County C-Section Rule Took Heavy Human Toll

Los Angeles County has paid $24 million to settle 49 claims of mothers and children who died or were injured when county doctors forced poor women to attempt to deliver babies vaginally--even in high-risk cases, according to a review of county and court documents.

The settlements mark the grim cost of the county’s leadership in a nationwide movement to reduce the number of costly caesarean sections, a trend that continues to place obstetricians under intense financial and social pressure to reduce the number of surgical births. And although the county has eased its strict rules on caesarean births, taxpayers will go on paying the costs for years to come, while those injured by the policy will bear its human toll for the rest of their lives.

Besides cash, the county settlements reached from 1992 to 1997 have included millions of dollars worth of lifetime health care for the permanently disabled children, a Times review of county and court records shows.

All of the mothers and children were on Medi-Cal.

Two mothers and three infants died. The 46 babies who survived suffer from conditions that include cerebral palsy, mental retardation and paralysis of the shoulder, arm and hand.

The injuries occurred as doctors in the county’s mammoth public health care system were carrying out an official policy that directed a trial of labor--an attempt at vaginal birth--for the vast majority of women who came to county hospitals to deliver babies.

Rafael Soto was in the breech position--posterior first--when his mother, Ercida Asuncion Soto, came to County-USC Medical Center to deliver him in 1993. Doctors tried but failed to turn Rafael around so that his mother could safely push him out during labor.

Then, instead of advising Ercida Soto that there were significant risks associated with continuing to deliver vaginally, and that a caesarean section was a safer option, doctors allowed her to continue to labor, according to a report by the county’s lawyers.

Rafael was stuck inside the birth canal for so long that he developed severe brain damage and cerebral palsy. He is not expected to live beyond age 10.

The county paid his parents $350,000.

*

The injuries sustained in county delivery rooms are typical of cases in which caesarean sections are not performed in a timely manner, doctors said. County hospitals include County-USC Medical Center, Martin Luther King Jr./Drew Medical Center, Olive View-UCLA Medical Center in Sylmar, and Harbor/UCLA Medical Center.

Two women suffered uterine rupture--including a 21-year-old who had two prior caesareans and whose child, severely brain damaged, is not expected to live beyond age 10. Both women underwent emergency hysterectomies at delivery and cannot bear more children.

Fifteen of the children are mentally retarded, five have cerebral palsy and seven have both.

Four more children are expected to die before age 10, and one will probably have a life span of about 20 years. Two women died.

Ten of the children suffer from paralysis of the shoulder, arm and hand. This common injury results when a baby is too large to pass under the mother’s pelvic bone during labor and becomes wedged there.

Labor was ordered for public hospital patients--even in cases where mothers had prior caesareans, despite increased risk of uterine rupture--according to a physician who helped formulate the policy.

Even women who had had two or more caesareans--a group in which the likelihood of rupture of the uterus is three times higher than among those who have had only one--were pushed by county doctors to attempt vaginal deliveries, said Dr. Richard Paul, head of Obstetrics and Gynecology at County-USC Medical Center.

“During that particular time we had a huge crisis with too many patients,” Paul said. “So there were things that happened because of a lack of ability to care for all these patients. . . . We were told during those crisis years by county counsel that we could say that everybody gets a trial of labor--without giving the patient an option.”

The requirement that nearly all women go through a trial of labor was developed by Paul and other doctors and administrators in the late 1980s, Paul said. Health administrators asked county lawyers in 1992 whether the policy was legal, and were advised that it was, Paul said. The policy “was not the ideal,” and was phased out in 1995, he added.

Today, the patient population is down and the hospital’s C-section rate hovers around 20%--nearly twice what it was when the policy was in place.

The most common operation for women in the United States, caesarean sections have increased fivefold since the 1960s, when the procedure was used primarily to save the life of the mother. Rates started to climb when doctors began to use it when there were signs that the fetus was in distress.

The county’s experience tragically parallels a powerful movement--led over the past decade by natural childbirth advocates, health maintenance organizations and the federal government--to reduce the rate of caesarean births. These surgeries, the argument goes, are too frequent--amounting to about 24% of all births nationally and 40% at some private hospitals--and often unnecessary, costing twice as much as vaginal deliveries and putting mothers at risk for postoperative complications.

But a growing minority of doctors--including several internationally recognized pioneers in the field--now argue that the rush to reduce surgical births has put children and their mothers at risk.

“Can we lower the caesarean rates too much?” asked Dr. Bruce Flamm, Kaiser-Permanente’s expert on reducing the rate of surgical births. “I think we can.”

Paul, himself a trailblazer in the movement to reduce caesareans, now believes that it would be unsafe for the overall rate to fall much below 20%. That is a third higher than the 15% rate now set as a goal by the federal government.

