Clinical Report 2017 - National Maternity and Perinatal Audit

National Maternity and Perinatal Audit Clinical report 2017 - revised version

Based on births in NHS maternity services between 1st April 2015 and 31st March 2016

National Maternity and Perinatal Audit Clinical report 2017 - revised version Based on births in NHS maternity services between 1st April 2015 and 31st March 2016

This revised report was issued in March 2018. A summary of changes to the previously published version can be found on pages 1-2.

The National Maternity and Perinatal Audit is led by the Royal College of Obstetricians and Gynaecologists (RCOG) in partnership with the Royal College of Midwives (RCM), the Royal College of Paediatrics and Child Health (RCPCH) and the London School of Hygiene and Tropical Medicine (LSHTM) Copyright Healthcare Quality Improvement Partnership (HQIP) This report was prepared by the NMPA project team: Ms Andrea Blotkamp, NMPA Clinical Fellow (Midwifery) Dr Fran Carroll, NMPA Research Fellow Dr David Cromwell, NMPA Senior Methodological Advisor Dr Ipek Gurol-Urganci, NMPA Senior Methodological Advisor Dr Tina Harris, NMPA Senior Clinical Lead (Midwifery) Dr Jane Hawdon, NMPA Senior Clinical Lead (Neonatology) Dr Jen Jardine, NMPA Clinical Fellow (Obstetrics) Ms Hannah Knight, NMPA Audit Lead Dr Lindsey Macdougall, NMPA Data Manager Ms Natalie Moitt, NMPA Statistician Dr Dharmintra Pasupathy, NMPA Senior Clinical Lead (Obstetrics) Prof Jan van der Meulen, NMPA Senior Methodologist (Chair) Please cite as: NMPA Project Team. National Maternity and Perinatal Audit: Clinical Report 2017. RCOG London, 2018.

Preface This report replaces the previously issued report (published on Nov 9th 2017) on births in Britain between 1st April 2015 and 31st March 2016. The data quality and results chapters have been updated.

Why is there a revised report? Following publication of the previous clinical report, a systematic data quality issue came to our attention. In caesarean birth records, some information, especially on the presentation of the baby at birth (head first or other) is considerably less complete than it is for vaginal births.1 The original NMPA measures had sought to classify births into Robson groups,2 in order to maximise the comparability between units. This is in line with both national and international recommendations.3 Thus, where relevant, measures were restricted to singleton, term, cephalic births. As the information required to identify these births was more often present for a vaginal birth than a caesarean birth, caesarean births were disproportionally excluded from some measures. This led to an underestimation of caesarean rates, and a corresponding overestimation of spontaneous vaginal birth rates. The other measures affected were induction of labour, obstetric haemorrhage and vaginal birth after caesarean section. As a result, the NMPA team together with our partners and stakeholders elected to replace the original report with this revised version.

What has changed? Definitions of measures The following measures have been redefined to remove the ‘cephalic’ restriction. Therefore they only measure rates among singleton, term births: 1. 2. 3. 4.

Mode of birth (caesarean, instrumental and spontaneous vaginal birth) Induction of labour Obstetric haemorrhage ≥1500ml Vaginal birth after caesarean (VBAC)

For these measures most results will have changed to some degree. The direction of change for most sites is an increase in caesarean section and haemorrhage rate, and a reduction in induction of labour and VBAC rates. Removal of obstetric haemorrhage as a measure for outlier reporting Obstetric haemorrhage ≥1500ml was one of three outlier indicators included in the previous version of this report. Due to the change in the definition of this measure, we have agreed with the Healthcare Quality Improvement Partnership (HQIP) and the Care Quality Commission (CQC) that obstetric haemorrhage will not be treated as an outlier indicator for the 2015/16 time period. Results for the other two outlier indicators remain unchanged. 1

Site, trust/board and national results For individual sites and trusts, in addition to the above changes, there may be: • Results for measures where there were previously none For example, if the presentation of the baby at birth was very poorly recorded, a site may not have previously met quality checks for rates of mode of birth. In this revised report where presentation is not required, this site may now be included. • No results for measures where there were previously During our systematic investigation of all results, we discovered a number of data issues that were unique to individual sites. Such sites have now been excluded from measures where they were found to have unreliable data. • Changed results in measures other than those above All results have been re-generated. Due to excluding and including different sites, the national average has changed for most of the measures. The corresponding effect on case mix adjustment will also have resulted in – usually very small - changes to individual site results. However, for country level results in Scotland and Wales, where very large hospitals were affected by data quality issues, more substantial changes may be seen. Results for all measures were circulated to trusts and boards prior to the publication of this report to allow results to be reviewed and validated against internal statistics.

