Characteristics and risk factors for medical malpractice among obstetric and gynecologic physicians in China.

In China, malpractice evaluations are commonly conducted by medical associations through a structured hierarchy. Requests may be submitted by patients, physicians, courts, administrative authorities, or mediation bodies. Evaluations are typically handled at the municipal level and may be escalated to provincial or national associations based on case complexity. Clients who are dissatisfied with the conclusion of an appraisal can request a reappraisal from higher-level medical associations or pursue litigation. CMA, the leading medical association in China, collects most medical malpractice reports, with the exception of those submitted to the military and judicial systems. This study analyzed all medical malpractice reports received by the CMA from January 2016 to December 2023. The inclusion criteria were claims related to incidents that occurred in China and directly involved physicians practicing obstetrics and gynecology. The appraisal process adhered to Chinese regulations, including “ The Regulation on the Handling of Medical Accidents ” [ 14 ], “ Interim Procedures for Technical Appraisal for Medical Negligence ” [ 15 ], and “ The Regulation on the Prevention and Handling of Medical Disputes ” [ 16 ]. The severity of malpractice-related disability was assessed according to the “ Medical Malpractice Classification Standards (Trial) ” [ 17 ], with death classified as the most severe outcome. Nonfatal malpractice was categorized as either disability or non-disability. The term “disability” refers to patient injuries resulting in lasting physical or functional impairments. Based on national forensic standards, disabilities are graded into ten levels. Levels 1 through 5 indicate severe injuries, including complete or substantial loss of body function, disfigurement, or total loss of sensory or organ function, which pose significant threats to patients’ overall health. Levels 6 through 10 represent minor injuries, such as partial impairments in physical appearance, organ function, vision, or hearing, which result in moderate but not life-threatening harm. The severity of liability was determined on the basis of the “ Interim Procedures for Technical Appraisal for Medical Negligence ” [ 15 ] and the “ Tort Liability Law of the People’s Republic of China ” [ 18 ]. The liability of involved medical parties was classified into six levels: complete, major, equal, minor, mild or none. Complete and major liability were regarded as primary liability. All reports were reviewed in detail. The hospitals and clinics involved were classified as public or private, and general or specialized, and further categorized into primary, secondary, or tertiary hospitals. In China, public hospitals dominate the healthcare system and are generally larger, better funded, and more reputable. They are financed by the government and provide care for the majority of the population, especially those with complex or severe conditions. Private hospitals, in contrast, are typically smaller and funded by private enterprises or individuals. They may be either for-profit or non-profit and receive less government support. Both public and qualified private hospitals may be contracted with public health insurance programs and are reimbursed through a fee-for-service model, combining insurance payments and out-of-pocket expenses [ 19 ]. However, private hospitals often serve patients with milder conditions or those seeking quicker or more personalized care. Hospitals were categorized as either general or specialized based on their service scope. General hospitals provide OB/GYN services as part of broader multidisciplinary