possible intervention because they feel that technology is going to prevent any complication, there is a large religious population which doesn’t want ANY antenatal screening or testing but still expects perfect outcomes.
    A great many lawsuits are frivolous and most are settled out of court, or dismissed. Israel does not have a jury system, btw.
    I also found the article rather confused–and wouldn’t be the least surprised if Siegel-Itzkowitz had been talking with some of my radical [ex-American] midwife friends who have definite agendas they are pushing and who are followers of the Ina May/Michel Odent et al group.

    • The legal system – in particular the medmal system – is very much tilted towards the plantiff here. The article in which the graph above appears discusses the rise in the absolute number of medmal lawsuits, and one of the doctors quoted also notes that the medical personnel sued are often not judged, by judges with mo medical training, to the ‘reasonable doctor’ standard, but the ‘always excellent doctor standard’ – which is an impossibly high one.

      Our HMO recently sent all its primary care physicians an email containing a recent legal decision in a case where a patient sued the HMO and a specific family doctor. The claim was made that the patient – who had longstanding diabetes, was extremely non-compliant, and developed complications of this disease – was inadequately informed of the possible consequences of his actions by the doctor and HMO staff, and if he had only known, he would have been more compliant with treatment. Though the medical record meticulously kept by the doctor showed many attempts to explain the necessity for treatment both by the doctor and the clinic staff, the patient won on some really stupid technical grounds. (It seriously made me question my future in the profession, let me tell you…).

      As for CS on demand, I can certainly see it gain traction in certain circles. There is a NCB movement here, but there is also a large segment of the secular, highly-educated and living in the Tel Aviv area public which would probably welcome CDMR. The same demographic which performs amniocentesis with every pregnancy, even before it’s covered by insurance at age 35+.

  6. As the mother of adult children, I frequently wonder why I am still so fascinated by these issues. Admittedly, I am currently engaged in supporting a daughter though a third high risk pregancy, which might be an excuse, but if I am honest that is not the reason. What fascinates are the issues, ideologies and puzzles that lie behind these discussions.

    What is central here is the disapproval and surprise at the idea that some women might willingly choose to forego the benefits and pleasures of a normal, “natural” birth. Modern CS carries the risks of any surgical procedure, but is generally safe and predictable. Vaginal birth is painful, unpredictable and can turn very bad indeed. Why are women who choose the former regarded by most of us with such disdain? Why is there so much denial around fear of childbirth? Are these women really unnatural wusses who need to be counselled? Or is vaginal birth as a “rite of passage” or whatever being mythologised in a way that defies logic? I would, of course, bow to the superior knowledge of medical professionals who tell me that vaginal birth is “better” for a woman. I concede that it is better not to have surgery generally, and that multiple CS may not be a good idea. But given that the majority of women do not want large families anyway, what is really at the bottom of the hostility to CS?

    As for frivolous law suits, I don’t doubt many get started, and maybe a very small proportion result in injustice to hard working doctors. But I think they are probably outnumbered by the people who have good cause and don’t sue.

    • There is somewhat less of a fetish about ‘vaginal birth at all costs’ here, I think – at least not for those reasons you stated. There is a desire to avoid CS in order to bring many subsequent children into the world, as detailed in the article – and CS rates are indeed much lower than in the US. This may change, perhaps is changing, in accord with the legal realities (when I was a med student, the hospital I gave birth at for 2/3 kids boasted a CS rate of 8%; currently that rate is slightly over 15%).

      I see CDMR as a personal choice, the other side of the coin from having a homebirth or a VBAC. If a woman can choose those, she can also choose to have a CS. Where it gets sticky is whether a healthcare provider (whether a specific OB or a medical center) can be forced to provide this service.

  7. So I read this as the chart is the amount of money being paid out to families to settle out of court.

  8. Wow I am relieved not to be a practicing L&D nurse. No amount of money is worth this to me. Glad I have a job teaching at the college.

  9. As I have implied above, what fascinates me is the gap between myth and reality – and how hard it is to find firm ground. In England, information about litigation is available on the NHSLA website, and I have just looked at it. The graph available looks nothing like this one. The number of claims per year is given, and it ranges from a high of just over 6.000 in 2000 to 397 last year! So much for escalating rates! 41% of cases were abandonned, 42% settle. The whole thing makes very depressing reading, especially with regard to the horrendous costs. But as far as I know, no-one has been able to come up with a workable, just alternative to this mess.

    Just realised that the graph in this post is “amounts paid out”, not increase in claims.

  10. One other thing that struck me in this rather careless article was the reference to the “precious” babies of older mothers. Does that mean the others were regarded as disposable? There used to be a rather matter of fact attitude to disasters along the lines of “You can always have another one”. My own rather extreme experiences mean that I get rather upset about mothers continuing to be treated as “low risk” past the point where that makes sense and this is a bit hard to reconcile with twitchy doctors averse to risk.

    • See, it’s a good thing you guys are reading along with me, seeing things I don’t or just take for granted 🙂 . This is a translation of the Israeli medicalese herayon yakar (dear prenancy, ‘dear’ in the British sense). It means a pregnancy achieved after many tries and possible failures (ART and/or miscarriages), or when a woman and her HCP’s feel this may be her last shot ever at having a child – perhaps due to her age. It doesn’t mean other pregnancies are disposable or less important, but it may well impact a woman’s (and HCP’s) decision-making process and explain a possible need to feel in control of the birth as humanly possible.

  11. That makes sense, and I can see that it would impact decisions regarding CS v vaginal – but doesn’t it still imply the old attitude that some “losses” are more easily managed than others when calculating risk?

    • I don’t know if ‘more easily managed’ is the right term, but multiple losses – or few remaining chances to win – defnitely has a profound effect on our attitude towards the chances we do get.

  12. I’m sure that there is a lot of vanity that has come into play with patient requested CS’s, but I know also people that were honestly afraid of the trauma of vaginal delivery. I had no choice due to complications to have a CS, but one of my friends was terrified of the risk of an episiotomy and requested a CS. Was that the right decision? I don’ t know, but that’s something each patient has to work through with her OB.

  13. Hi,

    If anyone is still checking these comments….I’d be really interested to hear from Israeli women who had a maternal request elective c-section. Did your kupa finance it? Did your obgyn have to give a specific reason? Has anyone requested a c-section on the ground of tokophobia or another psychological reason? If so, did you have to get the diagnosis via a kupa psychologist? I live in Israel, am pregnant, very much want a c-section for psychological reasons and am trying to navigate the system and pre-empt any opposition by medical professionals along the way, or any surprise bills from the kupa!


    • I asked one of the OB/GYNs I work with, and she said that hospitals differ in their policies towards primary MRCS (after a traumatic vaginal birth, most will accede to the mother’s wishes). Most, however, will have you sign a special consent form and give you your wish. It’s worth checking with your OB and/or the hospital you’re registered with.

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