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“We do not want to take risks”: Defensive medicine in maternity wards and its implications for maternal health


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Tekle Wakijira Firisa
Department of Obstetrics and Gynecology, Jimma University, Ethiopia
e-mail: tekleguda@gmail.com


Dejene Teshome Kibret
Department of Social Anthropology, Jimma University, Ethiopia
e-mail: dejenetk@gmail.com (corresponding author)


AGATHOS, Volume 15, Issue 2 (29): 431-441, DOI 10.5281/zenodo.13950372
© www.agathos-international-review.com CC BY NC 2024


Abstract: Efforts have been made to reduce high maternal mortality in Ethiopia through the expansion of health facilities, training of health professionals, and the promotion of delivery attended by skilled personnel. On the other hand, defensive medicine is one of the obstacles to ensuring maternal health. Therefore, we aimed to investigate the extent of defensive medicine, the reasons for its practice as well as its implications for maternal health in South West Ethiopia. We used mixed research and collected data from maternity wards in four public hospitals. We found that health professionals in maternity wards practice a significant degree of defensive medicine. However, the practice is difficult to detect since it is embedded in local contexts. Therefore, although commendable efforts have been made so far, maternal health and healthcare services are left with a long way to go in the study area.


Keywords: maternal health, defensive medicine, Ethiopia, maternity ward, referral system


Background

Maternal health has won the attention of policymakers and health professionals in Ethiopia mainly since the Millennium Development Goals. To this end, home delivery and traditional birth attendants have been outlawed. However, a threat to maternal health has been documented by various studies during institutional delivery. Studies from various countriesshow that defensive medicine is a common practice in maternity and labor wards. Defensive medicine involves“medical actions performed mainly to prevent being sued rather than actually to aid the patient’ (US Congress’s Office ofTechnology Assessment 1994). In other words, defensive medicine is “a doctor’s deviation from the usual behavior orthat is considered good practice, to reduce or prevent complaints or criticism by patients or their families” (Toker et al. 2004). The deviation from usual behavior occurs in this case when a doctor avoids high-risk patients or high-riskprocedures as well as when he/she orders tests, and procedures and makes visits to reduce malpractice liability. At thecore of deviation from usual behavior be it in ordering tests, diagnosis, or avoiding high-risk patients or procedures is toprotect a doctor or oneself from criticism or liability but not to primarily help a patient (Klingman et al. 1996; Ortashi et al. 2013; Zhu, Li, and Lang 2018). The practice compromises patients’ health and increases healthcare costs.

 However, a review of the literature shows that there is a dearth of studies in Ethiopia about the practice of defensive medicine in general and in maternity wards in particular. We came across a report by Biruk et al. (2015) which analysesmedical malpractice complaints between January 2011 and December 2013 and the decisions made by the HealthProfessionals Ethics Federal Committee of Ethiopia. Another report entitled “Surgical and Medical Error Claims in Ethiopia: Trends Observed from 125 Decisions Made by the Federal Ethics Committee for Health Professionals Ethics Review” was published in the Journal of Medicolegal and Bioethics in 2019 (Wamisho, Abeje Tiruneh, and Enkubahiry Teklemariam 2019). Similarly, a cross-sectional study on defensive medicine in Ethiopia was published in 2023 (Eskinder Amare Assefa et al. 2023) which focuses on surgeons in Ethiopia. The study reported the widespread practice of defensive medicine in the country and suggested the necessity for further studies. Therefore, it is essential toinvestigate this practice and its implications mainly for maternal health in Ethiopia where maternal mortality is still high (WHO 2019). Accordingly, we aimed to:

 • Investigate the extent of defensive medicine in maternity wards in public hospitals in South West Ethiopia.

 • Identify the characteristics of defensive medicine in the study area.

 • Analyze the implications of the practice for maternal health.


Methods and settings

Study area

The study was conducted in Ethiopia, a country located in East Africa. Jimma Zone1 was a specific study area. The Zone has a total of approximately 2.7m population, predominantly living in rural areas. There are 122 PHC, 562 health posts, 4 primary hospitals, 2 general hospitals, and one tertiary hospital in Jimma Zone. At each health post, 2 Health Extension Workers (HEWs) are staffed to provide preventive and some curative health care services. HEWs provide support to households within catchment areas and visit pregnant women and mothers with children.


