The Japan Obstetric Compensation System for Cerebral Palsy: Novel System to Improve Quality and Safety in Perinatal Care and Mitigate Conflict

Abstract

The Japan Obstetric Compensation System for Cerebral Palsy was launched in 2009 in response to a shortage of obstetricians and a surge in disputes. The system is characterized by the provision of no-fault compensation, investigation, and prevention. We have certified more than 3000 cerebral palsy cases for compensation and have delivered investigative reports, prevention reports, and educative media for professionals and expectant mothers. We have also produced recapitulation of individual investigative report to be uploaded on the webpage of the system to enhance transparency. The disclosure is reviewed to be consistent with lately revised Personal Information Protection Law in 2020. In order to expand the system by revising eligibility criteria, the system was and will be reviewed in 2015 and 2022. The new criteria that were crafted in ad-hoc committee in 2019–2020 will be applied in 2022 and later. As such, the system has been a significant part of perinatal care delivery system in Japan.

1. Introduction

The Japan Obstetric Compensation System for Cerebral Palsy [1, 2, 3, 4] was launched in 2009 by the Japan Council for Quality Health Care (JQ) as operating organization, with the background of a shortage of obstetricians in Japan and a surge in disputes particularly caused by occurrence of cerebral palsy (CP). More than 10 years have passed since the system commenced, and it has given rise to enormous achievements such as early resolution of disputes displayed in the rapid decrease in the number of lawsuit statistics and quality improvement of perinatal care. It is of note that the system was designed in an introductory committee in the presence of range of stakeholders such as professional organizations, academic organizations, insurance firm, lawyers, and patient representatives. They have been involved in implementing the system that was helpful in obtaining confidence in the system. Here, in this article, current status of the system and challenges ahead are described.

2. Background to the launch the system

2.1 Perinatal care and conflict

Among the disputes, those related to cerebral palsy were said to be a heavy burden for obstetricians because the cause of cerebral palsy was often unknown. In discussions with perinatal care professionals in Japan and abroad, it has been said that cerebral palsy is one of the causes of disputes, including court cases, and of obstetricians leaving their jobs, not only in high-income countries but also in middle-low-income countries (LMICs). In cases where a child is born in a distressed status despite normal course of pregnancy and delivery, or where the child’s neurological deficits become apparent to develop profound cerebral palsy in spite of little or no findings on hypoxic condition during delivery, the family’s sentiment may become complicated due to uncertainty on the cause of cerebral palsy and a dispute may arise. Therefore, obstetricians had been discussing for many years the establishment of a compensation system that runs on no-fault basis in anticipation for mitigating the conflict.

2.2 Deliberation on establishing no-fault compensation system

Discussions on the establishment of a no-fault compensation system have been held by the Japan Medical Association (JMA) since the 1960s. In the report entitled “Report on the Legal Response to Medical Accidents and Its Basic Theory” published in 1972, the following recommendations were set forth [5].

1. In the event of a medical accident, if the physician’s practices are deemed to be negligent through a rigorous examination, he or she will be immediately held responsible for compensation.

2. Compensation should be established on a national scale to provide relief for serious damage inevitably caused by physicians whose practices are not negligent.

