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.

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.

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.

Indenizações em obstetrícia: estudo das decisões do superior tribunal de justiça do Brasil de 2004 a 2014 / Indemnities in obstetrics: A study of the decisions of the Court of Justice of Brazil 2004-2014

Este artigo tem por objetivo identificar, nas decisões do Superior Tribunal de Justiça (STJ), as principais causas dos danos decorrentes da prática médica obstétrica no momento do parto. O estudo analisou 21 decisões julgadas pela corte entre 2004 e 2014 relacionadas a indenizações judiciais na obstetrícia. O critério de seleção dos casos utilizou como método a busca de decisões no site do STJ, cujos descritores foram: "parto", "erro médico"; "médico"; "paciente"; "profissional da saúde"; "dano moral"; "dano material"; "SUS"; "responsabilidade civil" e "indenização por erro médico". O Rio de Janeiro foi o estado com maior número de ações indenizatórias (28,6%) apreciadas pelo STJ, seguido de São Paulo e Minas Gerais, com 14,3% cada um. No tocante aos réus que figuraram no polo passivo das demandas, 38,1% eram médicos e hospitais. Verificou-se que 71% das supostas falhas médicas que originaram as ações ocorreram durante a realização do parto natural, contra 29% dos casos de cesariana. A principal causa dos danos relatados foi a demora na realização do parto, seguida dos traumatismos. Apesar de pesquisas demonstrarem que a cesariana oferece maiores riscos para a parturiente e o feto, os resultados obtidos das decisões judiciais analisadas pelo STJ evidenciaram que os danos que resultaram sequelas irreversíveis no nascituro foram recorrentes nos casos relacionados ao parto natural, sugerindo que atenção especial deve ser dada à formação médica obstétrica, bem como à compreensão dos aspectos socioculturais envolvendo a indicação e a escolha pelo tipo de parto.

This article intends to identify the main reasons of damage caused by obstetric medical practice during childbirth, on the decisions of the Supreme Court of Justice of Brazil. The study analyzed 21 decisions judged between 2004 and 2014 related to legal compensations concerning obstetrics. The criteria for the selection of cases was to search the Supreme Court's website, for decisions containing descriptors such as: "birth", "medical error"; "doctor"; "patient"; "health professional"; "moral damage"; "property damage"; "SUS"; "Liability" and "compensation for medical error". Rio de Janeiro was the state with the largest number of compensation claims (28.6%) appreciated by the court, followed by São Paulo and Minas Gerais with 14.3%. Among the defendants listed on the demands, 38.1% were doctors and hospitals. It was found that 71% of the alleged malpractices that led to these actions occurred during vaginal delivery and 29% of cases correspond to caesarean section. The main cause of damages reported was the delays in performing delivery, followed by trauma. Although research has shown that the cesarean section poses greater risks to the woman and the fetus, the results obtained from the decisions analyzed by the court showed that damages resulting in irreversible sequelae in unborn children were recurrent in natural birth related cases, suggesting that special attention should be given to obstetric medical training as well as to the understanding of the sociocultural aspects that surround medical indication and choice of the type of childbirth method

Is the policy of allowing a female labor companion feasible in developing countries? Results from a cross sectional study among Sri Lankan practitioners.

BACKGROUND: Companionship during labor is known to have both physical and psychosocial benefits to mother and baby. Sri Lanka made a policy decision to allow a labour companion in 2011. However, implementation has been unsatisfactory. Given the leading role Obstetricians play in the implementation of policy, a study was undertaken to assess the knowledge, attitudes and practices among them. METHOD: A descriptive cross sectional study was conducted among consultant obstetricians working in the state hospitals using the platform 'Survey Monkey'. RESULTS: Out of the 140 consultant obstetricians invited, 68(48.5%) participated. Among the study participants, 40 (58.8%) did not allow labour companions in their wards. Lack of space (n = 32; 80%) and the volume of work in the labor wards (n = 22; 55%) were the commonest reasons for not allowing a companion. Only 16.7% (n = 5) of the obstetricians handling more than 300 deliveries per month allowed a companion (p = 0.001). Less than 50% of the obstetricians were aware of the advantages associated with the practice such as shorter labor, lesser analgesic requirement, higher chances of a normal birth, improved neonatal outcome and reduced requirements for labor augmentation for slow progress of labor. Knowledge on advantages on breast feeding and reduced need of instrumental delivery also remained low. CONCLUSION: In an individual unit, the consultant often decides policy. The study points out the need to improve awareness among the practitioners.

Lessons from the MOHW compensation pilot program on birth incidents: First step and looking forward.

