The clinical factors behind UK’s soaring maternity liability payments

Past and Future

Yesterday I wrote about the single most important reason for the UK’s massive maternity payouts: the failure to properly investigate bad outcomes and the resulting failure to learn from them. That was the finding of a just released report, Five years of cerebral palsy claims: A thematic review of NHS Resolution data.

The author of the report proceeded to investigate the poorly investigated claims and found recurring clinical reasons for massive liability payments:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Nearly every error was a failure of omission and all involved failure to inform women of the risks of vaginal birth.[/pullquote]

The 50 claims were clinically varied but by reviewing them all together to get a national picture it was possible to identify common themes:

1) Errors with fetal heart rate monitoring
2) Breech birth
3) Inadequate quality assurances around staff competency and training
4) Patient autonomy and informed decision making

Nearly every error was a failure of omission. Nearly every error was a failure to undertake clinically indicated interventions. It’s not hard to see the impact of the Royal College of Midwives’ Campaign for Normal Birth at work here; in an effort to “achieve” vaginal birth, important warning signs were ignored and babies were grievously harmed as a result. Moreover, mothers were unable to make informed choices because they were not informed of the very real risks of vaginal births.

The most glaring errors occurred with fetal heart rate monitoring including failure to monitor, failure to properly interpret monitoring and failure to act on abnormal results.


Who made the errors?

Twenty four claims involved a midwife but only one involved a consultant.

Why did midwives repeatedly make serious errors? I suspect it is because UK midwives fundamentally misunderstand the value of fetal heart rate monitoring.

The report notes:

The most recent Cochrane review demonstrates that, compared to intermittent auscultation, continuous fetal monitoring using a CTG, is associated with a 50% reduction in neonatal seizures (RR 0.50 95% CI 0.31-0.80). However, it does not reduce the risk of developing CP and is not associated with any other benefits in fetal wellbeing. These finnings were consistent in high and low risk pregnancies and in preterm births …

Many midwives have looked at this data and concluded that fetal monitoring is worthless and therefore should be avoided or ignored. But the scientific evidence doesn’t show that fetal monitoring is worthless; it shows that continuous electronic fetal monitoring is no better than rigorously performed intermittent auscultation. Monitoring itself can provide critical information.

The other caveat about fetal monitoring is that it has a high false positive rate. That means that fetal monitoring may show an abnormal result for a normal baby, but that is not a reason to ignore abnormal results.

To put it in terms that may be easier to understand, finding a breast lump also has a high false positive rate. Most breast lumps are not cancer but that doesn’t mean that doctors should ignore breast lumps because most of them are not cancer. Some of them are cancer and it is only by investigating further and intervening (breast biopsy) that the correct determination can be made. Yes, if we wait long enough, the cancer will eventually progress and become obvious but that’s not an argument for watchful waiting.

Similarly, only some of the abnormal fetal heart rate tracings are due to fetal oxygen deprivation. Yes, if we wait long enough, the lack of oxygen will eventually become obvious by leading to fetal collapse, but that’s not an argument for watchful waiting. It’s an argument for investigating further and intervening (childbirth interventions).

UK midwives are fundamentally wrong about the value of fetal monitoring and that’s part of an even larger error: they’re fundamentally wrong about the value of vaginal birth because they confuse cause and effect.

Sure, scientific evidence shows that those who have easy, uncomplicated vaginal births fare better than those who have complicated C-section births but the C-sections don’t cause the complications; the complications cause the C-sections. Scientific evidence also shows that people who were never admitted to the ICU during their hospitalizations fare better than those admitted to the ICU, but that’s not because the ICU causes complications; it’s because people with complications are admitted to the ICU. Refusing to use childbirth interventions for those who develop complications in pregnancy is like refusing ICU admission to who develop complications during hospitalization. It’s a deadly mistake.

And that mistake is compounded by the most unforgivable clinical error identified by the report, the failure to obtain informed consent.

Evidence of a lack of informed consent was evident throughout the 50 claims reviewed.

That’s pretty damning.

An example was a woman who opted to have a vaginal birth after caesarean section (VBAC) but her initial caesarean was complicated by a difficult delivery that involved making a J-shaped incision on the uterus. This is not an absolute contraindication to VBAC but there is “insufficient evidence to support the safety for VBAC in women with previous T or J incisions” and there should have been a documented discussion by a consultant which made an individualised assessment around the suitability for VBAC and the possible increased risk of uterine rupture. The issue here is not that the woman was offered a VBAC but that she was not adequately given the information on which to make an informed decision.

In other words, the mother was not offered accurate information about the risks of vaginal birth. The same thing happened with breech births, history of shoulder dystocia and twins. There is a word for that type of behavior; the word is “paternalistic.” This paternalism is a direct violation of medical ethics.

… The practice of autonomy and patient consent revolves around the key feature of informed decision making, whereby the healthcare professional and the patient engage in dialogue about treatment options, their benefits, risks, consequences and alternatives… [T]his information must be clear, accurate, balanced without bias, take into consideration the individual patient, the nature of their condition and in a language that they understand.

Promotion of normal birth is bias pure and simple. It isn’t merely unethical; it’s a critical clinical factor behind the soaring UK maternity liability payments.

The promotion of normal birth doesn’t merely hurt babies and families. It is an extroardinarily expensive mistake.