Methods

We used a concurrent mixed research design in this study. We purposively selected seven key informants for the qualitative data while all health professionals working in the maternity and labor wards of four public hospitals inJimma Zone were respondents for quantitative data. The criteria used for inclusion in the sample for quantitative data are being a health professional in the maternity and labor wards and serving at least one year or more in any public hospital found in Jimma Zone. We observed the day-to-day activities in the maternity and laborwards, as well as conducted key informant interviews with seven health professionals using interview guides. However, we administered a survey questionnaire for the quantitative data where the response rate was 100%. We achieved a 100% response rate because we stayed at the study site collecting qualitative data. We were able to collect the datafrom a total of fifty-one respondents. Most (61%) of them are males. Around 72% (n=37) of them were B.Sc Degreegraduates while 7.84 % (n=4) were medical doctors.

 We collected the data in February and March 2020 and from September to November 2021 as part of our mega research project entitled “Anthropological Insights into Maternal Health and Health Care Services in Jimma Zone, South West Ethiopia”. The break in between was due to the Covid-19 lockdown. The other reason was the problem related to logistics.


Ethical clearance

We secured ethical clearance for this research from Jimma University before data collection. The chief clinical Director of each public hospital permitted access to research participants. The research participants also consented after they read our letter of ethical clearance from Jimma University in addition to our verbal explanations about the intent of the study.


Results

The Practice and Extent of Defensive Medicine

The health professionals reported that they order extra diagnoses and tests to increase their confidence in medicaldecisions and actions (60.78 %, n = 31), refer patients to other specialists when they believe that intervention is risky (66.67 %, n=34), and avoid high-risk procedures even if it could save the life of a patient (60.78%, n=31). Moreover, 52.94 % (n=27) believe that complaints by patients/their family members against health professionals are increasing whereas 21.57(n=11) were not sure of it. The data from key informant interviews also substantiate the practice of defensive medicine in the study area. A key informant explained:

… There are times when the health workers refer patients to Jimma University Specialized Referral Hospital to reduce the risk of bad health outcomes. However, risk-taking at times depends on the health worker's decision because some may fear to conduct surgery for fear of bad outcomes while others could conduct an operation assuming that they need to help the patient no matter what the outcome could be. So, some health workers could take risks to help a patient. However, others may refer a similar case to Jimma University Specialized Referral Hospital when they are afraid of taking risks. (Key informant Six)

The Local Context of Defensive Medicine

Although defensive medicine refers to the measures taken by health professionals to avoid being sued by patients or their caretakers, it could be practiced in different ways under different contexts. The healthcare system in our study area works by chains of referral systems where health extension workers advise patients to seek service at health centers, health centers refer patients to primary hospitals or general hospitals and these hospitals refer patients to tertiary hospitals. Ideally, this referral system intends to best treat a patient whose case is too complex to deal with at the lower chain of the referral system.

 However, the health professionals responded that they refer patients to other specialists when they believe that intervention is risky (66.67 %, n=34) and avoid high-risk procedures even if it could save the life of a patient (60.78%, n=31). However, the referral could be justified citing a shortage of blood units for transfusion or lack of electricity and backup diesel generator to conduct surgery. A key informant from one of the hospitals reported, “For example, we referred four mothers yesterday; two for cesarean section and two due to prolonged labor. All could have been delivered here. ... But we also do not want to take risks by trying to treat them in the environment where the necessary inputs are unreliable.” (Key informant One).


Why Defensive Medicine?

The health professionals reported different reasons for their practice of defensive medicine. Although the ultimate reason is their fear of harassment by the family member of a patient at best and litigation at worst, the knowledge and skill gaps as well as the unreliability of health care service inputs were also contributing to the practice of defensive medicine.


