In a carefully designed structured prenatal care system, there are no second- class patients. Every woman is offered all appropriate care and is fully informed about the process of prenatal care. This does not resolve issues about who will pay for such care, but it is ethically preferable to rationing care by having different standards of prenatal care for different socioeconomic groups. To the extent that a substantial number of physicians use structured systems with the same core of services, these systems define the acceptable level of care. Such evidence of a standard of care should aid physicians in disputes with third-party payers over what is reimbursable care.

There have been no large-scale controlled studies of the legal benefits of structured prenatal care systems. Preliminary data and our experience with one of these systems in the malpractice insurance context are very suggestive. Physicians have used this system (Pre-Natal Care—A Systems Approach, developed by Arnold Greensher and his colleagues in Colorado Springs) for more than 550,000 births over 18 years. During this time there have been approximately five lawsuits involving births using the system, and total payouts of less than $500,000.

The observed number of medical malpractice claims is much lower than would be expected for this number of deliveries. Analysis of the data is confounded by several potential biases

1. Are high-risk or difficult births excluded from the system? This does not appear to be the case. Physicians who use the system generally use it for all deliveries.

2. Is there a bias in the selection of physicians using the system? This raises an intriguing question. If it is not the prenatal care system that protects these physicians from litigation, then what other physician characteristics correlate with an extremely low rate of birth injury claims? (Experience with communities where all the physicians use the system seem to mitigate physician selection as the sole basis for the system’s effectiveness.)