Medical malpractice claims are the mechanism afforded to citizens to resort to a jurisdiction or to the administrative authorities in case of feeling violated their rights in the context of a performance of a health professional. In Colombia, there are different types of medical malpractice claims: ethical, criminal, civil, administrative, and disciplinary.¹

Ethical cases are brought before courts integrated by members of the profession of the defendant in accordance with Law 23 of 1981.² Criminal and civil cases are brought before a judge. In criminal cases, there is a formal indictment by the Fiscalía General de la Nación against the physician on the grounds of a violation against a protected legal right. In civil cases, the lawsuit seeks to obtain monetary remedies from an individual or by an insurance company to cover the damage suffered by the victim. Administrative proceedings are those in which a lawsuit is brought against public healthcare institutions together with the physician directly; or where the physician is brought in as guarantor by the institution; or where the institution initiates a repetition action against the practitioner.³ Similar to civil proceedings, administrative proceedings also aim for monetary remedies but, additionally, the remedy must come from the State, because of the involvement of a public institution. Finally, disciplinary proceedings are initiated by the institution against the physician because of the breach of its functions.⁴

Medical malpractice claims have become a problem for health systems because of their increased frequency and cost, affecting all actors in the healthcare system over the past 3 decades in most countries in the world.^1,5,6 This increase in medical malpractice claims has had an impact on physicians in many ways: higher medical practice insurance cost affecting their economic productivity;⁷ impact on the physical and mental health of the prosecuted practitioner, known as the "second victim phenomenon";^8,9 and the practice of defensive medicine that results in paraclinical tests being ordered just for legal reasons, or failure to perform optional treatments for the same reason.⁷

Factors that have been associated with a higher risk of becoming involved in a lawsuit are: the medical special-ty,¹⁰ where obstetrics is described as one of the specialties with a highest risk of receiving malpractice suits^1,11-14; the type of harm caused to the patient; and poor performance, among others.¹⁵ Regarding the source of the claim, Cohen and Schifrin¹⁶ states that most claim in obstetrics are related to labor. About the care provided, delays in diagnosis and communication issues between the medical team and the patient have been reported as the most frequent claims.^17,18

Knowledge regarding the characteristics of medical malpractice claims, their causes and the consequences for the practitioner and the health system comes mainly from developed countries,^16,19,20 where Common law prevails most often and where medical liability cases converge with malpractice proceedings,²¹ similar to what happens in civil proceedings in the Colombian context. A detailed characterization of the proceedings in accordance with the particular circumstances of the local context is considered relevant so that all stakeholders (practitioners, attorneys, and decision-makers) can have a more thorough knowledge of this problem. Consequently, the objective of this study is to give a detailed description of the characteristics of obstetric medical malpractice claims in Colombia from the perspectives of physicians, patients, institutions, medical care provided, and the legal proceedings.

Overall, 1578 candidate legal proceedings were reviewed and, of those, 982 met the inclusion criteria. Among these, 907 favorable cases and 75 unfavorable cases (7.7%) were identified. Of the initial sample of 279 cases, 56 did not meet the criteria and were replaced (Fig. 1).

Figure 1 Source: Authors.

The most frequent legal proceedings were ethical (44.4%) and criminal (36.6%). Legal proceedings were more frequent in intermediate cities (47.1%) and in private institutions (60.1%). In 77 cases (27.6%), there was involvement of more than 1 obstetrician. In 12.1% of the cases, association was found with a different lawsuit against the same obstetrician, more frequently ethical cases associated with criminal cases. Male sex was predominant (76%). Median age of male obstetricians at the time of the clinical event was 42 years (IQR: 28-64, minimum 23 years, maximum 72); and the median age of female obstetricians was 37 (IQR: 30-52, minimum 25 years, maximum 60). Among obstetricians, 42.4% had more than 1 lawsuit due to clinical events affecting other patients; 40.3% for female obstetricians, and 43.2% for male obstetricians (Tables 1 and 2).

Table 1

Characteristics	Total cohort n (%)	Male obstetricians (n = 212)	Female obstetricians (n=67)
Of the procedures (n = 279)
Duration of the legal proceeding (IQR) years	3.0 (1.5-5.0)	3.0 (2.0-5.0)	3.0 (1.5-1.0)
Type of case
Ethics	124 (44.4)	89 (42.0)	35 (52.2)
Criminal	102 (36.6)	85 (40.1)	17 (25.4)
Civil	22 (7.9)	15 (7.1)	7 (10.5)
Administrative	19 (6.8)	15 (7.1)	4 (6.0)
Disciplinary	12 (4.3)	8 (3.8)	4 (6.0)
Plaintiff
Patient	151 (55.9)	108 (52.7)	43 (66.2)
Partner	65 (24.0)	53 (25.9)	12 (18.5)
Relative	25 (9.3)	22 (10.7)	3 (4.6)
Official	27 (10.1)	21 (10.2)	6 (9.2)
More than 1 obstetrician involved	77 (27.6)	57 (26.9)	20 (29.9)
Institution (n = 278)
Location
Big city	119 (42.8)	84 (39.8)	35 (52.2)
Intermediate city	131 (47.1)	102 (48.3)	29 (43.3)
Rural township	28 (10.1)	3 (4.5)	25 (11.9)
Type of institution (private)	167 (60.1)	128 (60.7)	39 (58.3)
Obstetrician (n=279)
Obstetrician age Median (IQR) years	41 (36-8)	42 (28-64)	37 (30-52)

S.C.A.R.E. = Sociedad Colombiana de Anestesiología y Reanimación. IQR=Interquartile Range.

