Medical Professional Liability and the Delivery of Obstetrical Care -- Copyright -- Chairman's Preface -- Contents -- 1 Summary of Conclusions and Recommendations -- MEDICAL PROFESSIONAL LIABILITY CONTROVERSY -- PROBLEM MOST ACUTE IN OBSTETRICS -- LIABILITY'S BROADER SCOPE -- ETHICAL CONSIDERATIONS -- STUDY FOCUS AND FINDINGS -- Maternity Care in the United States -- Availability of Obstetrical Providers -- Obstetrical Care for Poor Women and Women Served by Medicaid -- Practice of Obstetrics -- Obstetrical Malpractice Insurance -- The Tort System and Its Alternatives -- THE COMMITTEE'S RECOMMENDATIONS -- Long-Term Recommendations -- Short-Term Solutions -- 2 Maternity Care in the United States -- OBSTETRICAL PRACTITIONERS -- Obstetrician-Gynecologists -- Family and General Practitioners -- Certified Nurse-Midwives -- Other Practitioners -- FACILITIES OFFERING PRENATAL CARE -- Hospitals -- Local and State Health Departments -- Community and Migrant Health Centers -- LABOR AND DELIVERY SERVICES -- FINANCING OF MATERNITY CARE -- NEED FOR OBSTETRICAL CARE -- Evidence of Existing Shortages of Obstetrical Services -- Insufficient Prenatal Care -- Arrested Decline in Infant Mortality -- Inability to Pay for Care -- Physician Shortage in Rural Areas -- Projected Increase in Need for Obstetrical Services -- REFERENCES -- 3 The Effects of Medical Professional Liability on the Availability of Obstetrical Providers -- OBSTETRICIAN-GYNECOLOGISTS -- Careers in Obstetrics -- Concerns About Professional Liability -- Response to Concerns About Liability -- Elimination of Obstetrical Practice -- Reduced Volume of Obstetrical Care -- Reduced Care of High-Risk Women -- Trends -- FAMILY PHYSICIANS -- Malpractice Insurance Costs -- Other Economic Factors -- Concerns About Professional Liability -- Response to Insurance and Liability Concerns.

Elimination of Obstetrical Practice -- Adverse Effects on Rural Areas -- NURSE-MIDWIVES -- Availability and Costs of Professional Liability Insurance -- Response to Insurance Problems -- Changes in Practice Setting -- Changes in Techniques of Practice -- REFERENCES -- 4 The Impact of Medical Professional Liability on the Provision of Obstetrical Care to Poor Women and Women Served… -- PROFESSIONAL LIABILITY AND OBSTETRICAL CARE UNDER MEDICAID -- BACKGROUND: THE ROLE OF MEDICAID IN THE DELIVERY OF OBSTETRICAL CARE -- Physician Participation in Medicaid -- Reduced Obstetrical Care for the Poor -- High Insurance Premiums, Low Reimbursement Rates -- Fear of Suit -- Professional Liability Concerns and the Reduction of Care -- PROFESSIONAL LIABILITY AND OBSTETRICAL CARE IN COMMUNITY AND MIGRANT HEALTH CENTERS -- Problems Recruiting Providers -- Problems with Access -- Reduced Quality of Care and Increased Risk of Suit -- Prohibitive Insurance Costs -- CONCLUSION -- REFERENCES -- 5 The Effects of Medical Professional Liability on the Practice of Obstetrics -- CHANGES IN PRACTICE PATTERNS OF INDIVIDUAL PHYSICIANS -- THE RISING CESAREAN SECTION RATE -- Electronic Fetal Monitoring -- History -- Regulatory Failure -- Results of Randomized Clinical Trials -- Effect of EFM on the Frequency of Cerebral Palsy -- Electronic Fetal Monitoring, Cerebral Palsy, and Medical Malpractice -- Conclusion -- PRACTICE PATTERNS IN DEPARTMENTS OF OBSTETRICS -- Reported Changes in Practice -- Implications for Training -- Effects on Careers in Obstetrics -- Effects on Access to Care -- IMPACT OF MEDICAL PROFESSIONAL LIABILITY ON THE PHYSICIAN-PATIENT RELATIONSHIP -- The Importance of Trust -- Consequences of the Breakdown in Trust -- REFERENCES -- 6 Obstetrical Malpractice Insurance -- THE STRUCTURE OF THE MARKET -- Limits of Coverage.

Availability of Medical Malpractice Insurance -- Physicians -- Nurse-Midwives -- THE AFFORDABILITY OF PREMIUMS -- Premiums as a Percentage of Gross Income -- Premiums as a Percentage of Professional Expenses -- Premiums as a Percentage of Net Income -- Rising Professional Liability Premiums Linked to Increases in Fees -- PROFITABILITY OF MEDICAL MALPRACTICE INSURANCE -- Insurer Risk Management Activity -- Data Gathering and Analysis -- Clinical Standard Setting and Protocol Development -- Educational Efforts -- Discounted Premiums as Risk Management Incentives -- PROPOSALS TO ALTER THE MEDICAL MALPRACTICE INSURANCE SYSTEM -- Spreading the Costs of Coverage Over a Wider Base -- Limiting the Number of Claims -- Limiting the Amount of Awards -- Experience Rating of Physicians for Medical Malpractice -- CONCLUSION -- REFERENCES -- 7 The Legal System: The Committee's Findings and Proposals for Change -- THE TORT SYSTEM -- Tort Reforms: The Committee's Findings -- TORT REFORM: THE COMMITTEE'S RECOMMENDATIONS -- ALTERNATIVES TO THE TORT SYSTEM -- No-Fault Compensation for Certain Events -- Virginia's Compensation System for Birth-Related Injuries: A Case Study of DCE -- The AMA-Specialty Society Medical Liability Project -- Claims Resolution Function -- Credentialing and Disciplinary Functions -- Codification of the Legal Elements of Medical Liability -- Private Contracts -- Economic Damage Guarantee (Moore-Gephardt Proposal) -- Social Insurance -- OTHER NEEDED REFORMS -- Expansion of the National Health Service Corps -- Extension of the Federal Tort Claims Act Coverage -- Liability Coverage for Physicians Providing Public Health Services -- REFERENCES -- 8 Principal Findings and Recommendations -- PRINCIPAL FINDINGS -- Medical Malpractice Insurance Trends and Their Implications -- Effects of Professional Liability Concerns on Access to Care.

Effects of Professional Liability Concerns on the Practice of Obstetrics -- Effects of Professional Liability Concerns on the Physician-Patient Relationship -- RECOMMENDATIONS -- Long-Term Recommendations -- Short-Term Solutions -- Glossary -- Bibliography -- CASES, REGULATIONS, AND STATUTES -- Appendixes -- Appendix A Summary of Methodology Used in Studies of Changes in Obstetrical Practice -- Survey Population -- Samples -- Response Rates -- Phraseology -- Appendix B Summary of Study Results Regarding Changes in Obstetrical Practice -- Appendix C Summary of Study Results Regarding Professional Liability, Family Practitioners, and Rural Areas -- Appendix D State and National Liability Surveys Summarized -- State Studies -- National Studies -- Appendix E Survey of Selected Risk Management Activities -- Appendix F Risk Management Activities and Experience Rating Policies of Selected Malpractice Insurers -- Appendix G Possible Modifications to the Virginia Neurological Birth-Related Injury Compensation Act -- Members of the Committee -- Index.