Fortalecimiento de las competencias y funciones de las obstétricas-os en la Argentina: un tema estratégico / El Trabajo Obstétrico en la Salud Sexual y Reproductiva / Strengthening the competencies and functions of obstetrics in Argentina: a strategic issue / Obstetric work in sexual and reproductive health

El objetivo de este documento es informar el debate acerca de la necesidad y oportunidad de una legislación federal que actualice las competencias y condiciones de ejercicio de la obstetricia. Así, se espera contribuir a la jerarquización de este colectivo profesional y, con ello, mejorar las oportunidades de alcanzar la cobertura universal en salud sexual, reproductiva y materna de calidad en la Argentina. Forma parte de la serie "El trabajo obstétrico en la salud sexual y reproductiva", que el CEDES desarrolla con la colaboración de Ipas como contribución a un mejor conocimiento de este colectivo profesional. También se enmarca en la estrategia conjunta que CEDES y UNFPA-Argentina desarrollan para fortalecer el trabajo de las/los obstétricas/os en la Argentina.

A retrospective, observational study of medicolegal cases against obstetricians and gynaecologists in South Africa's private sector.

BACKGROUND:  The viability of obstetric practice in the private sector has been threatened as a result of steep increases in professional indemnity fees over the past 10 years. Despite this, empirical research investigating key aetiological factors to target risk management interventions has been lacking. OBJECTIVES: To explore private practice medicolegal data linked to obstetricians and gynaecologists (O&Gs) to identify factors in clinical practice associated with claims, for the purposes of guiding future research and risk management solutions. METHODS:  This was a retrospective, observational study of private sector O&Gs' medicolegal case histories. All incidents declared to a prominent local professional indemnity insurer were categorised in terms of medicolegal case type, as well as clinical parameters. To allow for risk-adjusted calculations of case incidence, year of entry into private practice was estimated for all practitioners. RESULTS:  Steep increases in medicolegal investigations and demands were demonstrated for both obstetrics- and gynaecology-related cases from about 2003 to 2012. Whereas the total numbers of claims, regulatory complaints and requests for records were similar for obstetrics and gynaecology in recent years (accounting for 52% v. 48% of known cases, respectively), a significantly greater percentage of demands and paid settlements related to gynaecology rather than obstetrics (58% and 76% v. 42% and 24% of cases, respectively). In obstetrics, about half of all cases on record with a paid settlement were in the context of severe neonatal birth-related neurological injury (n=9). For gynaecology, procedure-related complications accounted for 92% of settlements, of which at least 41% were for intraoperative injuries to internal organs and vessels. Laparoscopic procedures were most frequently associated with such intraoperative injuries, followed by vaginal and abdominal hysterectomies/oophorectomies and caesarean sections. For O&Gs in private practice for >2 years, 50/458 (11%) accounted for 138/228 (61%) of demands over a 10-year period. CONCLUSIONS:  The higher number of gynaecological demands and settlements in comparison with obstetric cases was unexpected and is contrary to international experiences and public sector findings, calling for more research to identify reasons for this finding. Other than further exploring surgical outcomes in private sector gynaecological patients, aspects of surgical training and accreditation standards in gynaecology may need review. Regarding birth-related injuries, the contribution of system failures needs quantification and further interrogation. The high contribution towards the medicolegal burden by a small group of practitioners suggests a need for doctor-focused interventions, including strengthening of peer review and regulatory oversight.

Use of Telemedicine and Smart Technology in Obstetrics: Barriers and Privacy Issues.

While telemedicine had been utilized in varying ways over the last several years, it has dramatically accelerated in the era of the COVID-19 pandemic. In this article we describe the privacy issues, in relation to the barriers to care for health care providers and barriers to the obstetric patient, licensing and payments for telehealth services, technological issues and language barriers. While there may be barriers to the use of telehealth services this type of care is feasible and the barriers are surmountable.

Obstetrics, genetics, and litigation.

