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Poor outcomes related to childbirth are rare events, but continue to trigger malpractice claims and warrant increased attention from a risk management perspective, according to a new analysis.
Obstetric-related events are the fifth largest category of medical professional liability claims and the fourth highest category of indemnity payments for Coverys Inc., accounting for 4% of claims and 8% of indemnity paid, according to a report published by the Boston-based medical professional liability insurer on Wednesday.
The insurer’s analysis of 472 OB closed claims across the 2013-2017 period revealed that 80% of OB cases are high-severity cases, and 24% result in death of the baby, mother or both.
“These are relatively rare events, but these are often high-tragedy events,” said Robert Hanscom, vice president of business analytics for Coverys and a co-author of the report. “Whether it’s fetal death, maternal death or permanent fetal impairment, these are terrible, terrible cases. The issue for us is that many times we don’t see the negligence in these cases. We see a very, very bad outcome and we defend these cases vigorously because we don’t think the physicians were negligent.”
But jury verdicts often go against physicians even in cases where there is no negligence because of the economic hardships or emotional challenges associated with caring for a severely injured baby, which can lead to settlement in cases even when there is no negligence, he said.
“It is an emotional wallop,” he said. “Even if you think you did everything right as far as the care that was provided by the obstetrician and the defense is all ready to go, we’ve seen some surprising verdicts that have gone against the doctor. It’s that sympathy factor. It’s a real factor in these cases and it’s kind of the wild card.”
Errors in clinical judgment such as inappropriate management of labor and delivery, inappropriate management of pregnancy, negligent patient monitoring and a delay in performing cesarean section were cited in 53% of OB-related claims, according to the analysis.
Future infertility is the most common injury to mothers with regard to OB claims at 29%, followed by pre-eclampsia at 23%, according to the analysis.
Of OB claims involving injuries to babies, 41% result in neurological/brain damage and 34% result in fetal demise, including stillbirth, according to the analysis.
The single largest cause of obstetrical claims is alleged negligence during the management of labor, accounting for 40% of claims and 49% of indemnity paid. These risks include failure to recognize and act on nonreassuring fetal heart tracings, monitor the mother and fetus during administration of high-risk medications and recognize and act on obstetric emergencies, according to the report.
“Labor and delivery is treacherous,” Mr. Hanscom said. “Most deliveries occur without any problems whatsoever. The majority of babies are born without complications, but then there are these rare events. Because it’s such a natural process and in a lot of ways it’s a very personal process to the parents, it’s easy for the provider to almost get a little complacent in terms of the active management of the labor and delivery process. Don’t let that happen.”
Management of pregnancy accounted for 24% of claims and 16% of indemnity paid, according to the analysis. These risks include failure to conduct a thorough and relevant history and physical to uncover maternal and fetal risk factors such as diabetes and genetic conditions that may contribute to pregnancy complications, screen patients for presence of pre-existing or emerging conditions such as diabetes and pre-eclampsia that may contribute to maternal or fetal complications, and appropriately manage or refer patients with comorbidities such as obesity, diabetes or hypertension that contribute to maternal or fetal complications.
Claims related to the management of the pregnancy was one of the most surprising findings emanating from the analysis, said Maryann Small, director of data governance and business analytics for Coverys and a co-author of the report.
“In years past, our focus has always been on the labor and delivery side and less on the pregnancy,” she said. “Fewer problems were happening during the pregnancy. But with the prevalence of comorbidities and with the fact that some physicians are reticent to even label a woman as a high-risk pregnancy … if you’re not looking at those patients as riskier, you’re likely to end up having some issues and we’re starting to see that more in the data.”
In addition, vaginal births resulted in more claims than cesarean sections, 52% vs. 45%, and more than three times as many claims as emergency cesarean sections, 52% vs. 15%, according to the analysis.
“The fact that vaginal deliveries were more of a problem than C-sections was a bit of a surprise for us,” Ms. Small said. “It’s the situational awareness. When someone is having a C-section, everybody is focused on that. With vaginal deliveries, it’s that complacency factor.”
“With C-sections, surgery has gotten safer and safer and safer over the years,” Mr. Hanscom said. “Decades ago, it was definitely rife with more risks. Nowadays, it’s a very straightforward process. With vaginal deliveries, there are so many possibilities of what might go wrong related to the profile of the mother. If the mother has comorbidities, vaginal delivery could be complicated.”
ANAHEIM, Calif. — Hospitals will not be “fighting fires” concerning their professional liability insurance costs next year, said a co-author of a just-released study on the issue. “Things are pretty flat; things are pretty benign," said Erik Johnson.