• Fear of Harassment and Litigation

About 52.94 (n=27) of the respondents believe that complaints by patients and/or their family members against health professionals are increasing. The other 23.53% (n=12) disagreed with this belief whereas 23.53 % (n=12) health professionals reported that they were not sure. Moreover, 50.98% (n=26) of the respondents indicated they faced similar complaints during their service years. Similarly, the health professionals reported that they feel they could face physical harassment by the family members of patients due to bad treatment outcomes (49.02%, n=26), and they are concerned that they may be victims of the increasing complaints against health professionals and may face lawsuits (33.33%, n=17). Moreover, 70.59% (n=36) reported that they always keep in mind the legal implications of their day-to-day activities. A key informant explains these points as follows:

… There are times when the health workers refer patients to Jimma University Specialized Referral Hospital to reduce the risk of bad health outcomes. However, risk-taking at times depends on the health worker's decision because some may fear to conduct surgery for fear of bad outcomes while others could conduct the operation assuming that they need to help the patient no matter what the outcome could be. So, some health workers could take risks to help a patient. However, others may refer a similar case to Jimma University Specialized Referral Hospital when they are afraid of taking risks. (Key informant Six)

Another key informant dissected the intricate issues surrounding defensive medicine in which he stressed the involvement of many factors in the problem of defensive medicine and individual differences in its practices. He said:

The problem with the service we provide in this hospital is the fact that it is a referral hospital. This is an end stage. We admit patients whose condition is the worst. Therefore, our intervention may not always yield positive outcomes. But this is unacceptable to the relatives of a patient. The principle of right patient-right treatments is one of the solutions to the problem. It also reduces the concern of medical doctors… A limited number of family members of patients may also insult or try to physically attack health workers. For example, we had a fistula patient whom we treated here but died. Then, her brother tried to physically attack health workers claiming that the health workers killed his sister. Despite all these challenges, however, many medical doctors are sympathetic to their patients, take risks to save the lives of their patients, and even cover the expenses of their patients when they are unable to pay. (Key informant Seven)

While the above key informant reported the experience of insult and physical attack on health workers due to undesirable treatment outcomes, another key informant reported that there are times when relatives of a patient could take the case to court. In this regard, he recounted his experience before two years as:

Occasionally, the patient’s family may take the issues to court. For instance, there was a case two years ago where the health workers made surgical interventions and blood transfusion. But there was bleeding. So, they referred the case to Jimma University Specialized Referral Hospital where the patient died. So, the husband sued the health workers in our hospital who were involved in the surgery stating the problem lies here. But the court freed the professionals of the allegations. At times securing the consent of both patients and family members may take time for surgery. This on the other hand impacts the outcome. (Key informant Six)

• The gap in knowledge and skill

58.82 (n=30) respondents confirm that they always consult senior professionals before medical intervention. Common understating among health workers about the health status of their patients and when to do what is essential in health service. This facilitates what one of our key informants calls “the right patient-right treatment” (Key informant Seven). However, we found the existence of gaps in this common understanding as well as the skills necessary to provide quality service among health workers mainly at health centers and primary hospitals. For instance, a key informant at a general hospital lamented,

… the health workers at the health centers do not have the opportunity to update themselves. They make wrong assessments of the patient when they refer to us. We tried to solve this problem through mentorship though the mentorship is not active this time… (Key informant One)

Another key informant from the other hospital substantiated the existence of this gap. He said that one may come across gaps in understanding the right time for intervention on the part of health professionals. This complicates the process of health care services including maternal health (Key informant Five). While the above key informants are from primary and general hospitals, a key informant at a specialized referral hospital shared similar concern (Key informant Seven).


• Unreliable inputs

Healthcare service requires several material inputs in addition to trained human power. However, the availability of these inputs was not reliable in our study setting. This in turn facilitated the likelihood for the practice of defensive medicine. Health professionals equate the provision of health care services where inputs are unreliable with risk-taking. For instance, electric power fluctuation was reported as one of the major reasons behind the practice of defensive medicine. The other is the shortage of blood units in case a patient needs it. A key informant stated:

There are shortages of inputs to deliver services. There is a critical shortage of electric power. The power from the main line from Ethiopian Electric Utility is erratic. We have two diesel generators: one new and the other very old to cope with this. But the new one did not function for the last one year due to a lack of spare parts in the country. …. The other one is a very old diesel generator that functions irregularly. It is not reliable for operation. Hence, we refer patients to Jimma University Specialized Referral Hospital. The doctors are reluctant to take risks due to this erratic nature of power. … The assessment for referral cases often reads ‘no electric light, no blood for transfusion, OR is not functioning’ (Key informant One).