3. The establishment of a dispute resolution procedure as a national system separate from the current court system.

The JMA physician liability insurance system was established in 1973 in response to (i), but the other two items were not materialized for decades that followed. With decades passing by, the shortage of physicians in obstetrics and gynecology and the declining birthrate became social problems. In January 2006, the JMA made a proposition in its report entitled “Aiming at the establishment of a disability compensation system for medical care” stating “Ideally, it is desirable to implement a no-fault compensation system for entire medical specialties” and “however, neurological sequelae related to childbirth (so-called cerebral palsy) is prioritized for no-fault compensation.” In August of the same year, they presented the details on the novel system [6]. Furthermore, in November of the year, “A Framework for a No-Fault Compensation System in Obstetrics” (Study Group on Medical Dispute Resolution, Social Security System Study Group, Political Research Committee of the Liberal Democratic Party (LDP)) was published that was followed by growing anticipation to launch the system. It depicted that the novel system is equipped with two pillars such as compensation on no-fault basis and investigation and prevention. At the same time, relevant organizations and groups expressed their concern and requested that the JQ should be an operator of the system. Accordingly, the Preparatory Office for the novel system was installed in the JQ in February 2007 that served as secretariat for the Introductory Committee for the novel system. In March 2008, the Board of Directors of the JQ formally decided to be the operating organization. All in this way, the system has been in operation since January 2009 (Figure 1).

Figure 1.

No-fault compensation/investigation/prevention system for cerebral palsy, 2009.

2.3 Registration of childbirth facility

The system was launched and being hailed by professional societies such as the Japan Association of Obstetricians and Gynecologists (JAOG) and Japanese Midwife Association (JMA). They, therefore, helped the JQ to involve childbirth facilities across Japan for registration in the system. Although there is no legislation that mandates them participate in the system, the JQ successfully observed extremely high registration rate in the system as high as 99.9% achieved in close cooperation with the societies and relevant stakeholders [7] (Table 1).

Type of facility	No. childbirth facilities	No. participating facilities	% Participation
Hospital	1173	1173	100.0
Clinic	1557	1555	99.9
Birth center	445	445	100.0
Total	3175	3173	99.9*

Table 1.

Registration rate by type of facility. As of November 30, 2021.

^*

Institutions not registered: 2 clinics.

2.4 Review and compensation

The scope of those eligible for compensation must meet the general criteria, which consists of birth weight and weeks of pregnancy, or the individual criteria when the weeks of pregnancy are less than the general criteria : 28 weeks or more of pregnancy, case-by-case criteria: umbilical artery blood pH less than 7.1, meeting one of the prescribed patterns in the fetal heart rate labor diagram (CTG) that indicate hypoxia in the fetus, etc., meets severity criteria: degree equivalent to level 1 or 2 of the physical disability grade defined in the Welfare for the Disabled Act, and does not meet the exclusion criteria such as cerebral palsy obviously caused by congenital factors or factors taking place in neonatal period and later [8]. Even if congenital factors (brain malformation, genetic abnormality, chromosomal abnormality, etc.) exist, patients are not necessarily excluded because the factors may not be the obvious cause of profound CP. Decision for approval is made based on medical examination as to what caused profound CP that applicant suffers. The general criteria and case-by-case criteria were revised in reference to aggregated data and scientific progress on cerebral palsy. The latest criteria that applied to cerebral palsy who were born in 2022 or later does not include case-by-case criteria due to expansion of general criteria so that more cerebral palsy would be covered (Table 2). The revision of the criteria is described later.

