Professor Shin Ushiro is Executive Board Member – Japan Council for Quality Health Care (JQ) and Deputy Director and Professor of Patient Safety – Kyushu University Hospital.
Shortage of maternal care professionals and launch of no-fault compensation system
As outlined in my previous blog, the Japan Council for Quality Health Care (JQ) has been delivering patient safety knowledge and expertise through a nationwide adverse event reporting and learning system since 2004. However, frankly speaking, the system is not effective in accounting for individual events and mitigating conflict.
Cerebral palsy is the name for a group of lifelong conditions that affect movement and co-ordination. It's caused by a problem with the brain that develops before, during or soon after birth. It often happens during or in relation to childbirth due to deprivation of oxygen in the foetus. It had been said that cerebral palsy is inevitable to a significant extent regardless of careful observation, improvement of procedures and introduction of new technology.
Nevertheless, lawsuits related to cerebral palsy soared more than decades ago in my country and it significantly accounted for the reason that obstetricians left their jobs and for medical students who did not want to be an expert of obstetrics. Therefore, under political leadership, a framework was published in 2018 for a new system including monetary compensation that runs on a no-fault basis. This allows swift payment regardless of negligence, investigation, and prevention.
The JQ was nominated by stakeholders as the body to run the new system and successfully launched along with the framework the Japan Obstetric Compensation System for Cerebral Palsy in 2009.
The system was planned and initiated at speed to mitigate deterioration of the maternal and neonatal healthcare delivery system, so no new legislation was prepared. However, nearly 100% of childbirth facilities enrolled in the system at its inception in close co-operation with professional bodies, academic bodies and the government.
Patient and family engagement
I would like to share one of the important features that made the system sustainable and successful – the JQ has been working with patients and family groups as one of the key stakeholders.
During the introductory process in 2019 and 2020, patient/family representatives who were members of the introductory committee diligently requested for investigation and prevention in addition to compensation. They strongly opposed in the discussion that the system only provides no-fault compensation because they believed that only providing money does not improve quality in maternal care.
On the other hand, there was a small number of obstetricians and defendant lawyers who claimed that the system could encourage and help patients and families to sue more obstetricians. This could lead to a further decrease in the number of obstetricians.
Patient/family representatives opposed this view, stating that they had no other way but to sue doctors to be well informed of their childbirth, particularly to find the cause of profound cerebral palsy. They believed the new system could meet their demands, mitigate conflict which they did not want to be involved in and lead to safer maternal and neonatal care.
Now after 15 years of experience running the system, we proudly say that the number of lawsuits related to obstetrics and gynaecology rapidly plunged according to the statistics of the Supreme Court of Japan.
Eligibility review, investigation and prevention
The system has so far approved more than 4,200 petitions i.e. profound cerebral palsy, published nearly 4,000 investigative reports and 14 annual reports for prevention.
Reduction in harm, namely, reduction in the number of profound cerebral palsy cases is a goal shared by medical professionals and patient/family representatives. We knew that there was poor quality care that caused profound cerebral palsy when we looked at individual cases, while scientific evidence stated that cerebral palsy is difficult to diminish no matter how carefully medical professionals engage in maternal and neonatal care, due to probable congenital causes such as genetic abnormality.
What we have seen is that profound cerebral palsy which is eligible for compensation in the system has rapidly decreased, particularly during the initial years after the introduction of the system. It’s currently decreasing along with the decrease in the birth rate.
I believe the reduction of harm was achieved by quality improvement in care during delivery because a comparison study, with investigation reports at two different time points during the year, revealed that specific procedures such as fetal heart rate monitoring and interpretation, dose of administered oxytocin (i.e. uterine contracting agent) and swift neonatal resuscitation improved with less frequent comments for improvement.
An annual report for prevention circulated among scientific and professional bodies and data from the report were cited by clinical guidelines on maternal and neonatal care. As it was made possible to collect a large number of fetal heart rate monitoring records (Cardiotocogram: CTG) in the system, the experts in prevention committee produced an educational material on fetal heart rate monitoring. Another book on CTG was published in 2024 including 13 educational cases with more detailed comments cited from relevant investigative reports. It is, accordingly, notable that the JQ’s system has a scientific aspect that draws the attention of clinical researchers as well as an aspect on addressing issues that emerged in our society.
Novel system and conventional court system
The Supreme Court of Japan once touted the no-fault compensation system in a report on accelerating litigation and anticipated expansion of the system to cover more medical specialties:
“It is noteworthy that the Japan Obstetric Compensation System for Cerebral Palsy has brought investigative system by a third party and system of equally imposing financial burden for monetary compensation in our society sharing the notion that perinatal care inherently holds potential risk…It is concerned whether the system expands to cover other medical specialties…The system having approved significant number of CP cases supposedly has affected to a certain extent statistics of lawsuit of medicine.”
Japan learned from devastating medical accidents which took place around 2000 and spurred distrust in patient safety in healthcare. According to national policy and subsequent legislation and amendment of regulations, national reporting and learning system, the no-fault scheme for cerebral palsy was launched by JQ, a neutral body in healthcare. Products of the initiatives are widely accepted among healthcare professionals and litigation related to obstetrics and gynaecology has been mitigated. These systems work as infrastructures to maintain quality and safety in healthcare.