“What you’re going to see is a lot more claims, not less, as there is this drive to have more women attempt vaginal delivery,” said Dr. Michael J. McMahon, director of Continuous Quality Improvement in Obstetrics and Gynecology at the University of North Carolina in Chapel Hill. “It’s one thing to save a lot of money, but it’s another thing to have a lot of poor outcomes. We have to be very careful about this.”

*

Santos Rivera, for instance, strongly suspected that her daughter, Victoria, would be too large because her older child had been born with the same injuries later sustained by Victoria, according to county documents. At King-Drew Medical Center in 1994, Rivera “insisted on a caesarean section,” according to the county’s report on the incident, but was refused one.

Victoria, like her older sibling, became stuck, and now suffers from both arm and shoulder paralysis and developmental delays.

Last July, the county paid Victoria, who is now 3 years old, $490,000 and agreed to provide free lifetime acute medical care at county facilities.

Iris Banegas, a 26-year-old first-time mother, arrived at Olive View/UCLA Medical Center in March 1992, in active labor. Although a fetal monitor showed that the baby was in distress, Banegas was taken to a delivery room, where she labored for more than three hours before doctors agreed that her daughter, Susan, was in enough trouble to warrant an emergency C-section.

By the time Susan was born, she had suffered such severe damage that she “required mechanical and chemical resuscitation,” and was placed on a heart-lung machine, according to county documents. She suffers from mental retardation and hearing loss.

“The delay until 3:21 a.m. before the caesarean section was performed fell below the standard of care and resulted in brain damage to Susan,” the county’s lawyers said in their report on the case.

In 1995, the county agreed to pay Susan Banegas $450,000.

Dr. Jeffrey Phelan, a noted obstetrician and fetal medicine specialist who along with Paul of County-USC helped pioneer the idea of vaginal birth for women who have had caesareans, makes no bones about rejecting the ideas he once proposed.

Phelan, co-director of maternal-fetal medicine at Pomona Valley Medical Center and an attorney, recently called for increasing the caesarean rate to 50% of all births.

“Before we can attack the caesarean section rate, we have to understand why it is the way it is,” Phelan said. “We’re doing it because of the baby. We have developed monitoring and ultrasonography, which are windows to the womb that put us in the position of identifying stuff we never saw before.”

Phelan now believes that one in four cases of cerebral palsy nationwide could be prevented with properly administered caesarean sections.

Many doctors, however, remain passionately committed to reducing the number of C-sections.

“It’s true that caesarean sections not done frequently enough are as bad as caesarean sections too frequently,” said Dr. Howard Judd, chief of obstetrics and gynecology at Olive View. “But I think most of us feel that caesarean section rates in some hospitals are too high.”

According to Dr. W. Donald Shields, head of pediatric neurology at the School of Medicine at UCLA, relatively few cases of neurological impairment can be traced to a failure to perform a caesarean section.

A 1995 study by the National Institutes of Health showed that the rate of cerebral palsy in the San Francisco area did not diminish along with the dramatic rise in caesarean rates that has taken place since the 1960s.

Phelan, however, says those statistics are misleading. He argues that because medicine has advanced so far in 30 years, babies are now living--albeit with neurological impairments--who in the past might have died. And the rate of cerebral palsy and other disorders in these children may push up the numbers, masking any gains made by the increased use of C-sections.

Because the move to reduce the number of caesarean births is relatively recent, it is too soon for definitive statistics on whether birth injuries are increasing as a result of a decrease in surgical births, according to doctors interviewed for this story.

McMahon of North Carolina, however, believes that the evidence will soon begin to mount. In a study published in September 1996 in the New England Journal of Medicine, he found that babies were nearly twice as likely to die if the mother attempted vaginal birth after one previous caesarean. The mothers were also twice as likely to suffer serious complications.

Lingering at either edge of the debate is the question of money.

*

In 1993, it cost an average of $5,100 to deliver a baby by caesarean section, nearly twice the $2,800 price tag for a vaginal birth, according to one study. Women who have surgical deliveries must stay in the hospital for several days to recover and often need more nursing care.

It is unsurprising, therefore, that women with insurance were twice as likely to undergo caesarean sections as uninsured women who give birth at public hospitals, according to the same study.

From the mid-1980s to the mid-1990s, county hospitals were so crowded that volume alone dictated strict rules about when to perform a caesarean, Paul said.

When private hospitals, enticed by liberalized Medi-Cal rules, began luring maternity patients away, Paul and other doctors who had long pushed for relief from overcrowding seized the opportunity to liberalize the C-section rules.

Now, he said, the volume of maternity patients at County-USC Medical Center is down to about 4,000 per year, compared to 18,000 in late 1985. The caesarean rate in 1989, near the peak of the overcrowding, was about 10%.

By 1992, a year that saw 14,544 babies born at the hospital, the rate had crept up to 13%. By 1997, it was 20%.

“The risk had to be taken because we couldn’t do five sections at once,” Paul said.

As a consequence of running that risk, he said, “we had some very bad outcomes.”