	2009–2014	2015–2021	2022–
General criteria	33rd week or later and 2000 g or over	32nd week or later and 1400 g or over	28th week or later
Case-by-Case	“28th week or later” AND “A) OR B)”; (A) Umbilical cord arterial blood pH; less than 7.1; (B) Specific deceleration patterns* on CTG; * Any patterns of “a” AND “any of b-d”; a. Loss of variability of the baseline; b. Late decelerations observed at 50% or over of uterine contractions; c. Variable decelerations observed at 50% or over of uterine contractions; d. Severe bradycardia with reduced variability of the baseline	“28th week or later” AND “A) OR B)”; (A) Umbilical cord arterial blood pH; less than 7.1; (B) Specific deceleration patterns* on CTG; * Any patterns of a-h”; a. Abrupt and persistent bradycardia; b. Late decelerations observed at 50% or over of uterine contractions; c. Variable decelerations observed at 50% or over of uterine contractions; d. Loss of variability of the baseline; e. Severe deceleration with loss of variability of the baseline; f. Sinusoidal pattern; g. Apgar score at 3 or less at 1 min after birth; h. Arterial blood gas pH less than 7.0 within 1 hour after birth	None
Exclusion	a. Congenital causes; Bilateral diffuse cerebral malformation, chromosomal disorders, genetic disorders, congenital metabolic disorders or other congenital abnormalities; b. Neonatal causes; Encephalitis, brain injuries etc. that obviously take place after birth	a. Congenital causes; Bilateral diffuse cerebral malformation, chromosomal disorders, genetic disorders, congenital metabolic disorders or other congenital abnormalities; b. Neonatal causes; Encephalitis, brain injuries etc. that obviously take place after birth	a. Congenital causes; Bilateral diffuse cerebral malformation, chromosomal disorders, genetic disorders, congenital metabolic disorders or other congenital abnormalities; b. Neonatal causes; Encephalitis, brain injuries etc. that obviously take place after birth
Impairment degree	1st-2nd degree i.g. wheelchair defined in the Act on Social Care for the Disabled	1st-2nd degree i.g. wheelchair defined in the Act on Social Care for the Disabled	1st-2nd degree i.g. wheelchair defined in the Act on Social Care for the Disabled

Table 2.

Eligibility criteria: criteria of 2009, 2015 and 2022.

As of June 2021, 3374 cases have been approved for compensation, and payment for the cases have been swiftly made or in progress. The annual number of persons eligible for compensation to such criteria as 2009 and 2015 criteria that have been confirmed so far is 419 in 2009, 382 in 2010, 355 in 2011, 362 in 2012, 351 in 2013, 326 in 2014, and 376 in 2015. For children born in later years, the application is still allowed until they are 5 years old (Table 3). It should be noted that the number of approved patients rose to a certain extent in 2015 because new criteria that could cover more cerebral palsy were applied. In addition, applicants of uncompensated cases may apply to the Appeal Committee if they are not convinced on the results of the review.

Birth year	No. case reviewed	Eligible	Not-Eligible				Petition
		Eligible	Not Eligible	Preliminary to review	Total	Review in progress
2009	561	419	142	0	142	0	Expired
2010	523	382	141	0	141	0	Expired
2011	502	355	147	0	147	0	Expired
2012	517	361	155	0	155	0	Expired
2013	476	351	125	0	125	0	Expired
2014	469	326	143	0	143	0	Expired
2015	475	376	99	0	99	0	Expired
2016–2019	933	803	81	41	122	8	Valid
Total	4456	3374	1033	41	1,074	11

Table 3.

Statistics of eligible case by birth year.

A uniform compensation of 30 million yen is paid for each case once approved by the Review Committee. There are two different ways applied to the payment such as lumpsum payment and annual installment that continue 20 times (Figure 2). If childbirth facility is liable for the development of cerebral palsy, the compensation and the damage payment are adjusted to eliminate duplicative payments. In other words, the child and the family cannot receive both the compensation and the damage payment in the system [9].

Figure 2.

Sum of compensation payment (30 million JPY = 342,000 USD).

3. Investigation

3.1 Production of investigative report

The purpose of the investigation is (i) to analyze the case from a medical point of view based on record and data on the cerebral palsy to learn knowledge for prevention and (ii) prevent conflict between childbirth facility and patient/family and bring it to early settlement by sharing investigative report for mutual understanding on the childbirth event. Unlike court system, this is a process of analysis genuinely from medical and midwifery point of view [10].

The Investigation Committee holds seven subcommittees to compile a draft report (Figure 3). One committee is composed of 14 members: nine obstetricians including the chairperson, two pediatricians, one midwife, and two lawyers. The role of the medical members is to analyze the case from medical viewpoint, while the lawyers provide views so that the report will be easy for patient/family to understand. A working manual was crafted to ensure that the reports are compiled in standardized fashion. The draft report compiled therein is reviewed in the Investigative Committee for approval. At the same time, a “summarized edition” of the investigative report is issued with personal identifiers deleted and held available on the system’s website for prevention and improvement of perinatal care.

