A No-Fault Compensation System Is Crucial to Secure Obstetric Workforce and Treat High-Risk Pregnant Women
Article information
Maternal mortality is defined as the death of a woman during pregnancy, childbirth, or within 42 days of childbirth, resulting from any cause not accidental or intentional and is related to or aggravated by pregnancy or its management. According to a National Statistical Office report, there were 23 maternal deaths in 2023, with a maternal mortality ratio of 10.0 (Statistics Korea, 2025). Maternal mortality imposes significant socioeconomic burdens (White et al., 2022)
When neonatal morbidity, neonatal mortality, maternal morbidity, or maternal mortality occur, the pregnant woman's guardian may file complaints with medical intervention agencies or initiate criminal and civil lawsuits. At the same time, obstetricians may reduce their delivery work or close maternity hospitals to respond to medical litigation. Ultimately, the length of litigation and the amount of indemnity may be the main reasons why maternity medical professionals abandon delivery hospitals (Oh et al., 2012).
In particular, cases involving high amounts of indemnity, such as neonatal cerebral palsy and maternal death, are lengthy and costly, making it difficult for obstetricians to attend to delivery.
For safe childbirth, the individual health of pregnant women must be well-maintained throughout pregnancy and childbirth, and there must be a maternity hospital system capable of handling childbirth. Additionally, the national healthcare system must support these efforts.
However, when neonatal cerebral palsy and maternal death occur, the focus often shifts to emphasizing the responsibility of individual maternity hospitals and obstetricians, without adequately considering the various underlying factors. This has led obstetricians to avoid participation in childbirth and contributed to the childbirth infrastructure.
Recently, Japan and Taiwan have implemented a no-fault compensation system to maintain the availability of obstetric medical professionals and maternity infrastructure.
Therefore, I analyze foreign cases and present my opinions on the introduction of the no-fault compensation system in Korea.
INTRODUCTION TO MEDICAL LAWSUITS RELATED TO CHILDBIRTH
Medical lawsuits related to childbirth consist of factors related solely to the fetus, factors related solely to the newborn, factors related solely to the mother, and combined factors.
According to a study based on judgment reports from 2014, 200 childbirth-related lawsuits occurred between 2005 and 2010. Of these, 131 (65.5%) targeted maternity clinics and hospitals, representing the largest proportion.
There were 115 cases (57.5%) involving newborns, 30 (15 %) involving mothers, 29 (14.5%) involving pregnant women and fetuses, and 19 (9.5%) involving both pregnant women and newborns. When reclassified into newborns and pregnant women, 134 (67.0%) and 78 cases (39.0%) were related to newborns and pregnant women, respectively. When classified according to pregnancy and childbirth complications, maternal deaths accounted for 32 cases (16%) among pregnant women, neonatal deaths accounted for 79 cases (40.3%), and per-manent neonatal disabilities accounted for 56 cases (28.57%) among newborns.
Among the 69 cases in which medical negligence was acknowledged, the most common underlying condition was neonatal asphyxia (perinatal asphyxia) in 25 cases (42.37%), followed by postpartum hemorrhage in 10 cases (16.95%). The duration of childbirth-related litigation was 1,435 days. Among these, 162 (81.0%) were concluded in the first instance, 30 (15.0%) were concluded in the second, and 8 (4.0%) proceeded to the third.
The final court rulings awarded compensation in 111 cases (55.5%), with 68 cases (34.0%) partially in favor of the plaintiff and 43 cases (21.5%) resulting in a settlement recommen-dation. Plaintiffs lost in 89 (44.5%) patients.
The median claim amount in the first instance was 226,487,569 Korean won (KRW) ($164,300), with a maximum of 4,040,000,000 KRW($2,933,275). The median indemnity amount was 70,000,000 KRW ($50,805), with a maximum of 553,939,802 KRW ($402,046) (Cho, 2014).
Unfortunately, since 2014, there has been little research on medical lawsuits related to childbirth based on court rulings. We compared the results of the 2014 study with those of a study scheduled for publication in the Journal of Korean Maternal and Child Health in 2025. Although the 2025 study was limited to maternal deaths, making direct comparison with the 2014 childbirth-related study difficult, it can still serve as a reference.
According to a 2025 study on lawsuits related to maternal deaths, the average duration of litigation from maternal death to the final judgment was 1,434.3 days. In 46.2% of cases, litigation was concluded in the first instance, while 53.8% were appealed to the second instance.
In the final litigation outcome, 49.2% of the plaintiffs won, and 50.8% lost. The average claim amounts in the first instance were 480,362,152.0±300,110,198.0 KRW ($348,720±217,865), with a median of 408,321,898 KRW ($296,465). The average indemnity amount in the final judgment was 71,019,893.9±123,223,169.0 KRW ($51,564.5±89,467), and the median amount awarded was 112,861,926 KRW ($81,997). The rate of indemnity in claims was 14.8%.
When comparing the 2025 study with the 2014 study, the litigation period showed little difference; however, in 2025, the appeal rate increased, and the rate of plaintiffs' defeats also increased. Compared with the 2014 study, the median claim amount in the first instance increased by 181,834,329 KRW ($132,108), and the median awarded amount increased by 20,361,926 KRW ($14,795).
INTRODUCTION OF INTERNATIONAL CHILDBIRTH-RELATED LAWSUITS
Childbirth-related lawsuits account for a large proportion of medical lawsuits worldwide. Childbirth-related lawsuits in Japan accounted for 15.1% of all lawsuits in 2004, at 13.8 lawsuits per 100,000 live births. However, this figure decreased to 4.48 lawsuits per 100,000 live births by 2020 (Kamijo et al., 2025).