care, while specialized hospitals focused exclusively on obstetrics and gynecology. China’s healthcare system follows a Three-Tier Health Care Delivery System. Tier 1 institutions (primary hospitals) provide basic public health services and health education. Tier 2 facilities (secondary hospitals) offer primary care, chronic disease management, and rehabilitation. Tier 3 hospitals (tertiary hospitals) deliver specialized inpatient services and are responsible for medical education and research [ 20 ]. The incidents were categorized as related to either obstetric practice (including abortion, labor, neonatal conditions, and puerperium conditions) or gynecologic practice (including conditions involving the female reproductive system outside of pregnancy, such as benign and malignant tumors, pelvic inflammatory disease, endometriosis, and surgical procedures such as hysterectomy and laparoscopy). Malpractice incidents were divided into two categories with 14 subcategories. Cases could involve both technical and nontechnical errors; however, within each category, cases were labeled with the most severe outcome resulting from the incident. Technical errors included the following subcategories: Diagnostic errors (misdiagnosis); Insufficient evaluation; Observation or monitoring errors (insufficient monitoring of the patient’s condition); Errors in timing or indication for surgery/procedure or inadequate preparation; Errors in surgical/procedural process; Errors in timing or indication for medication; Errors in medication plan or dosage. Diagnostic errors (misdiagnosis); Insufficient evaluation; Observation or monitoring errors (insufficient monitoring of the patient’s condition); Errors in timing or indication for surgery/procedure or inadequate preparation; Errors in surgical/procedural process; Errors in timing or indication for medication; Errors in medication plan or dosage. Nontechnical or administrative errors included the following subcategories: Issues with hospital or healthcare personnel credentials; Errors in medical record documentation and management; Deficiencies in regulations for ward rounds; Errors in surgical verification procedures; Errors in nursing verification procedures; Deficiencies in multidisciplinary consultation, referral, or transfer regulations; Inadequate informed consent or delayed signing; Issues with hospital or healthcare personnel credentials; Errors in medical record documentation and management; Deficiencies in regulations for ward rounds; Errors in surgical verification procedures; Errors in nursing verification procedures; Deficiencies in multidisciplinary consultation, referral, or transfer regulations; Inadequate informed consent or delayed signing; The number of cases was reported as frequencies and percentages [N (%)]. For the primary outcomes, logistic regression was performed to evaluate risk factors associated with the occurrence of malpractice, patient mortality, severity of disability, and level of liability. The secondary outcome was the association between hospital characteristics and the type of error (technical vs. nontechnical). Due to limitations in the accuracy of the chi-square test and memory constraints encountered with Fisher’s exact test, the Monte Carlo simulation method was applied. Odds ratios (ORs) and 95% confidence intervals (CIs) were reported. All analyses were conducted with a two-sided significance level of 0.05 using Statistical Product and Service Solutions (SPSS) software, version 20.0 (IBM Corporation, Armonk, NY, USA). As this study was based on retrospective data analysis and did not involve direct interaction with patients or the public, it did not involve patients or the public in the design, conduct, reporting, or dissemination plans of the research. This study did not involve human or animal subjects. The data were obtained from the Chinese Medical Association with official authorization. All data were fully de-identified, contained no personally identifiable information, and are presented in Supplementary Table 1. Hence, this study was not considered to require assessment by the ethics review boards of the relevant institutions.

