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.

["Humanized childbirth and the right to choose:" analysis of a public hearing in Rio de Janeiro]. / "Parto humanizado e o direito da escolha": análise de uma audiência pública no Rio de Janeiro.

This work uses a field survey to analyze a plenary session of the Rio de Janeiro Legislative Assembly entitled "Humanized childbirth and the right to choose." Understanding this as a political space for conflicts of knowledge pertaining to the areas of medicine, nursing, and legislature, we consider the content of this session and discourses of power/knowledge surrounding the female body and reproduction. The article explores tensions around the political struggle for "humanized childbirth" via demands made by the Regional Council of Nursing. We also address the history of the medicalization of childbirth and the role of nurses, professionals specialized in low-risk births (obstetrizes), and midwives in this process.

O trabalho analisa, por meio de pesquisa de campo, uma plenária da Assembleia Legislativa do Rio de Janeiro, "Parto humanizado e o direito da escolha". Entendendo esse como um espaço político de conflitos dos saberes da área médica, da enfermagem e do Legislativo, é ponderado o conteúdo da plenária com os discursos de saber/poder acerca do corpo feminino e de sua reprodução. O artigo explora as tensões em torno da luta política pelo "parto humanizado" a partir de demandas feitas pelo Conselho Regional de Enfermagem. É abordada também a história da medicalização do parto e o papel das enfermeiras, obstetrizes e parteiras nesse processo.

Impact of free maternal health care policy on maternal health care utilization and perinatal mortality in Ghana: protocol design for historical cohort study.

BACKGROUND: Ghana introduced what has come to be known as the 'Free' Maternal Health Care Policy (FMHCP) in 2008 via the free registration of pregnant women to the National Health Insurance Scheme to access healthcare free of charge. The policy targeted every pregnant woman in Ghana with a full benefits package covering comprehensive maternal healthcare. PURPOSE: This study seeks to measure the contribution of the FMHCP to maternal healthcare utilization; antenatal care uptake, and facility delivery and determine the utilization impact on stillbirth, perinatal, and neonatal deaths using quasi-experimental methods. The study will also contextualize the findings against funding constraints and operational bottlenecks surrounding the policy operations in the Upper East Region of Ghana. METHODS: This study adopts a mixed-method design to estimate the treatment effect using variables generated from historical data of Ghana and Kenya Demographic and Health Survey data sets of 2008/2014, as treatment and comparison groups respectively. As DHS uses complex design, weighting will be applied to the data sets to cater for clustering and stratification at all stages of the analysis by setting the data in STATA and prefix Stata commands with 'svy'. Thus, the policy impact will be determined using quasi-experimental designs; propensity score matching, and difference-in-differences methods. Prevalence, mean difference, and test of association between outcome and exposure variables will be achieved using the Rao Scot Chi-square. Confounding variables will be adjusted for using Poisson and multiple logistics regression models. Statistical results will be reported in proportions, regression coefficient, and risk ratios. This study then employs intrinsic-case study technique to explore the current operations of the 'free' policy in Ghana, using qualitative methods to obtain primary data from the Upper East Region of Ghana for an in-depth analysis. DISCUSSION: The study discussions will show the contributions of the 'free' policy towards maternal healthcare utilization and its performance towards stillbirth, perinatal and neonatal healthcare outcomes. The discussions will also centre on policy designs and implementation in resource constraints settings showing how SDG3 can be achievement or otherwise. Effectiveness of policy proxy and gains in the context of social health insurance within a broader concept of population health and economic burden will also be conferred. PROTOCOL APPROVAL: This study protocol is registered for implementation by the Ghana Health Service Ethical Review Committee, number: GHS-ERC 002/04/19.

Birth Behind Bars: The Need for Labor Support in the Incarcerated Population.

