All ETDs from UAB

Advisory Committee Chair

Beverly A Mulvihill

Advisory Committee Members

Meredith L Kilgore

Michael A Morrisey

Leonard J Nelson

Martha S Wingate

Document Type


Date of Award


Degree Name by School

Doctor of Public Health (DrPH) School of Public Health


"Defensive medicine", medical practice decisions based on fear of malpractice litigation and where risks may outweigh health and cost benefits, is a proposed contributor to increasing cesarean rates in the U.S. Some studies suggest that changes in laws governing medical malpractice actions may decrease the cesarean rate by relieving pressures driving defensive medicine. This study examined whether, in states that have adopted certain tort reform measures, the probability of having a cesarean delivery is lower following implementation of the reform measures. A database of state legislation and court decisions and National Center for Health Statistics natality data files (1991-2004) were used to model state and year fixed effects. Tort laws were grouped as those directly affecting recovery in a legal action (non-economic damages caps, collateral source offset) and those with an indirect effect (contingency fees limits, periodic payments, joint and several liability rule, statutes of limitations, statutes of repose) and examined separately as individual reforms. The analysis was limited to live singleton births and adjusted for maternal age, race, education, marital status, diabetes, hypertension, tobacco use, pre-natal care utilization, gestational age, birthweight, and non-vertex presentation. Coefficients ranged from -0.01-0.03 for individual tort reforms. The effect was slightly greater for direct than for indirect tort reforms, -0.009 compared to -0.004. Non-economic damages caps were associated with a small reduction in cesarean rates, with a slightly greater effect shown for collateral source laws and statutes of limitations. The findings may indicate that there is little effect of tort reform on defensive medicine, for which cesarean was a marker. It is also possible that the minimal effect observed is due to small numbers of tort law changes during the study period or that unobserved time-varying factors influencing the decision to perform cesarean delivery exerted a greater effect than tort reform. Based on findings of this study and several others, tort reforms alone are likely insufficient to reduce defensive medicine. If tort reforms do not contribute to reduction in cesarean rates, attention must be focused on other approaches to influence clinical practice patterns and to achieve rate reduction goals.

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