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Relationship Between Malpractice Litigation Pressure and Rates of Cesarean Section and Vaginal Birth After Cesarean Section

Yang, Y Tony LLM, ScD*; Mello, Michelle M. JD, PhD; Subramanian, S V. PhD; Studdert, David M. LLB, ScD§

doi: 10.1097/MLR.0b013e31818475de
Original Article

Background: Since the 1990s, nationwide rates of vaginal birth after cesarean section (VBAC) have decreased sharply and rates of cesarean section have increased sharply. Both trends are consistent with clinical behavior aimed at reducing obstetricians’ exposure to malpractice litigation.

Objective: To estimate the effects of malpractice pressure on rates of VBAC and cesarean section.

Research Design, Subjects, Measures: We used state-level longitudinal mixed-effects regression models to examine data from the Natality Detail File on births in the United States (1991–2003). Malpractice pressure was measured by liability insurance premiums and tort reforms. Outcome measures were rates of VBAC, cesarean section, and primary cesarean section.

Results: Malpractice premiums were positively associated with rates of cesarean section (β = 0.15, P = 0.02) and primary cesarean section (β = 0.16, P = 0.009), and negatively associated with VBAC rates (β = −0.35, P = 0.01). These estimates imply that a $10,000 decrease in premiums for obstetrician-gynecologists would be associated with an increase of 0.35 percentage points (1.45%) in the VBAC rate and decreases of 0.15 and 0.16 percentage points (0.7% and 1.18%) in the rates of cesarean section and primary cesarean section, respectively; this would correspond to approximately 1600 more VBACs, 6000 fewer cesarean sections, and 3600 fewer primary cesarean sections nationwide in 2003. Two types of tort reform—caps on noneconomic damages and pretrial screening panels—were associated with lower rates of cesarean section and higher rates of VBAC.

Conclusions: The liability environment influences choice of delivery method in obstetrics. The effects are not large, but reduced litigation pressure would likely lead to decreases in the total number cesarean sections and total delivery costs.

From the *Department of Health Administration and Policy, George Mason University, Fairfax, Virginia; Departments of †Health Policy and Management and ‡Society, Human Development, and Health, Harvard School of Public Health, Massachusetts, Boston; and the §School of Law and School of Population Health, University of Melbourne, Melbourne, Australia.

Dr. Yang was supported by a dissertation grant from the Chiang Ching-Kuo Foundation for International Scholarly Exchange. Dr Subramanian was supported by the National Institutes of Health Career Development Award (NHLBI 1 K25 HL081275). Dr. Studdert was supported in part by a Federation Fellowship from the Australian Research Council. The funding organizations had no role in the design or conduct of the study; the collection, management, analysis, or interpretation of the data; or the preparation review, or approval of the manuscript for submission.

Reprints: David Studdert, LLB, ScD, School of Population Health, University of Melbourne, 207 Bouverie Street, Carlton, VIC 3053, Australia. E-mail:; or Y. Tony Yang, LLM, ScD, Department of Health Administration and Policy, George Mason University, MS: 1J3, 4400 University Drive, Fairfax, VA 22030. E-mail:

© 2009 Lippincott Williams & Wilkins, Inc.