Figure 3.

Production of standardized investigative report.

3.2 The relationship between the disclosure of the “Synthesized edition” of the investigative report and the latest revision of the Personal Information Protection Law and relevant administrative guidelines

The “Synthesized edition” of the investigative report has been published and posted on the website as one of the products of the system [11]. They have been referred by parents, patient groups, and medical professionals for various purposes such as confirming transparency and improving quality of perinatal care through scientific research. The revised Act on the Protection of Personal Information was enacted and promulgated in 2015 and fully enforced on May 30, 2017, which unprecedentedly forced the “Donor rule” applicable when we consider if the data we disclose on the web is “Personal information.” “Personal information” shall be provided to third parties through the prior consent of an individual to which the data belong with some exceptions such as the data provision for promoting public health. The “Donor rule” states that the data is defined as “Personal information” when the donor of the data, i.e., the JQ can identify an individual from whom the data derive even if recipient of the data, i.e., the general public does not know whose data it is. Accordingly, the “Synthesized edition” that had been available on the website turned out to be “Personal information” that could be transferred to third parties principally through prior consent procedure. Therefore, the “Synthesized edition” posted on the website, for which consent of family and childbirth facility for the disclosure had not been obtained, had to be temporarily withdrawn from the website, and the Steering Committee took deeper dive into the issue from a broad perspectives such as purpose and impact of the disclosure and procedures required for the disclosure in consistent with the revised Personal Information Protection Act [12].

In January 2019, the JQ consulted with legal experts and the government officials again on this issue. In light of their comments and guidance, the JQ decided to make efforts in obtaining the consent of the guardians, the childbirth institutions, and the relevant medical institutions on all the “Synthesized editions” in response to the public concern on the system and the changing public view with regard to the handling of personal information, although the JQ believed that it fell under the exceptions for obtaining prior consent to the provision of personal information to third parties in the revised Personal Information Protection Act (Table 4). Later, when the JQ’s policy on disclosure of the “Synthesized edition” was proposed at the 40th Steering Committee meeting held in January 2019, comments such as “all synthesized editions should be disclosed on the web as they were” and “The JQ should clarify the reasons for no-consent by guardians and/or childbirth facilities in detail” were raised from many of committee members.

Article 23; A business operator handling personal information shall not provide personal data to a third party without obtaining the prior consent of the individual, except in the following cases; (i)-(ii) Omitted. (iii) When it is particularly necessary for the improvement of public health or the promotion of the sound growth of children, and it is difficult to obtain the consent of the person concerned.

Table 4.

Article 23, paragraph 1, item 3 of the Personal Information Protection Act.

In February 2019, the JQ conducted a questionnaire survey targeting guardians and childbirth facilities to get hold of the reasons why they answered “agree” or “disagree” on the disclosure of the “Synthesized edition.” At the 41st Steering Committee meeting held in August 2019, the JQ reviewed the aim and value of this system to consider if we should disclose all the “Synthesized edition” that achieves public good such as quality improvement in perinatal care as only about 3/4 of the “Synthesized edition” is agreed on the disclosure [13]. The JQ concluded at that time that it continued its efforts to improve the rate of consent on disclosure and consulted with the relevant ministries and the government to explore measures to disclose more “Synthesized editions” on the web.

