How common is substandard obstetric care in adverse events of birth asphyxia, shoulder dystocia and postpartum hemorrhage? Findings from an external inspection of Norwegian maternity units

Acta Obstet Gynecol Scand. 2021 Jan;100(1):139-146. doi: 10.1111/aogs.13959. Epub 2020 Aug 5.


Introduction: The Norwegian Board of Health Supervision inspects healthcare institutions to ensure safety and quality of health and welfare services. A planned inspection of 12 maternity units aimed to investigate the practice of obstetric care in the case of birth asphyxia, shoulder dystocia and severe postpartum hemorrhage.

Material and methods: The inspection was carried out at two large, four medium and six small maternity units in Norway in 2016 to investigate adverse events that occurred between 1 January and 31 December 2014. Six of them were selected as control units. The Norwegian Board of Health Supervision searched the Medical Birth Registry of Norway to identify adverse events in each of the categories and then requested access to the medical records for all patients identified. Information about guidelines, formal teaching and simulation training at each unit was obtained by sending a questionnaire to the obstetrician in charge of each maternity unit.

Results: The obstetric units inspected had 553 serious adverse events of birth asphyxia, shoulder dystocia or severe postpartum hemorrhage among 17 323 deliveries. Twenty-nine events were excluded from further analysis due to erroneous coding or missing data in the patients' medical records. We included 524 cases (3.0% of all deliveries) of adverse events in the final analysis. Medical errors caused by substandard care were present in 295 (56.2%) cases. There was no difference in the prevalence of substandard care among the maternity units according to their size. Surprisingly, we found significantly fewer cases with substandard care in the units which the supervisory authorities considered particularly risky before the inspection, compared with the control units. Seven of the 12 units had regular formal teaching and training arrangements for obstetric healthcare personnel as outlined in the national guidelines.

Conclusions: Prevalence of adverse events was 3% and similar in all maternity units irrespective of their size. A breach in the standard of care was observed in 56.2% of cases and almost half of the maternity units did not follow national recommendations regarding teaching and practical training of obstetric personnel, suggesting that they should focus on implementing guidelines and training their staff.

Keywords: adverse events; asphyxia; failure of treatment; maternity units; postpartum hemorrhage; shoulder dystocia; supervision.

Publication types

  • Multicenter Study

MeSH terms

  • Adult
  • Asphyxia Neonatorum / epidemiology*
  • Female
  • Humans
  • Infant, Newborn
  • Medical Errors / statistics & numerical data*
  • Norway / epidemiology
  • Obstetrics and Gynecology Department, Hospital
  • Postpartum Hemorrhage / epidemiology*
  • Pregnancy
  • Registries
  • Shoulder Dystocia / epidemiology*