Thanks to considerable advances in obstetric management and technology, global maternal and neonatal mortality has dropped over the past 25 years.1 Despite such progress, the proportion of medical lawsuits involving obstetrics has not shrunk. Obstetrics is still one of the most sued specialties in most countries around the world.2 Obstetrics is also the most frequently sued specialty in countries such as Japan,3 Spain,4 Portugal,5 and Saudi Arabia.6 In the United States, there are approximately 67 claims submitted for every 100,000 deliveries and roughly 13 claims paid for every 100,000 deliveries.7 There are 17,000 cases annually in the United States.8 The obstetrics malpractice lawsuits account for 15.4% to 18.1% of the total cases.9,10 According to statistics from the National Health Commission of the People’s Republic of China, 70,000 medical disputes occurred each year.11 Up to 50.1% of medical disputes entered judicial proceedings, placing enormous pressure on the judicial system of China.12 Obstetrics is the specialty with the second most prevalent lawsuits in China.10 Medical services for pregnancy and childbirth are inherently risky and unpredictable. Unexpected adverse pregnancy outcomes and catastrophic outcomes caused by obstetric malpractice put a strain on patients’ families, hospitals, and society. In China, 60.1% of Chinese obstetricians and gynecologists reported that they had been involved in at least one malpractice dispute.13 Obstetric medical malpractice brought a huge burden to healthcare systems. In the United States, payments for medical malpractice are registered as U.S. $55 to $60 billion of annual healthcare costs.8,14 Unfortunately, access to such data is limited in China. However, the high incidence and high payment rate of obstetric malpractice10 add to the escalating expense to healthcare systems. It necessary to investigate the malpractice lawsuits for preventing future lawsuits and raising obstetric care providers’ awareness.
Although previous studies have reported the causes of obstetric malpractice claims in different countries, there are some limitations, including a limited number of lawsuits (19–207 cases),6,15–18 a narrow focus on few hospitals,16 data from a single court,12 and description of a single cause of injury.19 In addition, most of the cause categories were based on the damage outcomes, which could not guide the quality improvement of maternity care. The National Health Service Litigation Authority (NHSLA) coding taxonomy was developed for maternity care based on the cause for obstetric medicolegal claims.20 The NHSLA coding taxonomy was applied in the United Kingdom and the United States to direct the safety and service quality improvement for maternity care, which could guide the obstetrics providers pay more attention to prevent the risky cause. The purpose of this study was as follows.
- The present study primarily aimed to investigate the characteristics, injury outcomes, payment of obstetric malpractice lawsuits, and the risk factors associated with high payment (>$100,000) in China to better understand the severity and burden of obstetric malpractice lawsuits.
- The second purpose of this study was to investigate the cause of obstetric malpractice using an NHSLA coding taxonomy for further quality improvement in maternity care.
METHODS
Data Sources
Court records of legal trials were collected from the public legal database “China Judgments Online” (http://www.court.gov.cn/zgcpwsw/), which is a valuable dataset for studying malpractice lawsuits. Data were compiled on the injury outcomes, causes of the lawsuit, verdicts, and indemnity payments. Lawsuits containing the key words “medical injury lawsuit,” “medical lawsuit,” “medical dispute,” and “medical malpractice dispute” were searched on the “China Judgments Online” Web site from January 1, 2013, to December 31, 2021, with the type of cases set as civil cases. Ultimately, 3441 obstetric malpractice lawsuits were included (Fig. 1).
;)
FIGURE 1: The flow diagram for the inclusion of obstetric malpractice lawsuits.
Review Methods
Lawsuits related to obstetrics were retrieved manually, and case summaries were examined independently by 2 researchers with professional backgrounds in obstetrics. The 2 researchers reviewed obstetric malpractice lawsuits that met inclusion criteria respectively. The retrieved items should be filled in the information lists, including lawsuit number, province, geographic region, repeat defendant hospital, hospital level, liability degree of the hospital, closure year, length of the lawsuit (year), payment information, and injury outcomes. The causative domain was coded according to a revised version based on the NHSLA coding taxonomy.20 In the original version of NHSLA coding taxonomy,20 the “operative vaginal birth” domain contains 2 causative issues that “forceps or ventose delivery management” and “cesarean section management.” However, the “operative vaginal birth” was defined as a common procedure used to expedite birth after full cervical dilatation. Clinicians can access obstetrics forceps and vacuum instruments, which should be conducted with indication.21,22 In fact, the “operative vaginal birth” domain can hardly represent the cesarean section management. We split causative domain “operative vaginal birth” into new 2 separate causative domains, “forceps or ventose delivery management” and “cesarean section management.” Causative issues remained unchanged. Therefore, lawsuits were coded with a revised version containing 14 causative domains and 34 causative issues of NHSLA coding taxonomy. If one lawsuit had multiple equally relevant causes, it would be assigned to more specific and preventable causes. Finally, the third researcher checked the data, would review the court record, and correct the data if there were differences in the same case.