INTRODUCTION: Claims of medical negligence are universal. Unexpected adverse pregnancy outcome may trigger litigation. Such outcomes, especially with neurodevelopmental sequelae, may be compounded by a genetic disorder, congenital abnormality, or syndrome. MATERIAL AND METHODS: This is a report of 297 cases in which a pregnancy complication, error, or incident occurred that was followed by progeny with a genetic disorder, congenital abnormality, or syndrome that spawned litigation. The author assessed, opined, and in many cases, testified about causation. RESULTS: Pregnancies complicated by hypoxic ischemic encephalopathy were not infrequently compounded by offspring with a genetic disorder, congenital abnormality, or syndrome. Multiple cases were brought because of missed ultrasound or laboratory diagnoses, or failures in carrier detection. Teratogenic medication prescribed before or during pregnancy invited legal purview. Failure to refer (or confer) for genetic evaluation or counseling in the face of significant risk, occurred repeatedly. Ethical breaches and hubris promptly led to litigation. CONCLUSIONS: Many lessons and recommendations emerge in this report. These include the realization that the vast majority of errors in this series involved at least two caregivers, serial ultrasound studies are important, decreased fetal movements may signal a genetic disorder, congenital abnormality, or syndrome, family history and ethnicity are vital, cognitive biases profoundly affect decision-making. Finally, the simplest of errors have the potential for causing life-long grief.

Increasing Access to Abortion: ACOG Committee Opinion Summary, Number 815.

Individuals require access to safe, legal abortion. Abortion, although legal, is increasingly out of reach because of numerous restrictions imposed by the government that target patients seeking abortion and their health care practitioners. Insurance coverage restrictions, which take many forms, constitute a substantial barrier to abortion access and increase reproductive health inequities. Adolescents, people of color, those living in rural areas, those with low incomes, and incarcerated people can face disproportionate effects of restrictions on abortion access. Stigma and fear of violence may be less tangible than legislative and financial restrictions, but are powerful barriers to abortion provision nonetheless. The American College of Obstetricians and Gynecologists, along with other medical organizations, opposes such interference with the patient-clinician relationship, affirming the importance of this relationship in the provision of high-quality medical care. This revision includes updates based on new restrictions and litigation related to abortion.

Increasing Access to Abortion: ACOG Committee Opinion, Number 815.

Individuals require access to safe, legal abortion. Abortion, although legal, is increasingly out of reach because of numerous restrictions imposed by the government that target patients seeking abortion and their health care practitioners. Insurance coverage restrictions, which take many forms, constitute a substantial barrier to abortion access and increase reproductive health inequities. Adolescents, people of color, those living in rural areas, those with low incomes, and incarcerated people can face disproportionate effects of restrictions on abortion access. Stigma and fear of violence may be less tangible than legislative and financial restrictions, but are powerful barriers to abortion provision nonetheless. The American College of Obstetricians and Gynecologists, along with other medical organizations, opposes such interference with the patient-clinician relationship, affirming the importance of this relationship in the provision of high-quality medical care. This revision includes updates based on new restrictions and litigation related to abortion.

Penalties for Emergency Medical Treatment and Labor Act Violations Involving Obstetrical Emergencies.

INTRODUCTION: The Emergency Medical Treatment and Labor Act (EMTALA) was intended to prevent inadequate, delayed, or denied treatment of emergent conditions by emergency departments (ED). While controversies exist regarding the scope of the law, there is no question that EMTALA applies to active labor, a key tenet of the statute and the only medical condition - labor - specifically included in the title of the law. In light of rising maternal mortality rates in the United States, further exploration into the state of emergency obstetrical (OB) care is warranted. Understanding civil monetary penalty settlements levied by the Office of the Inspector General (OIG) related to EMTALA violations involving labor and other OB emergencies will help to inform the current state of access to and quality of OB emergency care. METHODS: We reviewed descriptions of all EMTALA-related OIG civil monetary penalty settlements from 2002-2018. OB-related cases were identified using keywords in settlement descriptions. We described characteristics of settlements including the nature of the allegation and compared them with non-OB settlements. RESULTS: Of 232 EMTALA-related OIG settlements during the study period, 39 (17%) involved active labor and other OB emergencies. Between 2002 and 2018 the proportion of settlements involving OB emergencies increased from 17% to 40%. Seven (18%) of these settlements involved a pregnant minor. Most OB cases involved failure to provide screening exam (82%) and/or stabilizing treatment (51%). Failure to arrange appropriate transfer was more common for OB (36%) compared with non-OB settlements (21%) (p = 0.041). Fifteen (38%) involved a provider specifically directing a pregnant woman to proceed to another hospital, typically by private vehicle. CONCLUSION: Despite inclusion of the term "labor" in the law's title, one in six settlements related to EMTALA violations involved OB emergencies. One in five settlements involved a pregnant minor, indicating that providers may benefit from education regarding obligations to evaluate and stabilize minors absent parental consent. Failure to arrange appropriate transfer was more common among OB settlements. Findings suggesting need for providers to understand EMTALA-specific requirements for appropriate transfer and for EDs at hospitals without dedicated OB services to implement policies for evaluation of active labor and protocols for transfer when indicated.