Next steps The NMPA uses information from three countries, over 140 different individual data sources and almost 700 000 births a year to derive measures which enable quality improvement. We remain committed to this mission and are currently in the initial phase of deriving results for 2016-2017. In late 2018 we will publish results for 1st April 2016 to 31st March 2017. For this analysis, we will not attempt to restrict to cephalic births. Going forward, we will continue our efforts to improve the quality of information collected about maternity care and outcomes in Britain. Participating sites can also help us by continuing efforts locally to ensure that data entered onto their electronic maternity records is as complete as possible. We apologise unreservedly for any inconvenience or confusion caused by the need to revise this report. We are available to answer any queries at nmpa@rcog.org.uk.

1

More detail is available at http://www.maternityaudit.org.uk/Audit/Charting/reports

2

Robson, M. (2001). Classification of caesarean sections. Fetal and Maternal Medicine Review, 12(1), 23-39. doi:10.1017/ S0965539501000122

3

European Board and College of Obstetrics and Gynaecology. (2017) EBCOG position statement on caesarean section in Europe. 219, pp129 doi:10.1016/j.ejogrb.2017.04.018

2

Contents Preface

1

Tables and figures

5

Acknowledgements

7

Foreword

8

Executive summary Introduction Methods Key messages Clinical findings Data quality Recommendations

10 10 10 12 12 14 15

Abbreviations and glossary

18

Introduction The National Maternity and Perinatal Audit Why was the NMPA commissioned? The overall aims of the continuous clinical audit What does this report cover?

21 21 21 22 23

Methods The NMPA approach to data collection Data sources used by the NMPA Selection of audit measures for the NMPA Outlier indicators Case ascertainment Analysis Construction of audit measures Case mix adjustment Presentation of data using funnel plots Levels of reporting Suppression of small numbers

24 24 24 26 27 27 27 27 28 28 29 30

Data quality Key findings How does the NMPA assess data quality? Country level differences Results of data quality assessments How does poor data quality affect our ability to derive nationally important measures? Recommendations

31 31 31 32 33 34 35

Findings Key findings Characteristics of women and their babies Maternal age Ethnic background Deprivation

37 37 38 38 39 40

3

National Maternity and Perinatal Audit – Clinical Report 2017

Parity Pre-existing medical conditions, obstetric history and current pregnancy-related problems Body mass index Smoking Gestational age at birth Birth weight Discussion Place of birth Measures of care before, during and after birth Smoking at booking and birth Induction of labour Elective deliveries between 37+0 and 38+6 weeks gestation without a documented clinical indication Babies born small Modes of birth Vaginal birth after caesarean section Episiotomy Third and fourth degree tears Obstetric haemorrhage of 1500ml or more Five minute Apgar score Skin to skin contact within one hour of birth Breast milk at first feed and at discharge Unplanned maternal readmission Discussion Recommendations

40 40 41 42 43 44 45 45 46 47 48 49 50 52 55 56 58 59 61 62 63 65 66 67

Stakeholder perspectives

69

Appendices 1 Contributors 2 Site level results

73 76

References

87

4

Tables and figures Tables 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

Estimated case ascertainment Results of data quality assessment Quality of data items required to construct a ‘birth without intervention’ measure Number of records in the NMPA clinical dataset Ethnic background Index of multiple deprivation Parity Pre-existing medical conditions, obstetric history and current pregnancy-related problems Body mass index at booking Birth weight Birth weight centiles Place of birth by site Place of birth by unit/birth setting Proportion of women who stop smoking during pregnancy Proportion of women with a singleton pregnancy at term receiving induction of labour Proportion of elective deliveries between 37+0 and 38+6 weeks gestation without a documented clinical indication Proportion of term babies born small for gestational age Proportion of women giving birth to a singleton baby at term, by mode of birth Proportion of women who had their first baby by caesarean section and who give birth to their second baby vaginally at term Proportion of women who have a vaginal birth of a singleton, cephalic baby at term and who have an episiotomy Proportion of women who have a vaginal birth of a singleton, cephalic baby at term and who sustain a third or fourth degree perineal tear Proportion of women who have a singleton baby at term and who an obstetric haemorrhage of 1500ml or more Apgar scoring system Proportion of singleton babies born at term who are assigned an Apgar score of