Definition and Coding of Variables
Hospital identified as repeat defendants in lawsuits denotes that the hospitals have been sued 3 times or more for different cases.
“Hospital level” represents the nature and qualification of hospitals. We categorized hospitals into 4 levels in this study, including private hospitals (private hospitals with more than 20 beds), primary hospitals (rural and urban public hospitals with less than 100 beds), secondary hospitals (rural and urban public hospitals with beds between 100 and 499), and tertiary hospitals (typically, advanced urban public hospitals with more than 500 beds).
“Liability degree of the hospital” is a measure of the proportion of the malpractice for which the hospital is liable. The higher the hospital’s degree of liability, the more significant error in the malpractice. “Liability degree of the hospital” is broken down into the following 5 categories: minor liability (≤10% or less), secondary liability (11%–49%), equal liability (50%), ultimate liability (51%–99%), and full liability (100%).
“Injury outcomes” represents the detailed outcomes of the malpractice. We measured “injury outcomes” by combining the 10 divisions based on disability levels ruled on in the Medical Accident Grading Standard in China (for Trial Implementation) into 2 categories and 15 detailed categories. Injury included the following 9 detailed categories: “unidentified neonatal injury” means a child with permanent and temporary harm but has not been identified, including physical and emotional injury. “Minor neonatal injury” means a child with 9 to 10 levels of disability. “Moderate neonatal injury” means a child with 5 to 8 levels of disability, moderate permanent or temporary injury, or loss of function. “Major neonatal injury” means a child with 1 to 4 levels of disability, major permanent disability, and loss of function. The neonatal injury coding method was the same to the maternal injury coding. Death included the following 6 detailed categories: “fetal death,” “neonatal death,” “maternal death,” “maternal death with child injury,” “maternal injury with child death,” and “deaths of both mother and child.”
Statistical Analysis
Data screening was the first step to identify error and missing values. All continuous data were nonnormally distributed after being inspected for normality of distribution visually and statistically in this study. Median and interquartile range were applied to describe the distribution of the continuous variables, and frequencies and percentage frequencies were determined for categorical variables. Mann-Whitney U test was conducted to compare indemnity payment between 2 groups. Comparison of an indemnity payment in multiple groups entailed Kruskal-Wallis H test, followed by the Steel Dwass test for multiple comparisons. The χ2 test was conducted for categorical data. Fisher exact test was applied when cells had expected counts of less than 5. Multivariate binary logistic regression analyses were performed for statistical analysis. Results were presented as an odd ratio (OR) and 95% confidence interval (CI) in binary logistic regression analysis, and P values less than 0.05 are considered statistically significant. Statistical data were processed using SPSS 25.0 software (IBM, New York).
RESULTS
Characteristics of the Obstetric Malpractice Lawsuits
A total of 3441 obstetric malpractice lawsuits in 30 provinces successfully claimed were reviewed in this study, with a total indemnity payment of $139,875,375. The median amount claimed was $71,843, almost 3 times the median indemnity payment ($25,898). Of the 2424 hospitals that were sued, 8.3% (201/2424) were referred to as “repeat defendant” because they were involved in multiple lawsuits (Table 1).
TABLE 1 -
Characteristics of the Obstetric
Malpractice Lawsuits
| Characteristic |
n/%/Median (IQR) |
| Province, n |
30 |
| Hospital, n |
2,424 |
| Involved multiple hospital |
4.9 (167/3441) |
| Repeat defendant hospital |
8.3 (201/2424) |
| Hospital with 3 lawsuits |
63.2 (127/201) |
| Hospital with 4 lawsuits |
20.9 (42/201) |
| Hospital with ≥5 lawsuits |
15.9 (32/201) |
| Hospital level of repeat defendant |
|
| Private hospitals |
7.0 (14/201) |
| Primary hospitals |
6.0 (12/201) |
| Secondary hospitals |
60.7 (122/201) |
| Tertiary hospitals |
26.3 (53/201) |
| Amount claimed, $ |
71,843(27,795–129,955) |
| Indemnity payment, $ |
25,898 (9,116–57,287) |
| Total claimed amount, $ |
344,389,397 |
| Total indemnity payment, $ |
139,875,375 |
| Length of the lawsuit, mo |
7 (3–14) |
IQR, interquartile range.
The number of obstetric malpractice lawsuits per year was consistent with the number of newborns. After peaking in 2017, the number of obstetric malpractice cases tends to decline with the fall in the birth population (Fig. 2A). Indemnity payments were made in 91.3% for less than $100,000. Although the percentages of lawsuits in the ≥100,000 groups was 8.7% in the total case number, the payment of the this group took 32.6% of the overall payments (Fig. 2B). The case with an indemnity payment of no less than $100,000 was therefore considered to have a high payment.
