Health Chief to Investigate Caesarean Practice

Los Angeles County health officials promised Tuesday to investigate a now-discontinued policy of forcing women to attempt to deliver babies vaginally at county hospitals.

Responding to a unanimous motion by the Board of Supervisors demanding information on the issue, county health Director Mark Finucane said he would also find out whether there are other areas in which budgetary policy is limiting individual medical decisions and frustrating recent reforms aimed at curbing instances of medical malpractice at public hospitals.

“We are prepared to give you the history of obstetrical practice in this county,” Finucane told the board. “We are prepared to give a report on the different ways we are handling things in the department” since reforms aimed at documenting and eliminating malpractice have been implemented.

The investigation will be conducted by a panel of physicians named by Finucane on Tuesday, among them the medical directors of all county hospitals, as well as the chairs of their obstetrical departments.

“The reality,” said county Supervisor Gloria Molina, who has long fought for closer oversight and better discipline of county doctors, “is that we didn’t monitor [malpractice].”

The Times reported Sunday that for about a decade--from the mid-1980s to 1995--doctors at county hospitals implemented a policy that sought to avoid costly caesarean section births by mandating an attempt at vaginal delivery by nearly all women who came to public facilities to have their babies. Since 1992, the county has paid $24 million to settle 49 claims involving women or children who were killed or injured by failure or delay in performing caesarean sections.

The policy, which was instituted in part to deal with limited resources and overcrowded delivery rooms, placed the county at the forefront of a national movement to reduce the number of surgical births. But it resulted in so many injuries and deaths that doctors eliminated the policy in 1995.

The county’s medical director, Dr. Donald Thomas, told the board Tuesday that the policy, which he termed a “guideline,” needed to be viewed in context of the nationwide movement to reduce caesareans, costly surgical births which by the late 1980s had increased fivefold nationally since the 1960s to 24%--and were running as high as 40% in some private hospitals.

County doctors, Thomas said, feared censure by the federal government for performing too many C-sections. But, he said, after it was clear that there were problems with the low rate that the county achieved--in 1989 just 10% of women giving birth at county hospitals received caesareans--the number of caesareans was allowed to rise to nearly 20% by last year.

“As our physicians realized that the rules on C-sections were being too stringently applied,” the practice was eased, said Thomas, who did not work for the county while the policy was in place.

The reports in The Times were “in and of themselves correct,” he said, while maintaining that the story put the county’s policies in too negative a light.

Finucane, who also did not work for the county when the policy was in place, said that he has instituted several changes in the way the health department responds to instances of bad medical outcomes in its hospitals.

For example, he said, hospitals now file reports on patient injuries or deaths on the day the incidents occur. And, he said, the department is much quicker to discipline medical personnel than in the past.

Neither Finucane nor Thomas disputed that overcrowding and low staffing contributed to the decision to press women to give birth vaginally. But they said that did not mean that the policy was financially motivated.

“At no time was any practitioner involved in a vaginal delivery for any financial reason whatsoever,” Finucane said.

He pointed out that Medi-Cal reimbursed the county for most caesarean births.

Still, doctors interviewed for The Times’ stories said that it would have required additional resources, which carry their own costs, had the county decided to perform more caesareans during the years when the policy was in place. Two surgeons and an anesthesiologist must be present, and the operation amounts to major surgery, requiring a hospital stay of several days.

Dr. Richard Paul, head of maternal-fetal medicine at County-USC Medical Center, said earlier that there were only enough doctors on staff--and enough operating rooms--to perform two caesareans at a time.

County Supervisor Mike Antonovich, who has led calls for an investigation into the practice, called the policy “totally callous,” and said it violated a patient’s right to make an informed decision about medical treatment.

“As a result of this wrongheaded policy, children lost lives and were crippled,” Antonovich said. “Mothers have been injured.”

The county’s experience, he said, can be seen against a backdrop of a move throughout medicine to limit the control that patients have over their own medical care.

In his motion, Antonovich asked health officials to investigate whether there are any policies that mandate a particular course of action for a group of patients.

“I hope there are not any other protocols in our county--or in the country--that are going to make human beings guinea pigs,” Antonovich said.