Better care costs less
: a system-based approach in maternity

  • Christopher Yau

Student thesis: Doctoral ThesisDoctor of Philosophy (PhD)


Escalating maternity litigation costs threaten the stability of any health system and are unsustainable. Improving patient care and reducing preventable harm during childbirth remain crucial in overcoming this litigation crisis. In order to make the widespread improvements in obstetric care required to alleviate this litigation burden, a system- based approach, acknowledging all levels (micro, meso and macro) of a health system, may be needed.
This thesis explores the use of a system-based approach to improve maternity care and tackle the increasing cost of litigation in obstetrics. Chapter 1 provides a general introduction to the thesis.
Part 1 of the thesis adopts a ‘bottom-up’ approach and focusses on the health economics of multi-professional simulation training for obstetric emergencies. Chapter 2 demonstrates that adults with obstetric brachial plexus injuries (OBPIs) and caregivers of children with permanent OBPIs have a worse quality of life compared to the general population. Chapter 3 highlights the cost of a multi-professional simulation training programme for obstetric emergencies. Chapter 4 investigates the cost-utility of simulation training for obstetric emergencies with particular regard to its impact on reducing OBPIs. This study demonstrates that national implementation of multi- professional obstetric training can be both cost-effective and cost-saving.
Part 2 of the thesis uses a ‘top-down’ approach and focusses on the role of the state- based medical indemnifier (MI) in influencing and improving patient care. Chapter 5 explores how MIs engage with clinical staff and offers some recommendations for how they could have a more effective role in patient safety. Chapter 6 demonstrates that obstetric simulation training is associated with a reduction in the maternity claim rate and mean monthly litigation cost. Chapter 7 identifies the rate of low 5-minute Apgar scores as a predictor of future litigation. Finally, Chapter 8 provides an overall summary of the thesis and its key messages.
Date of Award28 Nov 2019
Original languageEnglish
Awarding Institution
  • The University of Bristol
SupervisorErik Lenguerrand (Supervisor), Timothy J Draycott (Supervisor) & Elena Pizzo (Supervisor)

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