FIGURE 2: The distribution of obstetric malpractice lawsuits. A, The number of obstetric malpractice lawsuits per year was consistent with the number of newborns. The number of closure lawsuit from 2013 to 2021 was 120, 360, 437, 459, 650, 547, 541, 338, and 213. The number of newborns from 2013 to 2021 was 16.40 million, 16.87 million, 16.55 million, 17.86 million, 17.23 million, 15.23 million, 14.65 million, 12.00 million, and 10.62 million (the data from 2021 Chinese Statistical Yearbook). After peaking in 2017, the number of obstetric malpractice claims in China tends to decline as the country’s birth rate falls. B, There was 70.5% of indemnity payments in the less than $50,000 group, followed by the $50,000–$9,999,949 group (36.2%). Those 2 combined make up 91.3% of all lawsuits, indicating that most of the indemnity payments of lawsuits were less than $100,000. Although the percentages of lawsuits’ indemnity payments in ≥100,000 groups was 8.7%, the payment in total accounted for 32.6%. C, The proportion of the obstetric malpractice lawsuits in the east, midland, and west of China was 40.4%, 39.4%, and 20.2%, respectively. In these 3 regions, the distribution was similar in the number of habitants (505.25 million, 494.37 million, and 308.86 millions) and the birth population (3.89 million, 3.89 million, and 2.84 millions). The per capita disposable income, which represents the average per person may control the income. The east of China had the highest capita disposable income at RMB 49,012, followed by the midland (RMB 26,860) and the west (RMB 25,025; data of inhabitants, birth population, and capita disposable income were from the 2021 Chinese Statistical Yearbook). The high payment rate in east of China was highest (10.5%), higher than the midland and the west of China. D, More than half of injury outcomes (53.4%) were death. In total, the median indemnity payment of death was higher compared with injury (P < 0.05).
In China, 40.4% and 39.4%, respectively, of all lawsuits were filed in the country’s east and middle regions, respectively. The distribution of lawsuits was consistent with the number of habitants and birth population in the different geographic regions. The east of China had the highest payment rate (P < 0.05). The capita disposable income of east of China is higher than other, too (Fig. 2C).
Although secondary hospitals were the subject of 33.7% of lawsuits and made up 60.7% of repeat defendant hospitals, the high payment rate of secondary hospitals was the lowest (P < 0.05). Approximately 38.7% of the total was accounted for hospitals with ultimate liability (51%–99%). The high payment rate grew as the liability increased (P < 0.05; Table 2).
TABLE 2 -
Characteristics of the Obstetric
Malpractice Lawsuits and the High
Payment Analysis
| Characteristic |
n (%) |
Median Indemnity Payment, $ |
High Payment |
| High Payment Rate, % |
Without High Payment (<$100,000) |
With High Payment (≥$100,000) |
P
|
| Geographic region |
|
|
|
|
|
|
| The east of China |
1389 (40.4) |
24,602 |
10.5 |
1243 |
146 |
0.006 |
| The midland of China |
1357 (39.4) |
25,426 |
7.2 |
1259 |
98 |
|
| The west of China |
695 (20.2) |
30,293 |
7.8 |
641 |
54 |
|
| Hospital level |
|
|
|
|
|
|
| Private hospitals |
416 (12.1) |
21,639 |
8.7 |
380 |
36 |
<0.001 |
| Primary hospitals |
1078 (31.3) |
24,116 |
10.6 |
964 |
114 |
|
| Secondary hospitals |
1158 (33.7) |
18,549 |
5.2 |
1098 |
60 |
|
| Tertiary hospitals |
789 (22.9) |
47,353 |
11.2 |
701 |
88 |
|
| Liability degree of the hospital |
|
|
|
|
|
|
| Minor liability (≤10%) |
253 (7.4) |
6,444 |
2.4 |
247 |
6 |
<0.001 |
| Secondary liability (11% ~ 49%) |
1259 (36.6) |
21,532 |
2.1 |
1231 |
27 |
|