Discussion

Defensive medicine occurs when medical practitioners follow certain procedures primarily to avoid malpractice litigation. The maternity and labor ward is among the hospital wards where health professionals practice defensive medicine. In our study, both quantitative and qualitative data reveal that a significant number of health professionals were engaged in this practice. This is concurrent with studies that indicate defensive medicine is a common practice in maternity wards (Ali et al. 2016; Zhu, Li, and Lang 2018). The factors that force health professionals to practice include fear of litigation and harassment by the family members of a patient for bad health outcomes. In this regard, our study is aligned with (Eskinder Amare Assefa et al. 2023; Ortashi et al. 2013). The respondents reported that they fear legal actions against them for bad health outcomes of their services (Key Informant One, Two, Three, Four, Five, Six, and Seven). Accordingly, 70.59% (n=36) of our respondents reported that they always keep in mind the legal implications of their day-to-day activities. Their concern is high mainly when they have low confidence in themselves about their knowledge, skill, and experience. In addition to fear of litigation, fear of harassment including physical attack by family members of a patient was found to motivate health professionals to practice defensive medicine in our study. Therefore, they avoid high-risk patients and procedures, order unnecessary tests, and refer patients to other specialists working in specialized hospitals. These practices are similar to the findings by Ortashi et al. (2013), Klingman et al. (1996), and Ali et al. (2016).

 Nevertheless, the context of the practice is different in our study. i.e., health professionals use the local referral system to practice defensive in which they justify the referral by the unavailability or unreliability of inputs. In other words, while the referral system works using the national guideline for the referral system, implicit in the referrals especially from primary and general hospitals is the practice of defensive medicine. The referrals are not only justified by the seriousness of the health condition of a patient but also by the unreliability of inputs such as electricity to conduct operations and blood units in case a patient needs transfusion. This is the most common practice that our study shows.

 However, the implications of defensive medicine for maternal health are very worrying. Our study showed that about 67% of the respondents refer patients to specialists when they think the patient is at high risk. It is one thing knowing that the patient with a risky medical condition gets the service from a more experienced person. On the contrary, the referral complicates the condition of the patient because they have to travel long distances to seek the assistance of these senior professionals who are often found in tertiary hospitals. Moreover, our study revealed that the absence or low number of maternal mortality at health centers, and primary and general hospitals does not necessarily indicate better maternal health or low maternal mortality. The Key informants stressed that since health professionals do not take risks,maternal mortality is very rare in those hospitals from where they are referred.’’(Key informants One and Three). In addition, traveling long distances due to referrals drains the resources of patients. A key informant at a general hospital confirmed that patients and their families dislike the referral system because it exposes them to more costs (Key informant Two and Three). This is congruent with the findings of Kibret and Firisa (2024).


Conclusion

Institutional delivery has been promoted in Ethiopia as one of the best mechanisms to ensure maternal health. Efforts have been made to this end by expanding health facilities, training health professionals, and outlawing traditional birth attendants, and home delivery. On the other hand, studies in different parts of the world indicate the practice of defensive medicine in maternity wards which inspired us to conduct this research. We found that there weresystematic practices of defensive medicine to a large extent that negatively affected maternal health and healthymotherhood. Therefore, although commendable efforts have been made so far, maternal health and healthcare servicesare left with a long way to go in the study area due to the practice of defensive medicine in maternity wards.


Acknowledgements: We express our gratitude to the participants of this study who were willing to share their views.


Authors’ contributions: DTK and TWF initiated the session for brainstorming, where DTK was the principal investigator and TWF was co-investigator for University Mega Research Fund 2019. On the other hand, TWF was a principal investigator and DTK was a co-investigator for the subtheme on defensive medicine. DTK collected and analyzed qualitative data whereas TWF collected and analyzed quantitative data. Both authors were involved in writing the manuscript. Both authors have also read and approvedthe manuscript.


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1 Zone is the third administrative structure next to the federal and regional government.