A total of 4355 records of medical malpractice claims related to obstetrics and gynecology (OB/GYN) were reviewed from the CMA archives. After excluding 30 claims unrelated to OB/GYN physicians and 606 claims lacking complete information or conclusions, 3,719 claims were included in the analysis. Professional appraisals conducted by medical associations revealed that 43 cases (1.2%) were determined not to involve malpractice. The baseline characteristics of these claims are provided in Table  1 . Most claims were entrusted by health administrations (2,310, 62.1%) and reviewed by municipal medical associations (3,046, 81.9%) and involved secondary hospitals (2,038, 54.8%), public hospitals (3,216, 86.5%), or general hospitals (2,902, 78.0%). Obstetric practice accounted for 62.8% of the resolved cases. The annual number of medical malpractice cases peaked in 2017 (875 claims) but declined significantly after 2018 (522 claims). Table 1 Comparisons of malpractice severity and liability between various hospital/claim characteristics Malpractice Malpractice with death Malpractice with severe nonfatal disability (level 1 to 5) Complete or major liability n / n (%) OR (95%CI) n / n (%) OR (95%CI) n / n (%) OR (95%CI) n / n (%) OR (95%CI) Hospital type General 2867 (98.79) Reference 587 (20.47) Reference 224 (21.64) Reference 1466 (51.19) Reference Specialized 809 (99.02) 1.065 (0.515, 2.203) 145 (17.92) 0.785 (0.637,0.967) 75 (25.00) 1.143 (0.831,1.572) 411 (50.87) 1.005 (0.855, 1.181) Hospital tier Primary 468 (99.79) Reference 78 (16.67) Reference 29 (14.15) Reference 280 (59.96) Reference Secondary 2012 (98.72) 0.238 (0.048, 1.171) 398 (19.78) 1.115 (0.846, 1.468) 172(23.79) 1.698 (1.084, 2.658) 1073 (53.36) 0.783 (0.635, 0.965) Tertiary 1133 (98.61) 0.218 (0.042, 1.126) 250 (22.07) 1.280 (0.950,1.725) 97(25.39) 1.835 (1.121, 3.004) 476 (42.09) 0.527 (0.419, 0.664) Hospital ownership Public 3178 (98.82) Reference 657 (20.67) Reference 272 (24.29) Reference 1587 (50.00) Reference Private 498 (99.01) 0.757 (0.313, 1.832) 75 (15.06) 0.795 (0.600, 1.055) 27(12.56) 0.572 (0.361, 0.907) 290 (58.23) 1.057 (0.856, 1.304) Medical association level Municipal 3016 (99.02) Reference 557 (18.47) Reference 223(20.55) Reference 1579 (52.42) Reference Provincial 656 (98.06) 0.516 (0.274, 0.970) 173 (26.37) 1.484 (1.211, 1.820) 76(30.65) 1.692 (1.218, 2.351) 297 (45.27) 0.803 (0.674, 0.957) Entrusting party Health administration 2283 (98.83) Reference 449 (16.67) Reference 171(20.90) Reference 1251 (54.89) Reference Courts 685 (98.85) 1.085 (0.499, 2.358) 168 (24.53) 1.349 (1.087, 1.673) 77(28.84) 1.540 (1.090, 2.176) 274 (40.00) 0.587 (0.489, 0.705) Mediation party 70 (100.00) 1.771 (0.110, 28.419) 14 (20.00) 1.176 (0.636,2.175) 6(30.00) 2.015 (0.703, 5.774) 38 (54.29) 1.049 (0.642, 1.715) Physician-patient 638 (98.76) 0.887 (0.413, 1.903) 101 (15.83) 0.852 (0.667,1.088) 45(19.57) 1.097 (0.743, 1.619) 314 (49.22) 0.778 (0.649, 0.932) Major involved department Gynecology 1368 (98.77) Reference 149 (10.89) Reference 44 (8.82) Reference 782 (57.25) Reference Obstetrics 2308 (98.98) 1.139 (0.631, 2.057) 583 (25.26) 2.866 (2.347,3.501) 255(30.50) 4.637 (3.259,6.597) 1095 (47.48) 0.643 (0.559, 0.740) Comparisons of malpractice severity and liability between various hospital/claim characteristics 1.065 (0.515, 