Lessons Learned From a Review of Malpractice Litigations Involving Obstetric Anal Sphincter Injury in the United States.

OBJECTIVE: The aim of this article is to review all litigations involving obstetric anal sphincter injury (OASIS) in the United States to highlight the most common allegations and factors that aided the involved obstetricians and gynecologists (ob/gyns). METHODS: We used Lexis Nexis, a comprehensive legal database, to search all publicly available high-profile federal and state level litigations related to OASIS. RESULTS: Of 68 cases that resulted and reviewed, 19 were deemed to be pertinent to the question being addressed. These 19 cases occurred between 1964 and 2011 and all alleged medical negligence. Among these 19 cases, 6 were ruled in favor of the plaintiffs, with most of them being awarded an amount ranging from US $110,000 to US $841,810.80. All 6 cases involved episiotomy. Thorough medical recordkeeping, comprehensive discharge instructions and counseling, and timely evaluation and referral to a female pelvic medicine and reconstructive surgery specialist were the key factors that aided the ob/gyns facing these litigations. CONCLUSIONS: Avoidance of episiotomy, thorough medical recordkeeping, comprehensive discharge instruction and counseling, and timely evaluation and referral to a female pelvic medicine and reconstructive surgery specialist may help an ob/gyn prevail in OASIS-related litigations.

Learning from the law. A review of 21 years of litigation for nerve injury following central neuraxial blockade in obstetrics.

Medicolegal claims for neurological injury following the use of central neuraxial blockade in childbirth represent the second most common claim against obstetric anaesthetists. We present an analysis of 55 cases from a database of 368 obstetric anaesthetic claims. Common themes that emerge from the analysis include: consent; nature of nerve injury (non-anaesthetic; direct; chemical; compressive); recognition; and management. Specific advice arising from these cases includes: the importance of informing patients of the risks of nerve damage; keeping below the conus of the cord for intrathecal procedures; responding appropriately if a patient complains of paraesthesia; and having a high index of suspicion if recovery of normal neurological function is delayed. As ever, principles of good practice, including respect for patient autonomy, early provision of information, good communication and a high standard of record-keeping, will minimise the frustration of patients that can then lead them to seek a legal route to redress if they suffer an injury following central neuraxial blockade.

Coding and Legal Issues in Obstetric and Gynecologic Ultrasound.

This article addresses coding and liability related to obstetric and gynecologic ultrasound examinations. The coding section includes an overview of general concepts, highlighting the differences between coding in hospital-owned facilities and provider-owned clinics. It also addresses the importance of correct International Classification of Diseases, 10th edition, coding, emphasizing the use of the most specific applicable codes. This section discusses proper coding and applicable parameters for early pregnancy and gynecologic ultrasound examination. The liability section addresses common errors leading to litigation in obstetric and gynecologic ultrasound practice. Examples are given demonstrating how such errors lead to liability actions.

Using medico-legal claims for quality improvement in maternity care: application and revision of an NHSLA coding taxonomy.

