Medicolegal Issues

A survey of liability claims against obstetric providers highlights major areas of contention

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Communication breakdowns and treatment delays are frequent sources of malpractice claims

In this Article

  • Tips for reducing malpractice claims in obstetrics
  • Where are the really big malpractice awards?
  • Top 7 factors contributing topatient injury



An analysis of 882 obstetric claims closed between 2007 and 2014 highlighted 3 common allegationsby patients1:

  • a delay in the treatment of fetal distress (22%). The term “fetal distress” remains a common allegation in malpractice claims. Cases in this category most often reflected a delay or failure to act in the face of Category II or III fetal heart-rate tracings.
  • improper performance of vaginal delivery (20%). Almost half of the cases in this category involved brachial plexus injuries linked to shoulder dystocia. Patients alleged that improper maneuvers were used to resolve the dystocia. The remainder of cases in this category involved forceps and vacuum extraction deliveries.
  • improper management of pregnancy (17%). Among the allegations were a failure to test for fetal abnormalities, failure to recognize complications of pregnancy, and failure to address abnormal findings.

Together, these 3 allegations accounted for 59% of claims. Other allegations included diagnosis-related claims, delay in delivery, improper performance of operative delivery, retained foreign bodies, and improper choice of delivery method.1

Where are the really big malpractice awards?

Everything may be bigger in Texas, but New York is the biggest in at least 1 area: large medical malpractice payments. New York had more than 3 times as many $1 million-plus malpractice awards as any other state in 2014, according to data from the National Practitioner Data Bank (NPDB).1

New York physicians had 210 malpractice payments of $1 million or more reported to the NPDB last year, compared with 61 for Illinois, the next-highest state. Rounding out the top 5 were Massachusetts with 49, followed by California with 43, and New Jersey with 41, the NPDB data show.

After taking population into account, New York was still the leader with 10.66 large awards per million residents. Next in this category was the New England trio of Rhode Island, which had 9.42 such payments per 1 million population; Massachusetts (7.26); and Connecticut (6.39).

In 2014, there were 4 states that had no malpractice payments of at least $1 million reported to the NPDB: Alaska, Kansas, North Dakota, and Nebraska, with Kansas having the largest population. In states with at least one $1 million-plus malpractice payment, Texas physicians had the lowest rate per million population, 0.22—just 6 awards from a population of 27 million.

1. NPDB Research Statistics. National Practitioner Data Bank. Accessed
July 17, 2015.

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The Obstetrics Closed Claims Study findings were released earlier this spring by the Napa, California−based Doctors Company, the nation’s largest physician-owned medical malpractice insurer.1 Susan Mann, MD,a spokesperson for the company, provided expert commentary on the study at the 2015 Annual Clinical Meeting of the American College of Obstetricians and Gynecologists in San Francisco (see “Frequent sources of malpractice claims” below).

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Frequent sources of malpractice claims
Communication breakdowns and treatment delays are frequent sources of malpractice claims. Susan Mann, MD, spokesperson for The Doctors Company, the nation’s largest physician-owned medical malpractice insurer, discusses the underlying practice vulnerabilities revealed by the Obstetrics Closed Claims Study.
Dr. Mann practices obstetrics and gynecology in Brookline, Massachusetts, and at Beth Israel Deaconess Medical Center in Boston. She is president of the QualBridge Institute, a consulting firm focused on issues of quality and safety.

Top 7 factors contributing to patient injury

The Doctors Company identified specific factors that contributed to patient injury in the closed claims1:

  1. Selection and management of therapy(34%). Among the issues here were decisions involving augmentation of labor, route of delivery, and the timing of interventions. This factor also related to medications—for example, a failure to order antibiotics for Group A and Group B strep, a failure to order Rho(D) immune globulin for Rh-negative mothers, and a failure to provide magnesium sulfate for women with eclampsia.
  2. Patient-assessment issues (32%). The Doctors Company reviewers found that physicians frequently failed to consider information that was available, or overlooked abnormal findings.
  3. Technical performance (18%). This factor involved problems associated with known risks of various procedures, such as postpartum hemorrhage and brachial plexus injuries. It also included poor technique.
  4. Communication problems among providers (17%).
  5. Patient factors (16%). These factors included a failure to comply with therapy or to show up for appointments.
  6. Insufficient notes or a lack of documentation (14%).
  7. Communication problems between patient/family and provider (14%).

“Studying obstetrical medical malpractice claims sheds light on the wide array of problems that may arise during pregnancy and in labor and delivery,” the study authors conclude. “Many of these cases reflect unusual maternal or neonatal conditions that can be diagnosed only with vigilance. Examples include protein deficiencies, clotting abnormalities, placental abruptions, infections, and genetic abnormalities. More common conditions should be identified with close attention to vital signs, laboratory studies, changes to maternal and neonatal conditions, and patient complaints.”1 See “Tips for reducing malpractice claims in obstetrics” below.


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