Table 2

	Ethics (n = 124)	Criminal (n = 102)	Civil (n = 22)	Administrative/disciplinary (n = 31)
Characteristic	n (%)	n (%)	n (%)	n (%)
Unfavorable judicial decision	9 (7.3)	2 (1.9)	7 (31.8)	3 (9.6)
Location
Big city	57 (46.0)	40 (39.2)	12 (54.5)	10 (32.3)
Intermediate city	52 (41.9)	53 (52.0)	10 (45.5)	16 (51.6)
Type of institution (public)	51 (41.1)	35 (34.3)	2 (9.1)	23 (74.2)
Duration Median (IQR) years	2.6 (1.5-4.0)	4.0 (2.0-6.0)	3.5 (1.5-4.0)	4.0 (2.0-7.0)
Falls under the statute of limitations	37 (29.8)	61 (59.8)	0 (0)	0(0)
Compensation	0 (0.0)	2 (2.0)	8 (36.4)	4 (12.9)
More than 1 gynecologist involved	35 (28.2)	22 (21.6)	7 (31.8)	13 (41.9)
Regime (contributive)	72 (58.1)	63 (61.8)	17 (77.3)	13 (41.9)

S.C.A.R.E. = Sociedad Colombiana de Anestesiología y Reanimación.

The present study found a 7.7% frequency of unfavorable judicial decisions for the obstetrics specialty. The findings highlight that the most frequent actions filed in Colombia are of an ethical nature, followed by criminal actions. The highest proportion of unfavorable judicial decisions was found in civil proceedings. Legal proceedings were brought more frequently against private institutions, and the most frequent cause of the claims is neonatal compromise. Finally, the majority of the lawsuits are associated with patients in the third trimester with no risk factors or comorbidities.

The proportion of ethical cases found in our study (44%) was higher than the 20% described by López Ordoñez et al¹ in cases related to all the specialties. These data emphasize a slow increase in the proportion of ethical cases over the past 2 decades.

In the Common law system, the percentage of unfavorable judicial decision ranges between 25% and 60%,^19,20,23 similar to our findings for civil proceedings (31.8%), the only type of action comparable with the common law system.

The high frequency of legal actions against private institutions and patients affiliated to the contributive regime suggest that lawsuits are mainly filed by patients of a higher income level. This is so because of the relationship between the contributive regime and higher socioeconomic brackets;²⁴ this in turn could be related to a higher degree of empowerment in terms of health rights and a higher degree of dissatisfaction when medical care leads to unfavorable judicial decision.⁷

Our results showing 74.7% of lawsuits related to care during childbirth are consistent with the postulate by Cohen and Schifrin¹⁶ who state that the majority of legal actions in obstetrics are directly or indirectly related to care during childbirth and report, for the United States, 60% of lawsuits associated with delivery care. Other authors like Gomez-Duran et al²³ report a similar percentage (53.5%) for Spain.

Along the same lines, our study found a high frequency of lawsuits involving fetal (24.7%) or neonatal (38.9%) compromise, similar to what was reported by authors like Hale¹³, who describes that the 3 primary causes of lawsuits in obstetrics in the United States are neonatal injuries: neurological damage, death, and other types of injuries; and Domingues et al²⁵ who reports that the 2 primary causes of obstetric lawsuits in Portugal are perinatal asphyxia and traumatic injuries to the neonate.

The limitations of the study relate to the quality of the information considering that data were collected retrospectively, and considering also that 16% of data had to be replaced in the sampling because of quality issues, which could have resulted in a selection bias. However, when comparing the results for gender and unfavorable judicial decisions in the total cohort in relation to the sample, the deviation was minimal (77% of male obstetricians in the cohort versus 76% in the sample); and the proportion of unfavorable judicial decisions between the cohort and the sample was also equal (7%). Additionally, the observer was not blinded to the favorable or unfavorable judicial decisions of the case, which could have created a measurement bias.

Strengths of the study include the high number of cases included in the cohort, which were reviewed in detail, long-term follow-up to the cases, and the geographic heterogeneity of the cases coming from all the regions of the country.

For the obstetrics specialty, the frequency of unfavorable judicial decisions is 7.7%. Ethical lawsuits are the most frequent, and unfavorable judicial decisions are most frequent in civil proceedings. Legal claims are brought most frequently against private institutions. Lawsuits occur mainly in association with patients in the third trimester of gestation who have no risk factors or comorbidities. Care during childbirth, and fetal and neonatal mortality are critical areas in medical malpractice claims, and they should be the focus of future research into care deficiencies and interventions aimed at minimizing the impact of legal action on the practitioners and the health system.

Protection of human and animal subjects. The authors declare that no experiments were performed on humans or animals for this study.

Confidentiality of data. The authors declare that they have followed the protocols of their work center on the publication of patient data.

Right to privacy and informed consent. The authors declare that no patient data appear in this article.