C-Sections can cost as much as 60 percent more than natural births, and pose more risks for mothers—including “hysterectomy, hemorrhage, infection, and deep vein thrombosis,” according to the NYT. Yet they are performed far more often than necessary, with the rate increasing by 50 percent over the past decade. One-third of all U.S. births now are C-sections.Why is this happening? In large part, it’s because most hospitals still pay their doctors on a fee-for-service basis rather than paying them salaries, and a C-section is costlier than a natural birth. But there’s even more at play here:
But this is not the most important way that the financial incentives push doctors in the wrong direction. Perhaps more important is the fact that most of what a private-practice ob-gyn doctor earns from taking care of a pregnant woman comes from the delivery. That means doctors have a strong financial incentive to deliver their patients’ babies themselves.How is this a problem? It leads to more C-sections scheduled for the doctor’s convenience, and scheduled inductions of labor that often end in C-sections. Even for unscheduled deliveries, it contributes to the most important syndrome behind unnecessary C-sections: failure to wait.
At the California hospital highlighted in the article, nurse-midwives also play a big role in decreasing the use of C-sections:
If you are a patient at [San Francisco] General in a normal pregnancy, you can choose a nurse-midwife as your primary caregiver — you’ll see a doctor only if there are complications. Nationally, nurse-midwives are rare; [Stanford University sociologist Christine] Morton says they attend 7 percent of all births. Even rarer is General’s model of an autonomous nurse-midwife service with its own caseloads.
This story is a snapshot of a larger problem: The fee-for-service system incentivizes doctors to perform all sorts of expensive tests and procedures. Meanwhile, nurses and nurse practitioners continue to have limited autonomy, though they could take over many of the doctors’ duties and charge patients less for their services. We need to change this status quo if we want to save U.S. health care.