Discrezionalità medica e iatrogenesi istituzionale: i parti cesarei in Italia

Medical professionals are an emblematic example of street-level bureaucracy. By dealing with health and illness issues, their actions have a considerable impact on people’s lives, as is the case for other street-level bureaucrats. This article focuses on professional discretion in maternity health care services, and investigates the occurrence of cesarean section, in a comparative perspective with special reference to the Italian case. In EU member states, public health policies are explicitly aimed at reducing caesarean delivery to 15 percent, in line with the World Health Organization (WHO 2018) indications. Higher caesarean section rates are considered responsible for rising health costs, as well as increased health risks for women and newborns not only during birth, but, from a life-course perspective, in their subsequent health pathways. However, the implementation of this policy highlights great variation across Europe that can be related to the different institutional contexts. The case of Italy witnesses also major regional and sub-regional variation. In contrast to crystal-clear WHO and national indications, the relevant statistical data show very high rates of C-sections in Southern Italy, suggesting inappropriate medical behavior. Professionals’ discretionary margins are so wide that further variation can be observed within the same region. The evidence presented in the article supports the conclusion that professional discretion can potentially harm women and children’s health – an example of professional freedom that leads to a perverse iatrogenic effect, and stresses the importance of investigating street-level bureaucracy in policy implementation processes, and shedding light on the gap between institutional and professional mandates.