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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.

This PhD examines the impact of policies introduced to improve outcomes in health care in England in the first decade of the 21st century, focusing on their impact on outcomes in maternity care. It uses data from the primary hospital discharge data set for English National Health Service hospitals, known as Hospital Episode Statistics (HES). Chapter 1 examines the impact of a "payment by results" policy aimed at improving care outcomes in hospitals. This scheme was known as the Commissioning Quality and Innovation (CQUIN) payment framework. I examine the impact of this policy on csection rates in England. My focus is on the scheme as used in the financial year 2010/11. I investigate whether there are any reductions attributable to the CQUIN scheme in c-sections. [ find that the scheme does not have any statistically significant impact on c-section rates. Chapter 2 investigates the effect of being born on a weekend on the probability of dying among babies born at English NHS acute hospitals. The "weekend effect" has been documented in a range of hospital settings. We examine whether this is still present in maternity care after large increases in hospital staffing during the mid-2000s. We use 2009/10 Hospital Episode Statistics maternity data and control for a wide range of baby's and mother's characteristics. We find that being born on a weekend is not associated with any statistically significant increase in the odds of dying. Chapter 3 examines the use of the hospital (as distinct from the individual) as the unit of analysis in a difference-in-difference analysis. We provide evidence for our theoretical framework with an empirical application of the evaluation of Payment by Results (PbR) scheme, started in 2005/2006 in maternity care. We find that there is no statistically significant association of this scheme on the outcomes. However, we find modest evidence for the fact that NHS acute trusts game the scheme by increasing the amount of antenatal admissions not related to a delivery event. Chapter 4 examines the impact of Maternity Matters Agenda (2009) on maternal outcomes. The policy introduced choice of place of birth among women. This followed the introduction of competition across English NHS acute trusts. I investigate the impact of competition on the quality of maternity services. I find that although the market competition has increased over the 7 year period, this is not associated with any improvements in the level of quality of maternity services.

Reducing substandard care and improving healthcare quality is an NHS priority. Maternity care is a key area where improvements can be made. Through risk management strategies multiple quality-monitoring tools exist, including the clinical dashboard. Maternity dashboards were nationally recommended for use by all UK maternity units in 2008. However, it is unclear to what extent units have implemented dashboards or any associated issues with their use and quality monitoring as a whole.