In the United States, childbirth-related lawsuits account for 14.2% of all medical lawsuits (Schaffer et al., 2017). According to a 2016 study, there were 67 lawsuits per 100,000 births in the United States (Riley et al., 2016). A 2017 study reported a total of 10,915 obstetrics-related malpractice lawsuits between 2005 and 2014. An analysis of lawsuits by medical procedures revealed that 1,754 lawsuits were related to cesarean sections, normal vaginal deliveries, and vacuum-assisted deliveries, with 672 (35.2%) resulting in compensation payments, averaging $528,337.27. The outcomes of the lawsuits were as follows: 59.5% were dismissed or withdrawn before trial, 27.7% were settled before the trial with compensation paid, and only 12.6% of the actual lawsuits proceeded to trial. Among those that proceeded to trial, 2.5% resulted in mediation or settlement, and 1.1% resulted in a plaintiff's win with compensation paid (Glaser et al., 2017).
In China, 518 lawsuits related to maternal death were filed between 2013 and 2021. Of these, 389 (75.1%) involved maternal deaths, with a median compensation of $52,502. Maternal deaths accompanied by neonatal injury accounted for 11 cases (2.1%), with a median compensation amount of $84,642. Cases in which both neonatal and maternal deaths occurred simultaneously totaled 118 (22.8%), with a median compensation of $48,128 (Shi et al., 2023).
INTRODUCTION OF DEFENSIVE MEDICINE AND NO-FAULT COMPENSATION SYSTEM
A lot of medical lawsuits have altered the way doctors practice medicine and have imposed socioeconomic burdens, prompting developed countries to raise concerns and propose solutions as early as the early 20th century.
In the United States, the U.S. Congress Office of Technology Assessment defined defensive medicine as “when doctors order tests, procedures, or visits, or avoid certain high-risk patients or procedures, because of concern about malpractice liability” (U.S. Congress Office of Technology Assessment, 1994).
Defensive medicine influences medical practice in two ways. The first is overtreatment. To avoid risks, doctors may order unnecessary tests, admissions, or consultations, ultimately leading to increased medical costs. The second is risk avoi-dance. This involves avoiding procedures or surgeries for high-risk patients, or refusing tests or treatments for patients who are likely to file a medical malpractice lawsuit. Defensive medicine is practiced by 57% of physicians in the United States (Katz, 2019), and the national costs associated with it have been studied (Mello et al., 2010).
In Japan, extreme complications in medical litigation occurred in 2006. Following the death of a pregnant woman in 2006 due to intraoperative hemorrhage associated with placenta accreta at Ono Hospital, the only obstetric hospital in the region, an obstetrician was criminally charged in 2004. As a result, 350 obstetric hospitals closed within 3 years, leading to the collapse of the regional obstetric infrastructure.
Subsequently, in 2008, a pregnant woman with cerebral hemorrhage died after being unable to find a hospital for treat-ment in Tokyo, Japan, which sparked a social issue (Kamijo et al., 2025).
To reduce defensive medicine and medical disputes that cause socioeconomic problems, the United States implemented a pretrial settlement system, whereas Japan and Taiwan intro-duced and are operating a no-fault compensation system.
In Japan, a no-fault compensation system called the Japan Obstetric Compensation System for Cerebral Palsy (JOCSC) has been operational since 2009 (Hasegawa et al., 2016). This system provides a lump-sum compensation of Japanese yen 30,000,000 ($200,000/EUR 187,500) to families of children with cerebral palsy who meet the criteria for gestational age and birth weight and are approved through individual reviews.
From January 2009 to March 2023, 5,174 claims were filed and 3,915 were compensated. This program has contributed to preventing disputes and reducing litigation risks for obstetric and gynecologists (OB/GYNs). The proportion of childbirth-related lawsuits among all medical lawsuits decreased sharply from 15.1% in 2004 to 5.2% in 2022. In addition, the number of medical lawsuits per 100 obstetricians decreased from 0.9 in 2007 to 0.4 in 2016, a statistically significant reduction (Kamijo et al., 2025). According to a 2023 study, prior to the implementation of the JOCSC, there were more than 100 medical malpractice claims annually in the field of obstetrics and gynecology. However, following the introduction of the system, the number of closed mal practice claims declined significantly—dropping to 59 cases by 2012, nearly half the preimplementation average—and had further decreased to approximately one-quarter of preimplementation level by 2020 (Taniguchi et al, 2023). This system allows out-of-court settlements for neonatal cerebral palsy in Japan, potentially preventing disputes with patients from escalating to lawsuits (Iwashita, 2017).
Taiwan has enacted and implemented a no-fault compensation system called the Childbirth Accident Emergency Relief Act. In Taiwan, 2 million dollars is paid for cases of maternal death. The time from birth to application was 123.6 days, and the time from application to final compensation payment was 230.9 days, which was shorter than that in Korea (Huang et al., 2022).
There are various reasons why OB/GYNs in Korea give up delivering babies. The most common cause, cited by 74% of respondents, is the risk of legal litigation (Oh et al., 2012). In Korea, the number of high-risk and elderly pregnant women is increasing, which raises the likelihood of medical disputes involving obstetricians (Hwang, 2024).
The introduction of a no-fault compensation system in Korea is urgently needed to establish a childbirth infrastructure and secure obstetricians. Over the past 10 years, 314 pregnant women have died in Korea, averaging 31.4 deaths per year. In a 2025 study, the average compensation amount for maternal deaths was estimated to be 71,019,893 KRW ($51,635), with the maximum annual budget related to maternal deaths estimated at 2,230,024,640 KRW ($1,621,364). This budget is considered valuable for constructing childbirth infrastructure.
With the introduction of a no-fault compensation system in Korea, I hope that obstetricians will actively participate in childbirth care, ultimately leading to safer childbirths.
Notes
The author has nothing to disclose.