R1m bill: No one left to deliver our babies?

Cape Town - Would you continue to do your job if you had to pay R1m per year in insurance to cover you against legal claims? Most people wouldn't.

That’s the reason why the doctors who deliver babies are leaving the profession in droves. Or choosing not to enter it in the first place. Over 140 000 babies per year are delivered in South Africa, and if things continue as they are, the full burden of this will fall on the state hospitals within four years.

The increasing cost of insurance against medical malpractice suits has spiralled in the last few years, according to Health Minister Aaron Motsoaledi, who in 2015 commented on the problem. He stated that in the eight years between 2005 and 2013, the cost of indemnity insurance for private specialists in obstetrics (these are the doctors who actually deliver babies) had gone up by 382%.

R250 000 vs R850 000

The actual amount obstetricians have to cough up on an annual basis has, in the last four years, gone up from R250 000 to R850 000, according to Johannes van Waart, president of the South African Society of Obstetricians and Gynaecologists (SASOG). He added that medical fund tariffs usually increase by about 6% per year, a situation which is clearly untenable for obstetricians.

Most South African obstetricians have indemnity cover through the UK-based organisation, Medical Protection Society (MPS), which is registered as a non-profit organisation. It provides cover to obstetricians worldwide, but mostly in Commonwealth countries. Unlike most insurance companies, they are not run for profit, but they have experienced a sharp increase in the number of claims made against their members in recent years. Hence the sharp increase in their premiums.

The insurance is usually paid in 10 monthly instalments, according to the MPS, who states that they do not take debit payments in the first and the last months of the membership year. So to an SA obstetrician that would mean 10 instalments of R85 000 each. Medical schemes pay only a portion of delivery costs, most of which is eaten up by insurance instalments the doctors have to pay. It just simply no longer pays to be an obstetrician in private practice.

Why are obstetric claims so high?

While obstetric claims are not the only high ones in the medical profession, they do often seem to top the list.

If a child suffers damage or injury during birth as a result of negligent conduct by an obstetrician, parents can file a claim for medical costs, compensation for pain and suffering, and for the full costs of caring for the injured or disabled baby for the duration of his/her life. This can obviously run into millions of rand.

Some of these claims (according to the website of Thomson, Snell & Passmore, a UK-based legal firm well-versed in obstetrics claims) can include mismanagement of a high-risk pregnancy, misinterpretation of scans during pregnancy and labour, inappropriate management of labour or delivery, inappropriate methods of delivery and birth injuries, to name but a few.

Specific medical specialties are targeted for litigation, according to Motsoaledi. These include gynaecology, neurosurgery, neonatology (newborn babies) and orthopaedics. He also stated that lawyers were often motivated by the ‘pocket-lining phenomenon’ and not for the love of the patients. Many lawyers who take on these cases do it on a no-win no-fee basis, which means that a large percentage of the payout, if there is one, lands up in the pocket of the lawyers, and not in the pocket of the patient/patient’s parents, in the case of a baby.

Most of the claims against obstetricians are due to babies born with Cerebral Palsy (CP), said Van Waart. He stresses, however, that fewer than 15% of CP cases are caused by delivery problems. Experts do not really understand the pathophysiology (causes) of CP – and neither do the courts, he added. But sometimes they nevertheless ‘settle’ these cases for millions, and the obstetricians and their insurers end up having to foot the bill.

Nobody to deliver the babies

In many towns, such as Worcester, there are now no private obstetricians left. The high cost of indemnity insurance discourages young doctors to choose obstetrics as a career, explained Motsoaledi.

With fewer and fewer obstetricians in private practice, women are forced to deliver their babies in provincial facilities, shifting the workload and the liability onto the state, according to Graham Howarth in the South African Medical Journal (Vol 103, No 8, 2013). He mentions that this would increase the burden of child deliveries in state facilities by 10.6%.

Private obstetricians will be something of the past if this rising indemnity insurance trend continues, according to Van Waart. SASOG met with the minister of health in November 2016 to discuss this crisis.

The society predicts that if present trends continue with 50 – 100 obstetricians leaving the profession annually because of high insurance costs, by the year 2020, there will be no obstetricians in private practice in South Africa.

This also affects the state, and a huge amount (one-third) of the national health budget is taken up by the paying out of legal claims. Of the R49bn worth of claims pending against the state, 70% are in the field of Obstetrics, according to a SASOG report.

Motsoaledi suggested in November 2016 that payout claims should be capped in an effort to save the obstetrics profession. Further suggestions from SASOG to remedy this crisis situation include the structuring of payouts, rather than a lump sum, making lawyers foot the bill if doctors are found not to have been negligent, and going through a mediation process rather than a court case.

Mediation rather than litigation can cut costs by 40 – 50%, said van Waart.

An added problem for the state is that young doctors working in far-off rural areas are often faced with difficult deliveries or Caesarean sections without senior help or supervision. This exposes them to lawsuits.

The crisis in the field of private obstetrics is by no means limited to South Africa, as obstetricians in the US, UK and Australia face similar obstacles. It must be remembered, however, that if there has been negligence, claims are justified. But for many obstetricians it has simply become more than the job is worth.

(Sources: South African Society of Obstetricians and Gynaecologists, South African Medical Journal, Thomson, Snell and Passmore (UK lawyers), South African Health Department, Medical Protection Society)