| Equal liability (50%) |
437 (12.7) |
40,436 |
5.0 |
415 |
22 |
|
| Ultimate liability (51% ~ 99%) |
1332 (38.7) |
37,692 |
15.8 |
1121 |
211 |
|
| Full liability (100%) |
160 (4.6) |
28,907 |
20.0 |
128 |
32 |
|
| Causative domain |
|
|
|
|
|
|
| Antenatal care access and management |
88(2.6) |
11,997 |
4.5 |
84 |
4 |
<0.001 |
| Diagnosis |
291(8.5) |
13,439 |
5.2 |
276 |
15 |
|
| Fetal surveillance |
380(11.0) |
23,729 |
6.6 |
355 |
25 |
|
| Management of labor |
495(14.4) |
28,918 |
13.3 |
429 |
66 |
|
| Anesthetic |
48(1.4) |
46,105 |
29.2 |
34 |
14 |
|
| Forceps or ventose delivery management |
154(4.5) |
37,013 |
11.0 |
137 |
17 |
|
| Cesarean section management |
326(9.5) |
28,844 |
7.1 |
303 |
23 |
|
| Medication error |
59(1.7) |
15,387 |
0.0 |
59 |
0 |
|
| Management of birth complications and adverse events |
803(23.3) |
26,926 |
8.6 |
734 |
69 |
|
| Postnatal care |
57 (1.6) |
35,553 |
17.5 |
47 |
10 |
|
| Newborn care |
124(3.6) |
35,407 |
3.2 |
120 |
4 |
|
| Career decision making |
472(13.7) |
26,437 |
9.1 |
429 |
43 |
|
| Consent and conduct |
126(3.7) |
19,500 |
4.8 |
120 |
6 |
|
| Other |
18(0.5) |
33,469 |
11.1 |
16 |
2 |
|
| Total |
3441(100.0) |
25,989 |
8.7 |
3143 |
298 |
|
Injury Outcomes of Obstetric Malpractice Lawsuits
More than half of injury outcomes (53.4%) were death. Neonatal death was the most frequent outcome, accounting for 29.8% of all cases. Unidentified neonatal injury and unidentified maternal injury made up 11.8% and 4.5%, respectively, with low median indemnity payments at only $7,596 and $5,743, respectively. In total, the median indemnity payment of death was higher compared with injury (P < 0.05; Fig. 2D). In terms of detailed injury outcomes, the major neonatal injury had a higher median indemnity payment than neonatal death and fetal death (P < 0.05). The median indemnity payment of major maternal injury was higher than that of maternal death (P < 0.05; Table 3).
TABLE 3 -
Injury Outcomes of Obstetric Malpractice
| Injury Outcomes |
No. Lawsuits |
Median Indemnity Payment, $ |
High Payment |
| High Payment Rate, % |
Without High Payment (<$100,000) |
With High Payment (≥$100,000) |
P
|
| Injury |
|
|
|
|
|
|
| 1 Unidentified neonatal injury |
407 (11.8) |
7,596 |
2.2 |
398 |
9 |
<0.001 |
| 2 Minor neonatal injury |
63 (1.8) |
10,744 |
0.0 |
63 |
0 |
|
| 3 Moderate neonatal injury |
323 (9.4) |
24,415 |
5.3 |
306 |
17 |
|
| 4 Major neonatal injury* |
286 (8.3) |
47,659 |
24.5 |
216 |
70 |
|
| 5 Unidentified maternal injury |
154 (4.5) |
5,743 |
0.6 |
153 |
1 |
|
| 6 Minor maternal injury |
94 (2.8) |
15,087 |
0.0 |
94 |
0 |
|
| 7 Moderate maternal injury |
196 (5.7) |
30,943 |
5.6 |
185 |
11 |
|
| 8 Major maternal injury†
|
65 (1.9) |
68,562 |
35.4 |
42 |
23 |
|
| 9 Both maternal and neonatal injury |
15 (0.4) |
28,794 |
13.3 |
13 |
2 |
|
| Death |
|
|
|
|
|
|
| 10 Fetal death |
180 (5.2) |
9,971 |
3.3 |
174 |
6 |
|
| 11 Neonatal death |
1027 (29.8) |
34,157 |
4.3 |
983 |
44 |
|
| 12 Maternal death |
389 (11.3) |
52,502 |
20.8 |
308 |
81 |
|
| 13 Maternal death with child injury |
11 (0.3) |
84,642 |
36.4 |
7 |
4 |
|
| 14 Maternal injury with child death |
113 (3.3) |
25,366 |
12.4 |
99 |
14 |
|
| 15 Deaths of both mother and child |
118 (3.5) |
48,128 |
13.6 |
102 |
16 |
|
*Represents median indemnity payment of major neonatal injury higher than neonatal death and fetal death, P < 0.05.
†Represents the median indemnity payment of the major maternal injury was higher compared with maternal death, P < 0.05.
Causative Domain of Obstetric Malpractice Lawsuits
All 3441 lawsuits were assigned to 14 causative domains and 34 causative issues, covering 100% (14/14) of causative domains and 97.0% (33/34) of causative issues (Table 4).