2.203) 1.005 (0.855, 1.181) 0.238 (0.048, 1.171) 1.115 (0.846, 1.468) 1.698 (1.084, 2.658) 0.783 (0.635, 0.965) 0.218 (0.042, 1.126) 1.835 (1.121, 3.004) 0.527 (0.419, 0.664) 0.757 (0.313, 1.832) 0.795 (0.600, 1.055) 0.572 (0.361, 0.907) 1.057 (0.856, 1.304) Medical association level 0.516 (0.274, 0.970) 1.484 (1.211, 1.820) 1.692 (1.218, 2.351) 0.803 (0.674, 0.957) 1.085 (0.499, 2.358) 1.349 (1.087, 1.673) 1.540 (1.090, 2.176) 0.587 (0.489, 0.705) 1.771 (0.110, 28.419) 2.015 (0.703, 5.774) 1.049 (0.642, 1.715) 0.887 (0.413, 1.903) 1.097 (0.743, 1.619) 0.778 (0.649, 0.932) 1.139 (0.631, 2.057) 0.643 (0.559, 0.740) Among the 3,676 malpractice cases, 1,465 (39.9%) did not result in disability, while 1,339 (36.4%) involved nonfatal disability, and 735 (20.0%) resulted in death (see Fig.  1 ). The distribution of nonfatal disability levels, ranked from 1 (most severe) to 10 (least severe), is also illustrated in Fig.  1 . Across all malpractice cases, liability classifications were as follows: complete (347, 9.3%), major (1,538, 41.4%), equal (186, 5.0%), minor (1,043, 28.0%), mild (584, 15.7%) and no liability (8, 0.2%). Fig. 1 Cases of medical malpractice without disability and with disability (level 1 to level 10) and medical malpractice resulting in death Cases of medical malpractice without disability and with disability (level 1 to level 10) and medical malpractice resulting in death Among the 3,719 claims, 92.7% involved technical errors, whereas 40.6% involved nontechnical errors. The most prevalent technical errors were insufficient evaluation (873, 23.5%), errors in the surgical/procedural process (846, 22.7%), observation or monitoring errors (679, 18.3%), and errors in the timing or indication of surgery/procedures (511, 13.7%). The most common nontechnical errors were inadequate informed consent or delayed signing (747, 20.1%) and medical record documentation and administrative errors (499, 13.4%) (Fig.  2 ). A more detailed description of all claims is provided in Supplementary Table 1. Fig. 2 Specific malpractice in the categories of technical errors or nontechnical errors/administrative errors Specific malpractice in the categories of technical errors or nontechnical errors/administrative errors The multivariate analysis incorporated the type, tier, ownership of the hospitals, the major department involved, the medical association level, and the characteristics of the entrusting party (see Table  1 ). Specialized hospitals were associated with a lower risk of malpractice-related death compared to general hospitals (odds ratio [OR] = 0.785; 95% confidence interval [CI] = 0.637–0.967). Compared with public hospitals, private hospitals presented a reduced risk of severe nonfatal disability and technical error (OR = 0.572; CI = 0.361–0.907; OR = 0.643; CI = 0.448–0.924). Compared with primary hospitals, secondary and tertiary hospitals were associated with a greater risk of severe nonfatal disability (OR = 1.698; CI = 1.084–2.658; OR = 1.835; CI = 1.121–3.004) but a lower risk of primary liability (OR = 0.783; CI = 0.635–0.965; OR = 0.527; CI = 0.419–0.664). Compared with cases handled by municipal medical associations, those handled by provincial medical associations had a lower risk of malpractice and primary liability (OR = 0.516; CI = 0.274–0.970; OR = 0.803; CI = 0.674–0.957) but a higher risk of malpractice-related death and severe nonfatal disability (OR = 1.484; CI = 1.211–1.820; OR = 1.692; CI = 1.218–2.351). Compared with claims entrusted by health administration, mediation party, or physician-patient pair, claims commissioned by courts were more likely to involve malpractice-related death and severe disability (OR = 1.349; CI = 1.087–1.673; OR = 1.540; CI = 1.090–2.176), but