The population of women within carceral systems is growing rapidly. A portion of these individuals are pregnant and will deliver while incarcerated. Although shackling laws for pregnant persons have improved, incarcerated patients are forced to labor without the support of anyone but a carceral officer and their medical staff. We believe access to continuous labor support is critical for all pregnant persons. Carceral systems and their affiliated hospitals have the opportunity to change policies to reflect that continuous labor support is a basic human right and should be permitted for incarcerated pregnant persons in labor, either through a doula program or a selected person of choice.

"Parto humanizado e o direito da escolha": análise de uma audiência pública no Rio de Janeiro / "Humanized childbirth and the right to choose: " analysis of a public hearing in Rio de Janeiro

Resumo O trabalho analisa, por meio de pesquisa de campo, uma plenária da Assembleia Legislativa do Rio de Janeiro, "Parto humanizado e o direito da escolha". Entendendo esse como um espaço político de conflitos dos saberes da área médica, da enfermagem e do Legislativo, é ponderado o conteúdo da plenária com os discursos de saber/poder acerca do corpo feminino e de sua reprodução. O artigo explora as tensões em torno da luta política pelo "parto humanizado" a partir de demandas feitas pelo Conselho Regional de Enfermagem. É abordada também a história da medicalização do parto e o papel das enfermeiras, obstetrizes e parteiras nesse processo.

Abstract This work uses a field survey to analyze a plenary session of the Rio de Janeiro Legislative Assembly entitled "Humanized childbirth and the right to choose." Understanding this as a political space for conflicts of knowledge pertaining to the areas of medicine, nursing, and legislature, we consider the content of this session and discourses of power/knowledge surrounding the female body and reproduction. The article explores tensions around the political struggle for "humanized childbirth" via demands made by the Regional Council of Nursing. We also address the history of the medicalization of childbirth and the role of nurses, professionals specialized in low-risk births (obstetrizes), and midwives in this process.

Anticipating Issues with Capacitous Pregnant Women: United Lincolnshire NHS Hospitals Trust v CD [2019] EWCOP 24 and Guys and St Thomas' NHS Foundation Trust (GSTT) and South London and Maudsley NHS Foundation Trust (SLAM) v R [2020] EWCOP 4.

In United Lincolnshire NHS Hospitals Trust v CD and Guys and St Thomas' NHS Foundation Trust (GSTT) and South London and Maudsley NHS Foundation Trust (SLAM) v R, the Court of Protection was asked to make anticipatory and contingent declarations relating to the obstetric care and mode of delivery for currently capacitous women who were near to their due date but not yet in labour. In this case note I explore the judges' reasoning on the legal basis for these declarations. In so doing, I consider the wider implications of employing this seemingly new addition to the Court of Protection's armoury.

Ethics and Medico-legal implications in delivery room emergencies.

There is very little law-either case law or statutory law - that regulates delivery room decisions about resuscitation of critically ill newborns. Most of the case law that exists is decades old. Thus, physicians cannot look to the law for much guidance about what is permissible or prohibited. Local hospital policies and professional society statements provide some guidance, but they cannot be all-inclusive and encompass all potentially encountered scenarios. Ultimately, the physician, the medical team, and the parents must try to reach a shared decision about the best course of action for each individual infant and each unique family. In this paper, we review some of the case law that may be applicable to such decisions and make recommendations about how decisions should be made.

The most common patient safety issues resulting in legal action against neonatologists.

Common patient safety issues may result in injuries to babies in the newborn period. A medical malpractice lawsuit is one way in which an injured patient can obtain compensation for the injuries they sustained as the result of an error. There are a number of common areas of malpractice risk for neonatologists including the delivery room, jaundice, hypoglycemia, and late preterm infants. A better understanding of the medical malpractice system and common patient safety issues in neonatology can lead to protective strategies to reduce risk for untoward events and subsequent litigation. Strategies including maintaining competency, following national guidelines, and proper communication and documentation can improve the care and treatment of neonatal patients and their families resulting in less malpractice exposure.

Distribution and quality of emergency obstetric care service delivery in the Democratic Republic of the Congo: it is time to improve regulatory mechanisms.