TABLE 4 -
Causative Issues of Obstetric
Malpractice Lawsuits
| Causative Domain/Causative Issues |
No. Lawsuits |
% |
Death, % |
With High Payment (≥$100,000) (%) |
Median Indemnity Payment, $ |
| 1 Antenatal care access and management |
88
|
2.6
|
53.4
|
4.5
|
11,997
|
| 1.1 Inadequate level of pregnancy care |
16 |
0.5 |
50.0 |
6.3 |
12,229 |
| 1.2 Inadequate telephone advice |
— |
— |
— |
— |
— |
| 1.3 Inadequate/inappropriate management |
72 |
2.1 |
54.2 |
4.2 |
11,748 |
| 2 Diagnosis |
291
|
8.5
|
38.3
|
5.2
|
13,439
|
| 2.1 Mis/missed diagnosis |
72 |
2.1 |
63.4 |
8.5 |
26,037 |
| 2.2 Delayed diagnosis |
45 |
1.3 |
42.2 |
6.7 |
26,302 |
| 2.3 Diagnosis communication |
20 |
0.6 |
35.0 |
10.0 |
30,590 |
| 2.4 Aneuploidy screening |
155 |
4.5 |
27.1 |
2.6 |
10,660 |
| 3 Fetal surveillance |
380
|
11.0
|
80.5
|
6.6
|
23,729
|
| 3.1 Antenatal Cardiotocography (CTG) |
14 |
0.4 |
100.0 |
7.1 |
32,482 |
| 3.2 Intrapartum CTG |
263 |
7.6 |
81.7 |
7.6 |
29,408 |
| 3.3 Ultrasound |
103 |
3.0 |
74.8 |
3.9 |
11,420 |
| 4 Management of labor |
495
|
14.4
|
46.1
|
13.3
|
28,918
|
| 4.1 Induction/augmentation of labor |
379 |
11.0 |
34.8 |
13.2 |
28,225 |
| 4.2 Management of pre-existing maternal condition |
116 |
3.4 |
82.8 |
13.8 |
32,110 |
| 5 Anesthetic |
48
|
1.4
|
8.3
|
29.2
|
46,105
|
| 5.1 Regional anesthetic |
40 |
1.2 |
2.5 |
25.0 |
43,288 |
| 5.2 General anesthetic |
8 |
0.2 |
37.5 |
50.0 |
76,797 |
| 6 Forceps or ventose delivery management |
154
|
4.5
|
48.7
|
11.0
|
37,013
|
| 6.1 Forceps or ventose delivery management |
154 |
4.5 |
48.7 |
11.0 |
37,013 |
| 7 Cesarean section management |
326
|
9.5
|
46.6
|
7.1
|
28,844
|
| 7.1 Cesarean section management |
326 |
9.5 |
46.6 |
7.1 |
28,844 |
| 8 Medication error |
59
|
1.7
|
61.0
|
0.0
|
15,388
|
| 8.1 Prescription error |
48 |
1.4 |
66.7 |
0.0 |
22,827 |
| 8.2 Medication administration |
11 |
0.3 |
36.4 |
0.0 |
14,180 |
| 9 Management of birth complications and adverse outcomes |
803
|
23.3
|
43.6
|
8.6
|
26,926
|
| 9.1 Management of uterine rupture |
42 |
1.2 |
85.7 |
11.9 |
22,827 |
| 9.2 Management of shoulder dystocia |
298 |
8.7 |
1.0 |
1.3 |
14,875 |
| 9.3 Management of hypertensive and eclamptic disorders |
57 |
1.7 |
78.9 |
14.0 |
45,977 |
| 9.4 Management of maternal infection |
41 |
1.2 |
70.7 |
12.2 |
33,872 |
| 9.5 Management of amniotic fluid embolism (AFE) |
117 |
3.4 |
93.2 |
10.3 |
47,465 |
| 9.6 Management of postpartum hemorrhage (PPH) |
189 |
5.4 |
64.6 |
18.0 |
43,331 |
| 9.7 Management of perineal trauma |
34 |
1.0 |
14.7 |
2.9 |
27,834 |
| 9.8 Un-retrieved instrument/pack |
25 |
0.7 |
4.0 |
0.0 |
16,255 |
| 10 Postnatal care |
57
|
1.6
|
45.6
|
17.5
|
35,553
|
| 10.1 Complications and adverse outcomes |
32 |
0.9 |
25.0 |
15.6 |
14,190 |
| 10.2 Management of thromboembolic disease |
25 |
0.7 |
72.0 |
20.0 |
45,685 |
| 11 Newborn care |
124
|
3.6
|
87.9
|
3.2
|
35,407
|
| 11.1 Neonatal injury/ death |
124 |
3.6 |
87.9 |
3.2 |
35,407 |
| 12 Career decision making |
472
|
13.7
|
63.1
|
9.1
|
26,437
|
| 12.1 Medical care decision making |
445 |
12.9 |
63.8 |
8.5 |
26,180 |
| 12.2 Nursing and midwifery care decision making |
27 |
0.8 |
51.9 |
18.5 |
39,529 |
| 13 Consent and conduct |
126
|
3.7
|
62.7
|
4.8
|
19,500
|
| 13.1 Consent |
124 |
3.6 |
62.9 |
4.0 |
19,500 |
| 13.2 Professional conduct |
2 |
0.1 |
50.0 |
50.0 |
88,225 |
| 14 Other |
18
|
0.5
|
83.3
|
11.1
|
33,469
|
| 14.1 Other |
18 |
0.5 |
83.3 |
11.1 |
33,469 |
| Total |
3441
|
100.0
|
53.4
|
8.7
|
25,898
|
The leading causes of obstetric malpractice were the management of birth complications and adverse events (23.3%), management of labor (14.4%), career decision making (13.7%), and fetal surveillance (11.0%) and cesarean section management (9.5%). Management of shoulder dystocia (8.7%), management of postpartum hemorrhage (PPH, 5.5%), and management of amniotic fluid embolism (AFE, 3.4%) were the top 3 detailed issues in the management of birth complications and adverse events. Anesthetic resulted in highest payment (29.2%; Table 2). The distribution of causative domains, high payment, and outcome were seen in Figure 3.
