The “Worst Test in Medicine” Is Propelling America’s Record‑High C‑Section Rate

A growing chorus of obstetricians, researchers, and patient‑advocacy groups is warning that the routine use of continuous electronic fetal monitoring (EFM) — a practice often dubbed “the worst test in medicine” — is a major driver behind the United States’ soaring cesarean‑section numbers. An investigative report by *The Times* this week reveals that, despite mounting evidence that the technology offers little benefit for most low‑risk pregnancies, hospitals across the country continue to employ it in virtually every delivery. The persistence of EFM, the report argues, is rooted more in business imperatives and malpractice fears than in solid clinical justification.A Test With Limited ValueSince its introduction in the 1970s, continuous EFM was hailed as a breakthrough that could detect fetal distress early and reduce infant mortality. Decades of research, however, have painted a far more nuanced picture. Large‑scale studies and systematic reviews consistently show that while EFM may slightly improve the detection of rare cases of severe fetal compromise, it does not lower the risk of brain injury, developmental problems, or death for the newborn. Instead, the technology dramatically increases the likelihood of operative deliveries.According to a 2022 meta‑analysis published in *Obstetrics & Gynecology*, the use of continuous monitoring is associated with a 30‑40 percent rise in cesarean sections and a 20‑30 percent increase in instrumental vaginal births, without a corresponding decrease in adverse neonatal outcomes. The American College of Obstetricians and Gynecologists (ACOG) now recommends intermittent auscultation — listening to the fetal heartbeat at regular intervals — for low‑risk pregnancies, reserving continuous EFM for cases with known complications.Business and Legal Pressures Keep It in PlaceDespite these guidelines, *The Times* found that more than 90 % of births in U.S. hospitals still involve continuous electronic monitoring from the onset of labor. Interviews with hospital administrators and obstetricians suggest that the practice has become entrenched for two primary reasons.First, there is a financial incentive. EFM equipment is costly, and hospitals recoup expenses through billing for the monitoring service, which is often reimbursed at higher rates than intermittent auscultation. “Once you’ve invested hundreds of thousands of dollars in monitors and the associated software, there’s a strong push to use them on every patient,” said Dr. Laura Martinez, a health‑policy analyst at the Center for Health Economics.Second, the specter of malpractice looms large. In a litigious environment where a single adverse outcome can trigger costly lawsuits, many physicians feel compelled to document continuous monitoring as a defensive measure. “If something goes wrong, you want to be able to point to a continuous tracing and say you were watching the baby at all times,” explained attorney James Whitaker, who specializes in obstetric malpractice defense. That mindset, the report argues, fuels a culture where “more monitoring” is equated with “more safety,” even when the data say otherwise.Consequences for Mothers and BabiesThe overuse of EFM has tangible repercussions. Cesarean sections, while lifesaving when medically necessary, carry higher risks of infection, blood loss, longer hospital stays, and complications in future pregnancies such as placenta previa and uterine rupture. For mothers, the recovery period is often more painful and prolonged compared to vaginal births. For infants, the increased likelihood of operative delivery can lead to respiratory difficulties and a higher chance of neonatal intensive care unit admission.A recent survey by the National Partnership for Women & Families found that 68 % of women who underwent a C‑section reported feeling that the decision was “driven by hospital policy rather than a clear medical indication.” The same study highlighted that many patients were not fully informed about the limited benefits of continuous monitoring or the potential downsides of an unnecessary surgical birth.Calls for ChangeIn response to the findings, several professional bodies are urging a shift back toward evidence‑based practices. ACOG has updated its practice bulletin to emphasize that continuous EFM should be reserved for high‑risk pregnancies, such as those complicated by maternal hypertension, diabetes, or known fetal anomalies. The Society for Maternal‑Fetal Medicine is also promoting “monitoring stewardship” programs that encourage clinicians to discuss monitoring options with patients and to document the clinical rationale for any deviation from guidelines.Some hospitals are already taking steps. At Mercy General Hospital in Ohio, a pilot program launched last year replaced routine continuous monitoring with intermittent auscultation for low‑risk laboring patients. Early results show a 22 % reduction in cesarean rates without any increase in adverse neonatal outcomes. “We’re proving that we can safely cut back on unnecessary technology and improve the birth experience for both mothers and babies,” said Dr. Anjali Patel, the hospital’s chief of obstetrics.What Expectant Parents Can DoFor expectant mothers, the report suggests a proactive approach: ask providers about the reasons for continuous monitoring, request a copy of the fetal tracing, and discuss the possibility of intermittent auscultation when appropriate. “Informed consent isn’t just a signature; it’s a conversation,” noted Dr. Martinez. “When patients understand the limited benefits and real risks, they can make choices that align with their preferences and safety.”As the United States continues to grapple with one of the highest C‑section rates among developed nations — hovering around 32 % according to the Centers for Disease Control and Prevention — the spotlight on continuous fetal monitoring may finally prompt a reevaluation of entrenched practices. Reducing reliance on a test that offers scant benefit for most pregnancies could be a pivotal step toward lowering unnecessary surgical births and restoring a more balanced, patient‑centered approach to childbirth.