In December 2019, the Personal Information Protection Committee in the government published the “Outline of the Amendment of the System for the So-called Triennial Review of the Personal Information Protection Act” (Table 5), and in January 2020, the Ministry of Health, Labor and Welfare (MHLW) presented a new commentary (Table 6). At the 42nd Steering Committee held in February 2020 and the 43rd Steering Committee meeting held on July 3, this issue was discussed to eventually compile an audacious policy on releasing all the “Synthesized editions” on the web. In the meantime, at the 94th meeting of the Investigation Committee held on June 10, the following comments to support the full disclosure were proposed: “In the Investigative Report, the causes of cerebral palsy are analyzed in detail and carefully for each case. So, they are worthwhile to disclose, and “All the “Synthesized editions” need to be disclosed on the web as they were. Accordingly, it was unanimously agreed that the “Synthesized edition” is published for all the Investigation Reports. From the viewpoint of improving public health, the publication of the “Synthesized edition” falls under the exceptions of Article 23, Paragraph 1, Item 3 of the Personal Information Protection Act as described above (Table 4). In addition, in order to prevent the recurrence of CPs, which is the purpose of the system, and to widely commit to quality improvement in perinatal care, the JQ believed that it was incredibly important to disclose all “Synthesized edition” on the web after a year-long argument over the disclosure under the revised Personal Information Protection Act. As there were some opinions that a certain level of agreement has been formed between the JQ and the family and childbirth facility who had disagreed on the disclosure, the JQ needed to make efforts to carefully convince families and childbirth facilities to agree on the new policy on disclosure. After all those discussions, the new disclosure policy was agreed in the Steering Committee [14].

3. Clarification of the exception defined in the law pertaining to the handling of personal information for the purpose of public interest; With the rapid progress of information and communication technology, it has become possible to collect and analyze big data such as customer information. In this context, Japan is aiming to realize Society 5.0, which is a new society in which advanced technologies such as big data analysis are incorporated into all industries and social life to achieve both economic development and solutions to social issues. As social issues become more diverse, it is desirable to support an environment in which businesses can make use of data in order to efficiently and effectively solve these issues.; With regard to this point, the current Personal Information Protection Act has exceptions to the limitation of the purpose of use and provision to third parties, such as “when it is necessary for the protection of the life, body, or property of an individual and it is difficult to obtain the consent of the individual” and “when it is particularly necessary for the improvement of public health or the promotion of the sound growth of children and it is difficult to obtain the consent of the individual.” The use of personal information for public benefit is also considered acceptable in certain cases. However, since there is a tendency that these exceptions have been strictly applied so far, it is necessary to provide specific examples in guidelines and Q&As according to the expected needs. Therefore, we will promote the utilization of personal information that benefits the entire nation, such as the resolution of social issues, by providing specific examples in the guidelines and Q&As according to the expected needs.; For example, a case in which a medical institution or a pharmaceutical manufacturer uses the information for the purpose of contributing to the development of medical research in order to realize healthcare services, drugs, and medical devices of high quality in terms of safety and effectiveness.

Table 5.

The Personal Information Protection Law, dubbed as Triennial Review, Outline of System Revisions (December 13, 2019) (excerpt).

In December 2019, the Personal Information Protection Committee released the “Personal Information Protection Act: dubbed as Triennial Review: Outline of Revisions,” which also states that “the handling of personal information in the private sector is a matter for each business operator to decide. Therefore, it would be desirable for the JQ to consider the policy again, taking into account the balance between the promotion of public health and the protection of personal information. In addition, the MHLW has no objection if it is widely accepted by the society to disclose the summarized edition of all investigative reports as they were.”

Table 6.

Commentary issued to the JQ by the Ministry of Health, Labor and Welfare.

4. Prevention of cerebral palsy

4.1 Publication of annual prevention reports, educational materials on fetal heart rate monitoring, and leaflets for professionals and expectant mothers

The investigative reports are collectively analyzed in order to prevent recurrence and to improve quality in perinatal care [15]. Here, we applied the knowledge and procedure devised through the medical adverse event reporting and learning system that the JQ had run for more than a decade to produce materials for effective prevention of CP through collective analysis. Specifically, the JQ conducted a quantitative and epidemiological analysis of aggregated cases to produce report for prevention on annual basis based on such data as status of pregnancy, clinical courses of pregnancy, delivery and neonatal condition, and the local context of healthcare delivery system [16]. The JQ also produced educational materials such as fetal heart rate monitoring textbook of profound CPs and leaflets for medical professionals and pregnant women [17].