FIGURE 3: Sankey diagram of causative domain, high payment, and outcome. The distribution of causative domains, high payments, and outcomes were shown in a Sankey diagram. Management of birth complications and adverse events, fetal surveillance, management of labor, care decision making, and cesarean section contributed most death cases. Management of birth complications and adverse events, management of labor, diagnosis, cesarean section, and career decision making contributed to most injury cases. Death and injury were the outcomes in 53.4% and 46.6% of the cases, respectively. The results revealed that 8.7% of cases were judged in high payments, and 91.3% of cases were judged in without high payment.
Factors Associated With High Payment
The results revealed that 8.7% of cases were judged in high payments (≥$100,000; Fig. 3). We performed a multivariate binary logistic regression analysis to identify the risk factors of high payment in an obstetric malpractice lawsuit. The dependent variable Y = 0 represents a hospital without high payment (<$100,000), while Y = 1 represents a hospital with high payment (≥$100,000). We included obstetric malpractice lawsuit contributing factors in the binary logistic regression analysis. The results of the multivariate analysis demonstrated that high payment was associated with geographic region, hospital level, liability degree of the hospital, injury outcome, and causative domain (Table 5). The hospitals in the midland of China, in the west of China, as well as secondary hospitals had lower risks of high payment. A higher risk of high payment was associated with hospitals with ultimate liability, full liability, major neonatal injury, major maternal injury, maternal death, maternal death with child injury, maternal injury with child death, and deaths of both mother and child. In the causative domain, only anesthetics had a higher risk of high payment, but anesthetic-related lawsuits accounted for just 1.4% of all cases.
TABLE 5 -
Multivariate Analysis of the Factors Associated With High
Payment
| Factors |
Multivariate |
| Adjusted OR (95% CI) |
P
|
| Geographic region |
|
|
| The east of China |
1.000 |
|
| The midland of China |
0.476 (0.348–0.651) |
<0.001 |
| The west of China |
0.523 (0.357–0.767) |
0.001 |
| Hospital level |
|
|
| Private hospitals |
1.000 |
|
| Primary hospitals |
1.052 (0.664–1.665) |
0.829 |
| Secondary hospitals |
0.587 (0.356–0.967) |
0.037 |
| Tertiary hospitals |
1.405 (0.866–2.280) |
0.168 |
| Liability degree of the hospital |
|
|
| Minor liability (≤10%) |
1.000 |
|
| Secondary liability (11 ~ 49%) |
0.876 (0.346–2.216) |
0.779 |
| Equal liability (50%) |
2.178 (0.832–5.968) |
0.113 |
| Ultimate liability (51 ~ 99%) |
9.695 (4.072–23.803) |
<0.001 |
| Full liability (100%) |
16.442 (6.231–43.391) |
<0.001 |
| Injury outcome |
|
|
| Unidentified neonatal injury |
1.000 |
|
| Minor neonatal injury |
0.000 (0.000–0.000) |
0.997 |
| Moderate neonatal injury |
1.863 (0.801–4.336) |
0.149 |
| Major neonatal injury |
12.326 (5.836–26.033) |
<0.001 |
| Unidentified maternal injury |
0.252 (0.031–2.059) |
0.187 |
| Minor maternal injury |
0.000 (0.000–0.000) |
0.996 |
| Moderate maternal injury |
2.095 (0.799–5.492) |
0.133 |
| Major maternal injury |
20.885 (7.929–55.011) |
<0.001 |
| Both maternal and neonatal injury |
4.607 (0.844–25.159) |
0.078 |
| Fetal death |
1.945 (0.642–5.895) |
0.240 |
| Neonatal death |
2.045 (0.951–4.399) |
0.067 |
| Maternal death |
18.783 (8.887–39.697) |
<0.001 |
| Maternal death with child injury |
54.682 (10.900–274.319) |
<0.001 |
| Maternal injury with child death |
6.935 (2.773–17.344) |
<0.001 |
| Deaths of both mother and child |
12.770 (5.136–31.754) |
<0.001 |
|
Causative domain
|
|
|
| Antenatal care access and management |
1.000 |
|
| Diagnosis |
1.388(0.388–4.964) |
0.614 |
| Fetal surveillance |
1.720 (0.509–5.809) |
0.382 |
| Management of labor |
2.100 (0.653–6.756) |
0.213 |
| Anesthetic |
5.605 (1.347–23.320) |
0.018 |
| Forceps or ventose delivery management |
2.082 (0.585–7.414) |
0.258 |
| Cesarean section management |
1.297 (0.383–4.391) |
0.676 |
| Medication error |
0.000 (0.000–0.000) |
0.997 |
| Management of birth complications and adverse events |
1.066 (0.335–3.386) |
0.914 |
| Postnatal care |
1.759 (0.441–7.011) |
0.424 |
| Newborn care |
1.242 (0.263–5.867) |
0.784 |
| Career decision making |
1.990(0.608–6.507) |
0.255 |
| Consent and conduct |
1.499 (0.349–6.437) |
0.587 |
| Other |
1.147 (0.199–10.077) |
0.728 |
DISCUSSION
The Status of Obstetric Malpractice Lawsuits