OBJECTIVE: In Taiwan, the number of medical disputes and litigation has increased dramatically over the past 20 years. The seriousness of medical disputes continuing grows in clinical practice, especially in obstetricians. This study provided a possible solution to the medical dispute litigation issue. MATERIALS AND METHODS: The Ministry of Health and Welfare (MOHW) compensation program for birth incidents has been implemented since 2012 and it provided pecuniary compensation for mothers, newborns, and fetuses who got injured or died in birth-related medical incidents. We analyzed the amount and distribution of compensation, and assessed the effect of compensation on the number of medical dispute litigation. RESULTS: From 2012 to 2015, a total of 348 applications was received, 322 of which were examined by the committee. Among the examined cases, 278 were approved for compensation. The total amount of compensation had reached 266.16 million NTD (8.32 million USD). For the medical dispute litigation, a dramatic decrease in number was observed after the implementation of this compensation pilot program. CONCLUSION: Prompt compensation provided instant economic and spiritual support for patients and families. Pecuniary compensation could be an alternative choice of justice, which might encourage the injured to receive economic compensation, instead of filing a lawsuit against the physician or hospital institution. As a result, the number of dispute litigation has decreased. This indicates that the compensation program is an efficient way to improve medical dispute litigation difficulties.

What Is New in Medical-Legal Issues in Obstetrics and Gynecology?: Best Articles From the Past 2 Years.

This month we focus on current research in medical-legal issues in obstetrics and gynecology. Dr. Shwayder discusses four recent publications, which are concluded with a "bottom line" that is the take-home message. The complete reference for each can be found in Box 1 on this page, along with direct links to the abstracts.

US and territory telemedicine policies: identifying gaps in perinatal care.

BACKGROUND: Perinatal regionalization is a system of maternal and neonatal risk-appropriate health care delivery in which resources are ideally allocated for mothers and newborns during pregnancy, labor and delivery, and postpartum, in order to deliver appropriate care. Typically, perinatal risk-appropriate care is provided in-person, but with the advancement of technologies, the opportunity to provide care remotely has emerged. Telemedicine provides distance-based care to patients by consultation, diagnosis, and treatment in rural or remote US jurisdictions (states and territories). OBJECTIVE: We sought to summarize the telemedicine policies of states and territories and assess if maternal and neonatal risk-appropriate care is specified. STUDY DESIGN: We conducted a 2014 systematic World Wide Web-based review of publicly available rules, statutes, regulations, laws, planning documents, and program descriptions among US jurisdictions (N = 59) on telemedicine care. Policies including language on the topics of consultation, diagnosis, or treatment, and those specific to maternal and neonatal risk-appropriate care were categorized for analysis. RESULTS: Overall, 36 jurisdictions (32 states; 3 territories; and District of Columbia) (61%) had telemedicine policies with language referencing consultation, diagnosis, or treatment; 29 (49%) referenced consultation, 30 (51%) referenced diagnosis, and 35 (59%) referenced treatment. In all, 26 jurisdictions (22 states; 3 territories; and District of Columbia) (44%), referenced all topics. Only 3 jurisdictions (3 states; 0 territories) (5%), had policy language specifically addressing perinatal care. CONCLUSION: The majority of states have published telemedicine policies, but few specify policy language for perinatal risk-appropriate care. By ensuring that language specific to the perinatal population is included in telemedicine policies, access to maternal and neonatal care can be increased in rural, remote, and resource-challenged jurisdictions.

[Closed claims in obstetrics: A study based on French Sham insurance data]. / Sinistralité en obstétrique dans les hôpitaux publics français: données Sham.

OBJECTIVE: The aim of this study was to analyze the medicolegal claims related to obstetrics in French hospitals. MATERIAL AND METHODS: We did retrospective study on insurance claims provided by Sham insurances and which has been settled by a court over a 3-year period (2004-2006). RESULTS: We analyzed 66 closed claims that occurred between 1983 and 2005 in French hospitals (54 general hospitals and 12 academic). The average time between the declaration of the claim and the court conviction was 6 years. The average amount of compensation per claim was 500,000 €. The damage occurred during vaginal delivery (n=44), planned (n=5) or unplanned (n=4) cesarean. The more often claims are fetal asphyxia (n=24) or shoulder dystocia (n=8). The consequences are very important: cerebral palsy (16), death of the newborn (12), death of the mother (2) or brachial plexus injuries (6). CONCLUSION: The causes identified by the expert are always multifactorial with generally a misdiagnosis (n=27), a decision making error (n=36), a care error by the midwife (n=21) and/or a delay in medical care (n=13). These data should help strengthen the quality approach in obstetrics.

What Is New in Ethical Issues in Obstetrics?: Best Articles From the Past Year.

This month we focus on ethical issues in obstetrics. Dr. Burda discusses four recent publications, which are concluded with a "bottom line" that is the take-home message. The complete reference for each can be found in on this page, along with direct links to the abstracts.