OBJECTIVE: To validate the NHSLA maternity claims taxonomy at the level of a single maternity service and assess its ability to direct quality improvement. DESIGN: Qualitative descriptive study. SETTING: Medico-legal claims between 1 January 2000 and 31 December 2016 from a maternity service in metropolitan Melbourne, Australia. POPULATION: All obstetric claims and incident notifications occurring within the date range were included for analysis. METHODS: De-identified claims and notifications data were derived from the files of the insurer of Victorian public health services. Data included claim date, incident date and summary, and claim cost. All reported issues were coded using the NHSLA taxonomy and the lead issue identified. MAIN OUTCOME MEASURES: Rate of claims and notifications, relative frequency of issues, a revised taxonomy. RESULTS: A combined total of 265 claims and incidents were reported during the 6 years. Of these 59 were excluded, leaving 198 medico-legal events for analysis (1.66 events/1000 births). The costs for all claims was $46.7 million. The most common claim issues were related to management of labour (n = 63, $17.7 million), cardiotocographic interpretation (n = 43, $24.4 million), and stillbirth (n = 35, $656,750). The original NHSLA classification was not sufficiently detailed to inform care improvement programmes. A revised taxonomy and coding flowchart is presented. CONCLUSIONS: Systematic analysis of obstetric medico-legal claims data can potentially be used to inform quality and safety improvement. TWEETABLE ABSTRACT: New taxonomy to target health improvement from maternity claims based on NHSLA Ten Years of Maternity Claims.

Industry Payments to Obstetricians and Gynecologists Under the Sunshine Act.

OBJECTIVE: To evaluate financial relationships between obstetrician-gynecologists (ob-gyns) and industry, including the prevalence, magnitude, and the nature of payments. METHODS: We conducted a cross-sectional study in which we obtained a list of industry contributions to U.S. obstetricians and gynecologists through the Centers for Medicare and Medicaid Services Open Payments Database from August 1, 2013, to December 31, 2015. These data were cross-referenced with the entire cohort of practicing obstetricians and gynecologists, who were identified using the National Provider Identification database, because not all practicing ob-gyns received payments. These payments were analyzed with respect to 1) types of payments, 2) demographic attributes of health care providers receiving payments, and 3) comparisons between obstetrician and gynecologist subspecialties. Continuous data were compared using the Mann-Whitney test for variables that were not normally distributed and with the t test for variables that are normally distributed. RESULTS: A total of 517,077 nonresearch payments, totaling $79,965,244, were made to 23,292 ob-gyns. Physicians receiving payments were predominantly female, younger than 65 years old, allopathic physicians who graduated from U.S. medical schools in the late 1990s, and were board-certified subspecialists (P<.001 for all). Half of all ob-gyns received payments of varying amounts from drug manufacturers, device manufacturers, or both, with most of the payments for honoraria, faculty compensation, or consulting. Female pelvic medicine and reconstructive surgery physicians received the largest median dollar amount; maternal-fetal medicine physicians received the smallest. CONCLUSION: Obstetricians and gynecologists receive a substantial amount of payments from industry. Most of these payments were for honoraria, faculty compensation, or consulting and totaled less than $400 per health care provider. Although this total amount is less than typically received by surgical providers, including orthopedic surgeons who account for the highest compensated group in total and mean industry payments, the median payment value for obstetrics and gynecology subspecialists surpasses the median payment to orthopedic surgeons. These financial relationships warrant further exploration with future research.

A Violent Birth: Reframing Coerced Procedures During Childbirth as Obstetric Violence.

In the United States, women are routinely forced to undergo cesarean sections, episiotomies, and the use of forceps, despite their desire to attempt natural vaginal delivery. Yet, the current American legal system does little to provide redress for women coerced to undergo certain medical procedures during childbirth. Courts and physicians alike are prepared to override a woman's choice of childbirth procedure if they believe this choice poses risks to the fetus, and both give little value to the woman's right to bodily autonomy. This Note proposes a solution for addressing the problem of coerced medical procedures during childbirth by importing a framework created in Venezuela and Argentina that characterizes this issue as "obstetric violence." First, this Note contains an overview of the shortcomings of the existing American legal framework to address the problem. Second, it explains the advantages of the obstetric violence framework and argues that its adoption in the United States would address many of the failures of the existing system. And third, this Note introduces a few legislative and litigation strategies that can be used to implement this framework in the United States and briefly addresses some of the challenges these strategies may pose.