In our study, we examined 3441 obstetric malpractice lawsuits successfully claimed (in favor of the plaintiff), resulting in a total indemnity payment of $139,875,375, a huge burden for healthcare systems. There are different high payment criteria throughout countries. In the United States, 7.9% of cases resulted in high payment, which was defined as ≥$1,000,000 and referred to as a catastrophic claim.23 The high payment standard in Spain was greater than $200,000, and approximately 5.8% of cases caused high payment.24 We classified the claim with an indemnity payment of ≥$100,000 as a high payment one given the economic situation in China, and 8.7% of cases resulted in high payment.
The high payment associated with geographic region, hospital level, liability degree of the hospital, injury outcome, and causative domain. We discovered that the east of China had a higher number of lawsuit and higher risk of high payment than the middle and the western regions of China. The number of the lawsuit was consistent with the birth population per year, as well as regions. However, the high payment was related to the income of different region. The east of China had the highest capita disposable income and payment rate. The high payment was also associated with liability degrees of hospitals, which indicated that the more contribution to the injury outcomes, the more liability the hospitals for the malpractice. The risks of high payment are elevated in tandem with rising liability degrees.
Secondary Hospitals Likely to Be Repeat Defendants
We observed that secondary hospitals were sites of one-third of the lawsuits (1158/3441) and 60.7% (122/201) of repeat defendant hospitals. Secondary hospitals were usually the target of obstetric malpractice cases in China because they are frequently the primary birthing facilities for mothers. Secondary hospitals are more likely to be repeat defendants because they are always less competent and have weaker overall management than tertiary hospital. However, it is interesting that secondary hospital had a lower risk of recurring high payment. Obstetric care providers in secondary hospital preferred transferring high-risk patients to tertiary hospitals instead of treating them due to qualification limitations, lesser liability, and lower risks of high payment. Although the high payment rate is lower in secondary hospitals, it should be acknowledged that the secondary hospitals received the most frequent claims and were likely to be repeat defendant for their transfer delays or system errors. A universal proposal for quality improvement should be applied in secondary hospital including obstetric care provider training according to guidelines,25–27 comprehensive obstetric safety program,28 and teamwork.
Serious Injury Outcomes Lead to Lawsuits
Most of the lawsuits were accompanied by serious injury outcomes. The malpractice outcomes include injury during pregnancy, labor, or in the postpartum period.29 Thus, obstetric malpractice could injury the child, the mother, and both. In this study, more than half of injury outcome was death (fetal death, neonatal death, maternal death, maternal death with child injury, maternal injury with child death, deaths of both mother and child). The median indemnity payment of death was higher than injury (P < 0.05). These results imply that death was still the most common and costly reason leading to obstetric malpractice lawsuits. However, in the detailed injury outcomes, the major neonatal injury had a higher median indemnity payment than neonatal death and fetal death (P < 0.05). The median indemnity payment of the major maternal injury was higher than maternal death (P < 0.05). Major injury represents 1 to 4 levels of disability, which indicates the patient has a permanent impairment who is unable or hard to live independently. Therefore, major injury outcomes related to obstetrics can lead to substantial long-term costs. The same finding was reported in some other studies. A study of cases in the United States30 showed that payments for serious patient morbidity were higher than those for patient death. According to a study of the cases in Taiwan,31 patients with major injury outcomes had the largest average compensation, approximately 4.5 times the payout for patient’s death. The previous study also showed increasing payments with statistically higher payment for more debilitating and permanent injuries.32 Complex injury outcomes involving mother and child at the same time were more susceptible to receiving high payment. In this study, maternal death with child injury, maternal injury with child death, and deaths of both mother and child were at high risk of high payment. Given the burden of the complex injury outcomes, it is necessary to learn the causative issues from obstetric malpractice lawsuits and improve the quality of maternity care to avoid these catastrophic outcomes.