BACKGROUND: The Demographic and Health Survey 2013-14 indicated that the Democratic Republic of the Congo (DRC) is still challenged by high maternal and neonatal mortality. The aim of this study was to assess the availability, quality and equity of emergency obstetric care (EmOC) in the DRC. METHODS: A cross-sectional survey of 1,568 health facilities selected by multistage random sampling in 11 provinces of the DRC was conducted in 2014. Data were collected through interviews, document reviews, and direct observation of service delivery. Collected data included availability, quality, and equity of EmOC depending on the location (urban vs. rural), administrative identity, type of facility, and province. Associations between variables were tested by Pearson's chi-squared test using an alpha significance level of 0.05. RESULTS: A total of 1,555 health facilities (99.2%) were surveyed. Of these, 9.1% provided basic EmOC and 2.9% provided comprehensive EmOC. The care was unequally distributed across the provinces and urban vs. rural areas; it was more available in urban areas, with the provinces of Kinshasa and Nord-Kivu being favored compared to other provinces. Caesarean section and blood transfusions were provided by health centers (6.5 and 9.0%, respectively) and health posts (2.3 and 2.3%, respectively), despite current guidelines disallowing the practice. None of the facilities provided quality EmOC, mainly due to the lack of proper standards and guidelines. CONCLUSIONS: The distribution and quality of EmOC are problematic. The lack of regulation and monitoring appears to be a key contributing factor. We recommend the Ministry of Health go beyond merely granting funds, and also ensure the establishment and monitoring of appropriate standard operating procedures for providers.

The differential effect of the free maternity services policy in Kenya.

BACKGROUND: The Government of Kenya introduced the free maternity services (FMS) policy to enable mothers deliver at a health facility and thus improve maternal health indicators. AIM: The aim of this study was to determine if there was a differential effect of the policy by region (sub-county) and by facility type (hospitals vs. primary healthcare facilities [PHCFs]). SETTING: The study was conducted in Nyamira County in western Kenya. METHODS: This was an interrupted time series study where 42 data sets (24 pre- and 18 post-intervention) were collected for each observation. Monthly data were abstracted from the District Health Information System-2, verified, keyed into and analysed by using IBM-Statistical Package for the Social Sciences (SPSS-17). RESULTS: The relative effect of the policy on facility deliveries in the county was an increase of 22.5%, significant up to the 12th month (p < 0.05). The effect of the policy on deliveries by region was highest in Nyamira North and Masaba North (p < 0.001 up to the 18th month). The effect was larger (46.5% vs. 18.3%) and lasted longer (18 months vs. 6 months) in the hospitals than in the PHCFs. The increase in hospital deliveries was most significant in Nyamira North (61%; p < 0.001). There was a medium-term effect on hospital deliveries in Borabu (up to 9 months) and an effect that started in the sixth month in Manga. The relative effect of the policy on facility deliveries in PHCFs was only significant in Nyamira North and Masaba North (p < 0.001). CONCLUSION: The effect of the FMS policy was varied by region (sub-county) and by facility type.

Medico-legal considerations on "Lotus Birth" in the Italian legislative framework.

The term "Lotus Birth" identifies the practice of not cutting the umbilical cord and of leaving the placenta attached to the newborn after its expulsion until it detaches spontaneously, which generally occurs 3-10 days after birth. The first reported cases of Lotus Birth date back to 2004 in Australia.Supporters of such a procedure claim that the newborn is better perfused, endowed with a more robust immune system and "less stressed".However, it should be pointed out that histopathological study of the placenta is increasingly being requested in order to investigate problems of an infective nature or dysmaturity affecting the foetus, and situations of risk affecting the mother. Moreover, from the legal standpoint, there is no uniform position on the question of whether the placenta belongs to the mother or to the newborn. Lastly, a proper conservation of the embryonic adnexa is very difficult and includes problems of a hygiene/health, infectivological and medico-legal nature.The authors analyzed all these aspect in the Italian legislative framework, reaching the conclusion that Lotus Birth is inadvisable from both the scientific and logical/rational points of view.

