On 6th November 2017, a maternity audit report was published, based on births in NHS maternity services in England, Scotland and Wales over two years (1st April 2015 - 31st March 2016).
This blog summarises some of the key findings and methodological details of relevance for Midwifery Unit Network. We hope this will encourage you to take a look at the full report for further information.
NMP Audit Finding:
‘Increasing access to midwife-led birth settings is a national priority and although the majority of obstetric units are co-located with an alongside midwifery unit in England, only around 13% of women give birth in a midwife-led setting.’
Jane Sandall and colleagues showed 45% of women were eligible for midwifery-led care at the end of pregnancy, and a mapping study by Denis Walsh and colleagues suggests that ‘a pragmatic calculation of the percentage of women that potentially could birth in midwifery units after obstetric referrals in pregnancy and during labour is 36%’ (Sandall et al, 2014; Walsh et al, 2018)
Relevance for midwifery unit managers and support groups
The main points of interest are:
· The explicit call to action ‘Increasing access to midwife-led birth settings is a national priority’ – see above.
· Reporting that routinely collected alongside midwifery unit data can often not be separated from the obstetric unit data. This has been reported repeatedly before, but it is a serious impediment to ongoing comparisons of outcomes for selected groups of women, and for sites with different proportions of women receiving midwifery-led care and using midwifery units.
· The recommendations to ‘individual clinicians’, to services and commissioners, reproduced below.
Overall key findings
The key findings are helpfully summarised at the start of the report, they include reports on BMI, maternal age, smoking, access to midwifery units, 3rd and 4th degree perineal tears, heavy blood loss, low Apgar scores, and small for gestational age babies born at term and post 40 weeks. Missing data are also highlighted for planned caesarean births carried out at 37 and 38 weeks, when babies are more at risk of illness than after 39 weeks.
Aims of the audit
The overarching aim of the NMPA is to produce high-quality information about NHS maternity and neonatal services which can be used by providers, commissioners and users of the services to benchmark against national standards and recommendations where these exist, and to identify good practice and areas for improvement in the care of women and babies. The NMPA consists of three separate but related elements:
• an organisational survey of maternity and neonatal care in England, Scotland and Wales providing an up-to-date overview of care provision, and services and options available to women
• a continuous clinical audit of a number of key measures to identify unexpected variation between service providers or regions
• a programme of periodic ‘sprint’ audits on specific topics.
‘The project is estimated to have captured 92% of births in England, Scotland and Wales during the (two year) time period, based on comparisons with hospital administrative and birth registration data for the reporting period.
‘The measures in this report were arrived at using an iterative process with consultation from external stakeholders through a Clinical Reference Group and members of the public through our Women and Families Involvement Group. They were evaluated for feasibility, data quality and statistical power, given the data that the NMPA has been able to collect and access in its first year.
‘In order to compare like with like, the majority of measures are restricted to singleton, term births.’
‘As a general principle, the denominator for each measure is restricted to women or babies to whom the outcome or intervention of interest is applicable. For example, the measure of the ‘proportion of women with a third or fourth degree tear’ is restricted to women who gave birth vaginally.
‘Rates of measures are also adjusted for risk factors which are beyond the control of the maternity service, such as age, ethnicity, level of socio-economic deprivation and clinical risk factors that may explain variation in results between organisations.’
It should, however, be remembered that the data are not complete, and there are known data quality issues. The authors state elsewhere ‘rates that appear to be ‘positive’ outliers … may be due to under-diagnosis or data quality issues’.
These, selected, recommendations of specific relevance for midwifery units have been quoted verbatim. Comments in bold have been added by the author. Recommendations that have been highlighted are of particular importance to Midwifery Unit Network.
…for individual clinicians
• Clinicians involved in maternity care should, in multidisciplinary teams, familiarise themselves with the findings for their own service and how these compare to national averages in order to determine the focus of quality improvement activity required. How many women in YOUR trust or board give birth in a midwifery unit or at home?
• Services should examine their own findings and data quality and compare these to internal audits where available, both to evaluate their data quality and to consider how they compare with national rates, and to determine action plans for quality improvement.
• Results for individual measures should not be interpreted in isolation. Rather, services should examine all measures together, attempting to understand possible relationships between them, and use this analysis to improve services as a whole, not just to one particular target. Measures in this report should also be considered together with perinatal mortality results from MBRRACE and measures of neonatal care from the National Neonatal Audit Programme (NNAP).
• Where the rate for a service differs substantially from the overall rates, the service should identify reasons for this. This includes rates that appear to be ‘positive’ outliers as this may be due to under-diagnosis or data quality issues. Where true positive outliers are identified, services should consider ways of sharing best practice with their peers (emphasis added) and with the NMPA so that these can be shared with other services.
• Services should ensure that local information about the rates of care processes and outcomes in labour is made available to women using their services. This should be by planned or actual place of birth, eg home birth, freestanding midwifery unit, alongside midwifery unit and/or obstetric unit.
• Audit departments should facilitate dissemination of these findings among all relevant staff and services and commissioners should share and discuss the findings as part of their Maternity Voices Partnerships (formerly Maternity Services Liaison Committees).
• Further work is needed to understand the potential for increased use of midwife-led settings. This includes gaining a better understanding of the proportion of women considered suitable to use these settings and the criteria applied by different services through local review by providers and commissioners, inclusion of relevant questions in national surveys of women, and further research.
• Commissioners should facilitate the dissemination of these results to GPs and local authorities.
• Commissioners, together with clinicians, services and policymakers should strongly prioritise the provision of resources to support breastfeeding, both in maternity units and in the community, to reduce the variation in the proportion of babies receiving breast milk at their first feed and at discharge from the maternity unit.
• Commissioners should support services to collect information on planned and actual place of birth, distinguishing between obstetric units, alongside midwifery units, freestanding midwifery units and home, and to collect information on transfers in utero, and during labour and the postnatal period.
For this, the first NMPA report, three measures were selected as indicators for ‘outlier reporting’. These indicators are:
• proportion of vaginal births with a severe (3rd or 4th degree) perineal tear
• proportion of women with an obstetric haemorrhage of 1500ml or more
• proportion of singleton, term, liveborn babies with a 5-minute Apgar score of less than 7.
The report includes ‘site level’ findings for these outcomes (p76) and for other measures of clinical importance (see list below), and reports those that are statistically higher or lower than the mean (average). Unfortunately, there are no published results for births in midwifery units, but these should be available locally.
Some ‘sites’ (usually a trust/board, obstetric unit or a combined obstetric unit and alongside midwifery unit) have no findings listed, as their data were either not submitted, or were woefully incomplete. Check out the results for your trust/board, obstetric unit or a combined obstetric unit and alongside midwifery unit. If your local site is not listed find out about the problem and ask your LMS Board (in England) to sort it out.
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)
Summary written by Mary Newburn for MUNet.
Sandall, J., Murrells, T., Dodwell, M., et al., 2014. The efficient use of the maternity
workforce and the implications for safety and quality in maternity care: a population based,
cross-sectional study. Health Services and Delivery Research 2, 1–289.
Walsh D., Spiby H., Grigg C., et al 2018 Mapping midwifery and obstetric units in England. Midwifery 56, 9-16. Available online at http://dx.doi.org/10.1016/j.midw.2017.09.009