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Eugene Declercq and Judy Norsigian

The folly of 1 percent policy

THE PHRASE that comes to mind when you hear Dick Cheney is probably not "reshaping American childbirth." Yet Vice President Cheney's "One Percent Doctrine" -- the title of Ron Suskind's 2006 book on post9/11 national security policy -- perfectly captures an approach to decision-making in American medicine that misallocates resources and undermines primary care. By focusing maximum resources on preventing an extremely rare but potentially disastrous outcome over necessary preventive care, this model has shaped healthcare decision-making in areas ranging from hysterectomies to coronary bypasses. One shift -- the rapidly rising caesarean rate -- exemplifies this problem.

Suskind reports that in debates over national security policy following 9/11, Cheney repeatedly invoked the principle that if there's even a 1 percent chance of a terrorist attack, we must prepare as if it were a certainty. This extreme position invariably gave Cheney the moral high ground in debates, where he could appear more willing to protect American interests than others with a broader focus. Of course, in winning the immediate argument, Cheney also ignored myriad longer-term complications involving problems not solved while the "emergency" is addressed.

In healthcare, caesarean sections represent the most recent example of this doctrine, as births are increasingly treated as potential emergencies requiring expensive, high-tech interventions. The caesarean rate in the United States has increased from 20 percent in 1996 to a record high of more than 30 percent in 2005, trailing only Italy (37 percent) and South Korea (35 percent) among industrialized countries. Obstetricians are more skilled at performing caesareans than ever before and caesareans are safer than ever. But they are not without negative consequences. When they are performed as elective surgery on mothers with little or no medical risk, these harms outweigh the benefits.

Yet caesareans are advocated as necessary to avert potential disasters that might occur. At a 2006 meeting sponsored by the National Institutes of Health, one doctor captured the 1 percent (or in this case 1/30th of 1 percent) doctrine when he described rare conditions and noted the benefits of a 100 percent caesarean rate (you read that right) in avoiding these outcomes in 3 in 10,000 cases.

Likewise, a 2006 position statement from the American College of Obstetricians and Gynecologists states that "Labor and delivery is a physiologic process that most women experience without complications," but then goes on to emphasize the 1 percent doctrine: ". . . serious intrapartum complications may arise with little or no warning, even in low risk pregnancies." The statement and the doctor's claim are true, of course -- anything can occur -- but does that mean that society benefits when every birth is handled as a disaster (or worse yet a lawsuit) waiting to happen?

No one wishes a health problem on any mother or child, but the "1 percent" advocates of higher caesarean section rates assert they care more about infant outcomes than those who oppose them. However, the consequences of universal caesarean sections on a largely healthy population are profound in both the short run (longer recovery, greater postpartum pain, higher maternal rehospitalization rates for surgical complications, higher costs) and long run (higher rates of subsequent stillbirths, greater risk of future uterine rupture, longer stays requiring more hospital space). The 1 percent doctrine cares little about such consequences since its focus is on winning the current argument.

Creating a crisis atmosphere is essential to the 1 percent doctrine and its ability to override all obstacles -- be they constitutional restrictions on national security measures or concerns about the United States ranking last among industrialized countries on infant mortality. Such an atmosphere encourages more centralized decision-making and stifles debate. The fact that most of these crises never occur and that countless resources are expended to prevent something that was unlikely to happen anyway is lost in the relief of the immediate positive outcome (a healthy baby or no terrorist attack). In the long run, however, we've wasted time and money, created new problems, and ignored systematically documented, if less emotional, evidence.

A version of the 1 percent doctrine has been invoked for decades in steering the US healthcare system away from an emphasis on preventive care for the whole population to an obsession with treating rare events. As a debating strategy, the 1 percent doctrine is extremely persuasive. As a policy guideline, it makes no sense in either politics or healthcare.

Eugene Declercq is a professor of maternal and child health at the Boston University School of Public Health. Judy Norsigian is executive director of Our Bodies Ourselves.

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