Caesarean sections in the in the context of the Chiranjeevi Yojana public private partnership program to promote institutional birth in Gujarat, India; does the embedded disincentive for caesarean section work?

BACKGROUND: The government of Gujarat, India runs a large public private partnership program to widen access to emergency obstetric care (EmOC). The program include a disincentive for Cesareans section (CS) which are capped at seven per 100 women. In this paper, we study if the disincentive works by comparing CS rates among similar groups of women who deliver within and outside the program. METHODS: Community-based panel study in three districts of Gujarat, India. SAMPLE SIZE: 2123 women. Data was analyzed using multivariable logistic regression. RESULTS: Overall seven point seven % (164/2123) of the all women in the study had a CS. After adjusting for confounding factors women within the program had 62% (AOR 0.38, 95% CI 0.22-0.44) lower odds of having a CS than to non-beneficiaries. In a separate model of predictors of CS among women giving birth only in program accredited hospitals, we found that CY program beneficiaries had lower odds of having a CS birth than non-beneficiary women (paying clients) (AOR 0.40, 95% CI 0.24-0.67). CONCLUSIONS: The Gujarat government is trying to ensure access to EmOC (including CS) for its vulnerable population through CY. The embedded disincentive to prevent unnecessary cesareans by private obstetricians is a novel one, and appears to work, though one could argue it works 'over-efficiently' by depriving some women who need CS from receiving one under the program. The state needs to revisit and review what is happening in the program periodically, and have oversight over whether women who need CS under the program actually receive the care that they need.

Kristeller maneuvers or fundal pressure and maternal/neonatal morbidity: obstetric and judicial literature review.

AIM: A significant amount of data concerning maternal-fetal damage arising from the exertion of Kristeller maneuvers (KMs) or fundal pressure (FP) go unreleased due to medicolegal implications. MATERIALS AND METHODS: For this reason, the paper gathers information as to the real magnitude of litigation related to FP-induced damages and injuries. The authors have undertaken a research in order to include general search engines (PubMed-Medline, Cochrane, Embase, Google, GyneWeb) and legal databases (De Jure, Italian database of jurisprudence daily update; Westlaw, Thomson Reuters, American ruling database and Bailii, UK Court Ruling Database). RESULTS: Results confirm said phenomenon to be more wide ranging than it appears through official channels. Several courts of law, both in the United States of America (USA) and in European Union (EU) Member States as well, have ruled against the use of the maneuver itself, assuming a stance conducive to a presumption of guilt against those doctors and healthcare providers who resorted to KMs or FP during deliveries. Given how rife FP is in mainstream obstetric practice, it is as if there were a wide gap between obstetric real-life and what official jurisprudence and healthcare institutions-sanctioned official practices are. CONCLUSION: The authors think that it would be desirable to draft specifically targeted guidelines or recommendations on maneuvers during vaginal delivery, in which to point out exactly what kinds of maneuvering techniques are to be absolutely banned and what maneuvers are to be allowed, and under what conditions their application can be considered appropriate.

An unusual traumatic delivery malpractice: a case report.

Head trauma may occur during delivery and can lead to a number of conditions. When an infant is injured during birth, the cause of injury is generally due to mechanical forces, such as compression, excessive or abnormal traction during delivery, and the use of forceps. A 39-year-old woman who was a primagravida (first pregnancy) with a gestational age of 26 weeks premature pregnancy was referred to a hospital in Tehran due to premature rupture of membranes (PROM) and fever. She arrived 2 h after rupture (noting that the rupture lasted for one week and then the baby was delivered). Antibiotics were given early on. After weak labour pain, vaginal examination revealed that the cervix was fully dilated and one of the feet of the foetus had come out of the cervix and was seen in the vagina. The foetus had died. The delivery staff used traction with force. Due to the age of the foetus, the head was relatively big and could not be delivered; the neck was thin and broken and the head separated from the body. The mother underwent a caesarean section to deliver the head of the foetus a week after PROM. The father of the dead newborn foetus sued the hospital and the staff responsible for the delivery. When medical professionals damage the trust between patients and their families and babies are injured children, they should be held accountable.