4.2 Scientific achievements of the Prevention Working Group

Under the Prevention Committee, a working group for prevention, which consists of obstetricians nominated by the Japan Society of Obstetrics and Gynecology (JSOG) and the Japan Association of Obstetricians and Gynecologists (JAOG), as well as academic experts such as epidemiologists, was established in May 2014 that has carried out data analysis of the aggregated Investigative Reports. With the data, comparative study between the data of CPs that were subject to compensation in this system and that of the “Japan Society of Obstetrics and Gynecology Perinatal Registration Database” was conducted. In addition, an analysis of intrauterine infections and fetal heart rate patterns in children with CP was conducted in response to the requests mentioned in the Prevention Report to the relevant academic societies and organizations. The analyses have been implemented in the working group from such multifaceted viewpoints as obstetrics and public health.

As the system requests that childbirth facility submit application with relevant documents such as medical chart, cardiotocogram (CTG) recording and so on, the system happened to provided experts an opportunity to scientifically look into CTG data through collective analysis. It is normally difficult in Japan to obtain CTG data of profound cerebral palsy as it suddenly happens at any childbirth facility across the country. Taking advantage of the considerable number of CTG recordings, the experts published an educational book on CTG interpretation, which is available on the website of the system (Figure 4) [18].

Figure 4.

Educative book on CTG pattern of CPs.

4.3 Impact on lawsuit statistics

The purpose of the system is to prevent disputes and to improve quality in perinatal care through no-fault compensation, investigation/prevention. The lawsuit statistics of obstetrics and gynecology as a breakdown of “the number of completed lawsuit of entire medical specialty” published by the Committee on Medical Lawsuit of the Supreme Court of Japan shows a remarkable decreasing trend (Figure 5). The “Report on the Verification of the Speeding Up of Trials” published in July 2013 by the Supreme Court of Japan stated that: [19]

Figure 5.

Lawsuit statistics 2004–2020.

“It is noteworthy that the Japan Obstetric Compensation System for Cerebral Palsy has brought investigative system by a third party and system of equally imposing financial burden for monetary compensation in Japanese society sharing the idea that perinatal care inherently holds potential risk.

It is concerned whether the system expands to cover other medical specialties.

The system having approved significant number of CP cases supposedly has affected to a certain extent statistics of lawsuit cases of medicine.”

As such, the system was hailed not only by medical society but by legal circle in Japan. As described in the report, medical professionals anticipated to expand the system or launch a similar system to cover more clinical specialties. However, there has never been emergence of desire in medical society comparable to the one observed in late 2000s that led to the launch of the system for cerebral palsy. Therefore, the expansion is still under discussion in academic society such as the Japan Surgical Society.

5. Review and overhaul of the system: 2015 and 2022

5.1 Timetable for review and overhaul agreed at the inception of the system

The Japan Obstetric Compensation System for Cerebral Palsy was launched in expedited manner in the wake of deteriorating perinatal care delivery system with challenges difficult to address at the time of the inception. Therefore, the report of the Introductory Committee stated that “the system will be verified in five years at the latest, and necessary revisions will be made to the scope of eligible patients, the amount of monetary compensation, price of insurance premium, and the governing structure of the system as appropriate. As such, periodical review and overhaul has been systematically embedded in the system” [20, 21, 22, 23, 24].