One of the most surprising findings was the large proportion of unidentified neonatal injury and unidentified maternal injury, accounting for 11.8% and 4.5%, respectively, with the median indemnity payment only $7,596 and $5,743, respectively. This large proportion of unidentified injury with lower payment made the median indemnity payment in injury is lower than death. The previous study made it clear that malpractice litigation includes compensation of injury for substandard care but also one emotional vindication.33 Most of unidentified injury, whether they affected the mother or child, were temporary harm in physical or emotional aspects. The careful personal conduct, effective patient communication, and early involvement in prenatal education are essential for obstetric care providers to prevent lawsuits with unidentified injuries.
Management of Birth Complications and Adverse Events
The “management of birth complications and adverse events” domain was the most common causative domain of obstetric malpractice lawsuits, resulting in more than half maternal death and major maternal injury. Management of birth complications and adverse events are also responsible for most complex injury outcomes, such as deaths of mother and child, maternal death with child death, maternal death with child injury, and maternal injury with child death. Postpartum hemorrhage and AFE were 2 common birth complications and adverse events, which caused catastrophic outcomes hereinabove.34–37 Postpartum hemorrhage is viewed as a preventable cause related to maternal death,23 while the AFE is considered an unanticipated and unavoidable pregnancy complication that could result in the complex injury outcomes both in mother and child.37 Obstetricians or midwives should follow the obstetrics guidelines, enhance quality maternal care to identify abnormal issues and take action immediately. Management of shoulder dystocia was the leading causative issue contributing to the management of birth complications and adverse events (23.3%). Shoulder dystocia always resulted in brachial plexus injury.6,38,39 Brachial plexus injury occurs during difficult deliveries, mainly caused by improper midwifery in vaginal delivery.40 Because shoulder dystocia training may lower the incidence of obstetric brachial plexus injury,41 every obstetric care provider should be accepted shoulder dystocia training regularly. Teamwork training is required because the coordination of teamed response by multiple healthcare providers is crucial for preventing obstetric brachial plexus injury.42
Anesthetics
In the 14 causative domains, only anesthetics showed a higher risk of high payment (OR, 5.605; 95% CI, 1.347–23.320), but anesthetic-related lawsuits accounted for just 1.4% of all cases. Research reported by D'Alton et al23 also shows that the anesthesia allegation group was one of the factors most associated with high payment. The Sankey diagram demonstrated that anesthesia caused most major maternal injuries in our study. According to the analysis of the American Society of Anesthesiologist Closed Claims database, a similar result was revealed that maternal nerve injury increased in 1990 or later claims.43 Anesthetic events are frequently accompanied by the mother’s coma or paralysis. The catastrophic outcomes resulted in high payment. Delay in anesthesia care and poor communication between the obstetrician and anesthesiologist were potentially preventable anesthetic events.
Limitations
This study collected data from China Judgment Online’s database for retrospective analysis. As a result, there were some inherent database limitations in our analysis. We included cases that had all of the relevant information, cases that lacked this information were excluded, which may have resulted in selection bias. Because of the difficulty in obtaining information from the database, another limitation is the lack of analysis of the intention to treat. However, the study aimed to examine obstetric malpractice lawsuits with successful claims. Identifying the primary cause with the NHSLA coding taxonomy was complicated and subjective. To reach a standard agreement, the 2 reviewers read the records and avoided subjective information to the maximum extent possible. Despite certain limitations, to our knowledge, this study is the first to clarify the characteristics and factors that contributed to successful obstetric malpractice lawsuits between 2013 and 2021.
CONCLUSIONS
This study has provided a deeper insight into the obstetric malpractice lawsuits from 2013 to 2021. We observed that the number of obstetric malpractice lawsuits consistent with birth population regardless of the year or regions. Secondary hospitals were confronted with most lawsuits and were likely to be repeat defendants. Death was the result of more than half of injury outcomes. The large proportion of unidentified neonatal and maternal injury with lower payment made the median indemnity payment in injury was lower than death in total. This study demonstrated that high payment was associated with geographic region, hospital level, liability degree of the hospital, injury outcome, and causative domain. The riskiest domains according to our research, included management of birth complications and adverse events, management of labor, career decision making, and fetal surveillance and cesarean section management, which were more common in the incident and contributed to most death outcomes. Anesthetics was another risky domain with a high risk for a high payment. Better quality of obstetric practice in these risky domains required even more extraordinary efforts.
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