less likely to involve primary liability (OR = 0.803; CI = 0.674–0.957). In contrast, compared to those entrusted by health administration, mediation party, and court, claims commissioned by physicians-patient pair were less likely to result in primary liability (OR = 0.587; CI = 0.489–0.705). Compared with gynecology departments, obstetric departments had a greater risk of malpractice-related death (OR = 2.866; CI = 2.347–3.501) but a lower risk of primary liability (OR = 0.643; CI = 0.559–0.740). No significant differences were observed in the proportion of technical or nontechnical errors across hospital tiers, ownership, or departments (Table  2 ). However, secondary and tertiary hospitals reported a greater frequency of errors related to inadequate informed consent or delayed signing than primary hospitals did ( P  = 0.01). Compared with tertiary hospitals, primary and secondary hospitals encountered more errors related to healthcare personnel’s credentials. Table 2 Comparisons of error types among hospital characteristics Hospital tier Hospital ownership Major involved department Error type Primary Secondary Tertiary p Public Private p Gynecology Obstetrics p Technical Errors 437(93.38) 1878(93.34) 1040(91.79) 0.2421 2961(93.17) 454(91.16) 0.1049 1278(93.42) 2137(92.59) 0.3435 Timing or Indication for Surgery/Procedure 64(14.65) 275(14.64) 158(15.19) 0.0744 425(14.35) 84(18.50) 0.0220 169(13.22) 340(15.91) < 0.0001 Surgical/Procedural Process 122(27.92) 470(25.03) 238(22.88) 736(24.86) 107(23.57) 434(33.96) 409(19.14) Medication Plan or Dosage 14(3.20) 54(2.88) 22(2.12) 72(2.43) 20(4.41) 29(2.27) 63(2.95) Timing or Indication for Medication 13(2.97) 71(3.78) 28(2.69) 99(3.34) 19(4.19) 36(2.82) 82(3.84) Observation or Monitoring Errors 87(19.91) 391(20.82) 189(18.17) 595(20.09) 80(17.62) 158(12.36) 517(24.19) Insufficient Evaluation 105(24.03) 452(24.07) 301(28.94) 769(25.97) 101(22.25) 257(20.11) 613(28.69) Diagnostic Errors 32(7.32) 165(8.79) 104(10.00) 265(8.95) 43(9.47) 195(15.26) 113(5.29) Non-technical Errors 203(43.38) 825(41.00) 451(39.81) 0.4159 1284(40.40) 223(44.78) 0.0648 562(41.08) 945(40.94) 0.9348 Hospital or Healthcare Personnel Credential Issues 19(9.36) 41(4.97) 13(2.88) 0.0101 44(3.43) 39(17.49) < 0.0001 38(6.76) 45(4.76) 0.0846 Deficiencies in Multidisciplinary Consultation or Referral 16(7.88) 73(8.85) 39(8.65) 108(8.41) 21(9.42) 40(7.12) 89(9.42) Surgical Verification Procedures 8(3.94) 16(1.94) 7(1.55) 25(1.95) 6(2.69) 15(2.67) 16(1.69) Nursing Verification Procedures 3(1.48) 6(0.73) 4(0.89) 12(0.93) 1(0.45) 5(0.89) 8(0.85) Deficiencies in Ward Round Regulations 0(0.00) 6(0.73) 2(0.44) 7(0.55) 1(0.45) 1(0.18) 7(0.74) Medical Record Documentation and Management Errors 76(37.44) 255(30.91) 159(35.25) 437(34.03) 59(26.46) 167(29.72) 329(34.81) Inadequate Informed Consent or Delayed Signing 81(39.90) 428(51.88) 227(50.33) 651(50.70) 96(43.05) 296(52.67) 451(47.72) Comparisons of error types among hospital characteristics Compared with public hospitals, private hospitals reported more errors related to personnel credentials issues, but fewer errors related to inadequate informed consent, delayed signing, and medical record documentation and management ( P  < 0.001). Compared with public hospitals, private hospitals presented higher rates of errors in timing or indications for surgery/procedures, but fewer errors in observation, monitoring, and insufficient evaluation ( P  = 0.02). Compared with gynecological cases, obstetric cases presented more errors in terms of timing or indications for surgery/procedures, observation or monitoring, and insufficient evaluations. Gynecological cases were more frequently associated with surgical/procedural process errors ( P  < 0.001).