5.2 2015 Overhaul

Accordingly, the Steering Committee of the system began deliberation over the review of the system in February 2012. The committee conducted fact-finding research including the collection and analysis of population-based data on the incidence of cerebral palsy, which is necessary for estimating the number of eligible patient and is crucial for re-designing the system. The results were reported to the Steering Committee in July 2013, and the committee and the Medical Insurance Subcommittee of the Social Security Council of the MHLW reviewed to revamp the system in terms of the scope of eligibility, the amount of monetary compensation, the price of insurance premium, and the way to spend surplus that had aggregated since the launch of the system. The review concluded that the system expanded the scope of eligibility with the same amount of monetary compensation to be applied in January 2015 and later. As to how to spend growing surplus, the Medical Insurance Subcommittee agreed that the insurance premium was reduced to the price that work with the surplus to sustainably ensure budget for compensation. It was planned that the surplus was spent for the next 10 years by 2024 to consume it.

5.3 2022 Overhaul

With the system being run carrying out the revised eligibility criteria, the Steering Committee meeting held on July 20, 2018, found that such issues had arisen as “more than 50% of the patients on case-by-case review were not covered by the system”, “a sense of unfairness is spreading because some patients were covered and others were not despite of suffering commonly from CP with similar clinical course,” and “the revised criteria has already been inconsistent with the latest knowledge from scientific viewpoint.” Therefore, it was concluded that the system needed to be revised as soon as possible. In July of the same year, the Steering Committee submitted a request to the MHLW that the committee commenced the review of the system to overhaul because the MHLW is authorized to fix the price of childbirth lumpsum payment under the government regulation that substantially gives rise to financial source of compensation. Later in the year, the MHLW responded to the JQ claiming that the JQ listens to the voices of relevant parties such as healthcare-related entities, patient groups, and insurers, proposes the blueprint to reform the system, and reports the conclusion to the MHLW so that the MHLW would take necessary action for the reform.

With those dialogs between the JQ and the MHLW, the first round of the Committee on the Review of the Japan Obstetric Compensation System for Cerebral Palsy was held on September 2020. At the meeting, the items to be examined and reviewed were presented to the committee members such as “Efficiency in running the system,” “Latest estimates of the number of eligible patients,” “Price of insurance premium,” “Eligibility criteria for compensation,” “Financial resource for compensation,” and “Price of compensation.” The JQ engaged in Q&A session in the committee in exploring the expansion of the system, which was in line with the views of the most committee members who engaged in perinatal care. In addition to the agreement with members with healthcare background, it was necessary to make efforts to reach a unanimous agreement of the stakeholders including public health insurers involved in the meeting. Therefore, the JQ requested committee members and all those involved in perinatal care across the country for attention and support for the direction, i.e., expansion of the system that JQ proposed in response to the difficult reality in perinatal care delivery system.

The Committee compiled a report on the blueprint of the revision to submit to the MHLW subcommittee on healthcare insurance that works under the MHLW Social Security Panel. The subcommittee includes members such as healthcare insurers, academic experts, and representatives of healthcare professionals, industries, and labor unions. It endorsed the report in December 2020 that led to the launch of the revised system in January 2022 (Table 2).

5.4 Future implication of the no-fault compensation system

The Japan Obstetrics Compensation System for Cerebral Palsy, which was launched in 2009, celebrated its tenth anniversary in 2019. During this period, the system has made enormous achievements such as delivery of no-fault compensation for profound CPs, provision of investigative report to share both with families and childbirth facilities, prevention activities through collective analysis of aggregated investigative reports, and sharing plenty of scientific data on CPs gained through the system on a national scale. The system was reviewed 5 years after it was launched on a planned timetable produced initially. The review concluded that the system was run appropriately in line with the original objectives, such as provision of monetary compensation on no-fault basis, early resolution of disputes, and quality improvement of perinatal care through investigation and prevention. Then, the revised system was partly initiated in January 2014 on such details as procedure of investigation and adjustment of monetary compensation and damage payment, and in January 2015 on the rest of the details such as scope of eligibility to cover more CPs and other issues relevant to insurance. The JQ completed another review of the system to explore further expansion to cover more cerebral palsy cases in January 2022 and later. As seen above, the JQ believes that it is vital to improve the system in continued fashion through periodical review in cooperation with stakeholders.