How Should Trainees Respond in Situations of Obstetric Violence?

Argentina passed a law for humanized birth in 2004 and another law against obstetric violence in 2009, both of which stipulate the rights of women to achieve respectful maternity care. Clinicians and women might still be unaware of these laws, however. In this article, we discuss the case of a fourth-year medical student who, while visiting Argentina from the United States for his obstetric rotation, witnesses an act of obstetric violence. We show that the student's situation can be understood as one of moral distress and argue that, in this specific instance, it would be appropriate for the student to intervene by providing supportive care to the patient. However, we suggest that medical schools have an obligation to better prepare students for rotations conducted abroad.

The effect of Kenya's free maternal health care policy on the utilization of health facility delivery services and maternal and neonatal mortality in public health facilities.

BACKGROUND: Kenya abolished delivery fees in all public health facilities through a presidential directive effective on June 1, 2013 with an aim of promoting health facility delivery service utilization and reducing pregnancy-related mortality in the country. This paper aims to provide a brief overview of this policy's effect on health facility delivery service utilization and maternal mortality ratio and neonatal mortality rate in Kenyan public health facilities. METHODS: A time series analysis was conducted on health facility delivery services utilization, maternal and neonatal mortality 2 years before and after the policy intervention in 77 health facilities across 14 counties in Kenya. RESULTS: A statistically significant increase in the number of facility-based deliveries was identified with no significant changes in the ratio of maternal mortality and the rate of neonatal mortality. CONCLUSION: The findings suggest that cost is a deterrent to health facility delivery service utilization in Kenya and thus free delivery services are an important strategy to promote utilization of health facility delivery services; however, there is a need to simultaneously address other factors that contribute to pregnancy-related and neonatal deaths.

Caesarean section rate and cost control effectiveness of case payment reform in the new cooperative medical scheme for delivery: evidence from Xi County, China.

BACKGROUND: In China, increases in both the caesarean section (CS) rates and delivery costs have raised questions regarding the reform of the medical insurance payment system. Case payment is useful for regulating the behaviour of health providers and for controlling the CS rates and excessive increases in medical expenses. New Cooperative Medical Scheme (NCMS) agencies in Xi County in Henan Province piloted a case payment reform (CPR) in delivery for inpatients. We aimed to observe the changes in the CS rates, compare the changes in delivery-related variables, and identify variables related to delivery costs before and after the CPR in Xi County. METHODS: Overall, 28,314 cases were selected from the Xi County NCMS agency from 2009 to 2010 and from 2014 to 2015. One-way ANOVA and chi-square tests were used to compare the distributions of CS and vaginal delivery (VD) before and after the CPR under different indicators. We applied multivariate linear regressions for the total medical cost of the VD and CS groups and total samples to identify the relationships between medical expenses and variables. RESULTS: The CS rates in Xi County increased from 26.1% to 32.5% after the CPR. The length of stay (LOS), total medical cost, and proportion of county hospitals increased in the CS and VD groups after the CPR, which had significant differences. The total medical cost in the CS and VD groups as well as the total samples was significantly influenced by inpatient age, LOS, and hospital type, and had a significant correlation with the CPR in the VD group and the total samples. CONCLUSION: The CPR might fail to control the growth of unreasonable medical expenses and regulate the behaviour of providers, which possibly resulted from the unreasonable compensation standard of case payments, prolonged LOS, and the increasing proportion of county hospitals. The NCMS should modify the case payment standard of delivery to inhibit providers' motivation to render CS services. The LOS should be controlled by implementing clinical guidelines, and a reference system should be established to guide patients in choosing reasonable hospitals.

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.