To our knowledge, this study is the first national analysis of malpractice claims in obstetrics and gynecology in China. Judicial appraisals of medical malpractice involve nuanced considerations such as disease progression, advances in medical technology, and the quality of care provided. A comprehensive understanding of these factors can drive meaningful improvements in the healthcare system [ 21 , 22 ]. In our study, 98.8% of malpractice claims were confirmed as malpractice with varying consequences. In contrast, a study in Beijing, China, reported that 83.7% of 726 alleged malpractice cases were confirmed as malpractice after final verdicts, suggesting a disconnect between malpractice lawsuits and malpractice appraisals [ 5 ]. This discrepancy underscores the importance of analyzing malpractice claims not only to assess the presence of negligence but also to identify underlying causal factors that can inform targeted prevention strategies. Such in-depth evaluations offer valuable insights beyond legal outcomes, helping to guide evidence-based improvements in clinical practice and risk management. Our findings revealed that higher-tier hospitals—specifically tertiary hospitals—were associated with an increased risk of severe disability but a decreased likelihood of being assigned primary liability. These results align with prior research indicating that tertiary hospitals manage complex, high-risk conditions and procedures, which inherently increase the likelihood of adverse events [ 23 ]. Additionally, tertiary hospitals often perform complex surgeries and high-risk procedures, which increases the potential for technical errors [ 24 ]. Renkema et al. reported that care complexity is one of four factors potentially influencing the connection between medical errors and physician behavior, which compromises patient safety [ 25 ]. Similarly, Li et al. noted that medical mistakes are more prevalent in complex hospital settings, such as those typically found in tertiary hospitals [ 23 ]. In contrast, private hospitals presented a lower risk of severe injury and technical errors than public hospitals, although nontechnical errors, such as credentialing issues, were more prevalent. Private hospitals generally cater to a more selective patient population and focus on low-risk, non-acute treatments such as health check-ups, cosmetic surgeries, and routine specialist clinics, which reduces the likelihood of serious complications [ 26 ]. Their smaller size allows for personalized and refined management with smoother communication between administrative and clinical departments, which facilitates the rapid identification and resolution of safety risks [ 27 ]. However, credentialing and staffing issues remain prominent, highlighting the need for stronger auditing and supervision and enhanced training programs for private hospital personnel [ 28 ]. Compared with gynecologists, obstetricians in our study faced a greater risk of accidents that led to higher mortality rates; however, accidents were associated with lower primary liability. Similar patterns have been observed in other healthcare systems, where high malpractice premiums and fear of litigation have led some family physicians to discontinue obstetric services [ 29 , 30 ]. A history of obstetric litigation has been linked to increased use of defensive medicine [ 31 , 32 ]. Despite the critical implications, few obstetric litigation policies have been rigorously evaluated, likely due to the complex and multifactorial nature of associated risks [ 33 , 34 ]. This study highlighted distinct differences in the types of medical errors between gynecology and obstetrics. Obstetric cases presented more errors in the timing of or indications for surgery/procedures, whereas gynecological cases presented a greater frequency of errors in the surgical/procedural process. These findings align with those of a previous study, which reported that obstetric procedures—particularly cesarean sections and vacuum-assisted deliveries—contributed significantly to total indemnity payments. In contrast, uterine surgeries in gynecologic care were among the most frequently litigated [ 2 ]. These findings underscore the need to enhance surgical skills training for gynecologists and improve obstetricians’ decision-making regarding labor management and the timing of cesarean sections. These insights can inform targeted quality improvement strategies. For obstetric care, efforts should focus on strengthening clinical decision-making, particularly in labor management and timing of interventions. This may include enhanced simulation training for emergency scenarios, standardized labor protocols, and the incorporation of multidisciplinary case reviews. For gynecologic surgery, the emphasis should be placed on improving technical proficiency through surgical mentorship programs, skill-based assessments, and adherence to evidence-based operative guidelines. Hospital systems can use these findings to prioritize risk-prone procedures for quality monitoring and allocate resources for continuing education. Collectively, such strategies can contribute to reducing preventable harm, minimizing litigation, and ultimately enhancing patient safety in both specialties [ 35 ]. Successful models, such as multilevel integrated practice and coordinated communication models, have been demonstrated to be effective in mitigating malpractice risks during labor and delivery [ 36 – 38 ]. Compared with public hospitals, private hospitals presented a lower risk of severe nonfatal disability and fewer technical errors. While this finding may be linked to the fact that private hospitals primarily accept non-acute, low-risk cases, it also suggests their potential role in promoting medical safety and enhancing service quality. This finding indicates that private hospitals may complement public healthcare services and contribute to easing the burden on public institutions [ 39 ]. However, their credentialing issues call for improved auditing and staff recruitment measures. Additionally, the higher risk of severe disability but lower primary liability in tertiary hospitals reflects their role in managing critical cases and highlights the progress of hierarchic healthcare in China [ 40 ]. Future efforts should prioritize the continued implementation of hierarchic healthcare, promote the development of private hospitals, and optimize the medical system to deliver safer, more accessible patient care. The strengths of this study include its large sample size and meticulous review of case files. Through in-depth analysis, medical errors were classified into technical and nontechnical types, which were further subdivided into 14 detailed subcategories. This approach allowed for precise identification of leading errors, such as insufficient evaluation, procedural mistakes, and inadequate or delayed informed consent. Such comprehensive categorization enabled a nuanced understanding of error patterns and provides actionable insights to inform quality improvement efforts and enhance patient safety initiatives. Query ID="Q1" Text="Please confirm the section headings are correctly identified." Resolved="yes"However, several limitations exist. First, not all malpractice claims in China are submitted to or reviewed by the CMA. Our dataset was limited to cases formally appraised by the CMA and did not include claims resolved through litigation, mediation, or private settlement. As such, the findings may not represent the full spectrum of OB/GYN-related malpractice cases nationwide. However, by including all OB/GYN-related cases appraised by the CMA from 2016 to 2023, our study draws upon one of the largest datasets in this field, thereby enhancing the robustness and generalizability of the findings within the context of formal medical dispute resolution in China. Second, the complexity of malpractice events limits the comprehensiveness of any classification system, particularly in maternal and neonatal care, where clinical decisions often involve rapidly evolving conditions and high-stakes outcomes for both mother and infant. Many adverse events result from a chain of interrelated factors, making it difficult to attribute errors to a single category. This inherent complexity poses challenges in accurately capturing all contributing factors within a rigid classification framework. Thirdly, this study lacks data on malpractice compensation. While malpractice claims are often linked to legal and financial outcomes, our dataset from the CMA includes only the determination of malpractice and responsibility levels. Our analysis focuses on the association between error types and healthcare system characteristics to inform system-level improvements.

Our analysis of OB/GYN malpractice claims in China over an eight-year period revealed critical insights. Fatal incidents occurred more frequently in obstetrics but involved less primary liability, whereas gynecology cases presented more surgical errors. Specialized, private, and primary hospitals experienced fewer claims resulting in severe outcomes. Strengthening hierarchic healthcare and encouraging the growth of grassroots and private hospitals could contribute to a safer and more efficient healthcare system.

Medical errors are a leading cause of preventable deaths worldwide. Among all medical specialties, obstetrics and gynecology are particularly vulnerable to malpractice claims, with procedures involving the uterus among the most frequently litigated [ 1 – 3 ]. In China, the annual incidence of medical malpractice litigation has risen sharply [ 4 ], making obstetrics and gynecology one of the specialties that are most frequently involved in such claims [ 4 – 8 ]. Medical lawsuits in obstetrics are more likely to result in rulings against the defendant than those in other specialties [ 5 , 6 , 9 ]. Most studies have relied on data from lawsuits, which often involve prolonged disputes, focus primarily on fatal injuries, and emphasize monetary compensation [ 4 , 10 ]. While legal claim analyses can identify clinical conditions, they are less effective at pinpointing human or system errors [ 11 ]. However, system errors remain the most common cause of deficiencies in maternal care [ 12 ]. These limitations in current investigative approaches have hindered a comprehensive understanding of medical malpractice and its associated risk factors. A detailed analysis of malpractice claims could provide deeper insight into the sources of deficiencies in medical services and potential avenues for improvement [ 13 ]. In China, most medical malpractice claims are first reviewed by medical associations before entering the judicial system. The documentation generated during this assessment process includes detailed case reports outlining the incident, analysis of the provider’s fault, and evaluation of the outcome. These data offer valuable insights into the complexities of medical malpractice and enable the identification of specific human or systemic errors, as well as guidance to prevent the recurrence of safety incidents. This study is based on all medical malpractice files received by the Chinese Medical Association (CMA) from 2016 to 2023. It aims to describe and categorize incidents of medical malpractice in obstetrics and gynecology in China, analyze the risk factors associated with malpractice leading to death, disability, or liability, and explore the correlation between the structure of the medical system and medical errors.

Below is the link to the electronic supplementary material. Supplementary Material 1 Supplementary Material 1