In this article Kirstin Webster, ANNP and NMPA Neonatal Clinical Fellow, presents an overview of the recently published National Maternity and Perinatal Audit annual clinical report. Highlighting key findings and recommendations for improvements in clinical care and data quality. She also provides an update on other recent activities and developments within the audit.
The latest annual clinical report published by the National Maternity and Perinatal Audit (NMPA) focusses on births occurring between 1 April 2018 and 31 March 2019 in NHS maternity units in England and Wales. Results are presented for over half a million women and birthing people and their babies. The methods outlining the selection of audit measures, the NMPA approach to data collection and data sources used can be found online. A summary of the key findings is also available.
This report, capturing 89% of eligible births in England and Wales, finds variation in care and outcomes between trusts and boards, and highlights key messages with respect to data quality and completeness.
In reporting mode of birth, we found that of the women and birthing people giving birth for the first time, 23% had an instrumental birth (a birth assisted with either forceps or ventouse), 23% had an emergency caesarean birth, and of those who gave birth vaginally, 44% had an episiotomy. Whereas for women giving birth for the second time, 4% had an instrumental birth, 10% had an emergency caesarean birth, and of those who gave birth vaginally, 9% had an episiotomy. Of those opting for a vaginal birth after caesarean (VBAC) for their second birth, 61% experienced a vaginal birth.
As many as 1 in 20 women and birthing people who had a birth assisted by forceps did not have an episiotomy, of these 31% experienced an obstetric anal sphincter injury (OASI). Therefore, we call for routine counselling for all women and birthing people about the risks of OASI and the offer of an episiotomy for those experiencing a forceps-assisted birth.
Whilst we found that around one third of all women and birthing people with singleton pregnancies giving birth at term underwent an induction of labour (IOL), there was considerable variation in rates between trusts and boards. A funnel plot showing the trusts and boards that fell outside of the expected range for IOL can be found in the full report. An explanation of how to interpret a funnel plot, also with a video, is provided in the Frequently Asked Questions (FAQs) page of the NMPA website, along with how midwives and maternity care professionals can use the NMPA results.
We found that around 50% of small-for-gestational-age (SGA) babies were born after their due date. This is in contrast to national guidance recommending earlier induction be offered if there are concerns about a baby being born SGA. Our finding may indicate that either an instance of SGA was not appropriately detected, or that the woman or birthing person made an individual choice to continue with expectant management instead of opting for an induction of labour.
When reviewing the data for unplanned postnatal maternal readmission, we found the rates were higher for women and birthing people who had had a caesarean birth (4.3%) when compared with those who had given birth vaginally (2.9%). We recommend trusts and boards review all unplanned maternal readmissions to try and understand the common reasons, and to identify changes in practice or areas for improvement that may reduce the chance of readmission.
We would like to see an improvement in the availability and quality of information made available to women and birthing people about their choices during pregnancy, labour and birth. Information should be evidence-based, in a language and format which is accessible and tailored to each woman or birthing person’s circumstances. An NHS England and Improvement decision making tool called IDECIDE is currently in production to help healthcare professionals in supporting women and birthing people to make informed decisions during labour.
Each trust and board must review their own results from the NMPA, utilising local audit of measures to investigate differences in practice that may contribute to the observed variation in rates. For example, the majority of trusts in England had a proportion of babies with an Apgar score of less than 7 at 5 minutes within the expected range, however for a few trusts the rates were more than twice the average. An Apgar score is determined by evaluating the baby’s physiological condition at specific time points – often 1 minute and 5 minutes, and a score of less than 7 is a sign that the baby needs medical attention. Trusts where a higher proportion of babies are born with an Apgar score less than 7 should utilise local audit to investigate care practices to improve outcomes.
This latest NMPA report also highlights the need for healthcare professionals working in maternity services and maternity care providers to conduct reviews about data completeness for their own trust or board or individual hospital site. There was a noticeable proportion of missing or incomplete data in both England and Wales for variables such as anaesthesia, augmentation, and smoking at the time of birth. Insufficient data capture was also found for labour onset, episiotomy, BMI at booking, babies receiving breast milk at discharge, and for ethnicity. Therefore, we recommend that user feedback be used to review patterns in missing data, and to identify areas for system development that improve data collection without compromising clinical care. It would also be helpful to amend data fields to enhance the ease of recording of types of intrapartum analgesia, and more detail such as the availability and timeliness of epidural anaesthesia.
National audit data and results such as those reported in NMPA outputs and online offer an opportunity for maternity care providers to reflect on the care they provide. By interrogating their own practice and by sharing good practice examples from others, they may initiate quality improvement processes to enhance care and outcomes.
The NMPA team would like to see maternity and neonatal healthcare professionals, maternity services providers and, most importantly, women and birthing people, and their families, work together to identify meaningful measures of perinatal and postnatal care to improve the experience for families. This is important as, for example, there are currently differences in the choice of postnatal variables captured in the English and Welsh maternity datasets, such as breast milk and skin-to-skin measures. It became apparent during discussions with our women and families involvement group (WFIG) that these variables do not adequately capture the experience of women, birthing people, or their babies and families.
The voices of our WFIG members are woven throughout the report, highlighting the valuable contribution they bring to interpreting the results, identifying the key findings and in developing recommendations. We have included the WFIG and other service user representatives in the co-production of our report summaries and incorporated their experiences and interpretation of results into our annual clinical and sprint audit reports. The use of language and terminology in our outputs is discussed during our advisory group meetings and we welcome the results from the Royal College of Midwives Re:Birth project in stimulating conversations with maternity care professionals and women and birthing people about how language can improve safety, outcomes and experiences.
Our Family Gateway is now live and offers information on the NMPA as well as links to other charity and maternity care organisations. The site and its content has been co-produced with our WFIG, and designed with the aim of supporting women, birthing people and their families in initiating discussions to help them make informed choices about their maternity care.
Alongside producing national audit reports and sprint audits, the team at the NMPA have published a number of research papers interrogating national data in more detail.
Following the recent publication of the Ockenden Review final report, we analysed NMPA data for births occurring between 1 April 2015 and 31 March 2017 to publish national hospital-level data on the use of induction of labour and emergency caesarean section and perinatal outcomes in English maternity services. The results show considerable between-hospital variation in the use of induction of labour and emergency caesarean section for singleton births at term. The hospitals that had a higher rate of induction of labour had a lower risk of adverse birth outcomes, however, a similar association was not found for emergency caesarean births.
The next annual clinical report will include births occurring between 1 April 2019 and 31 March 2020, meaning a number of those births will have occurred during the beginning of the first COVID-19 pandemic lockdown period. The NMPA have previously published research on the effects of the pandemic periods on pregnant women and their babies, the effects of COVID-19 infection during pregnancy, and described inequalities through the COVID-19 pandemic.
The re-tender process for the audit is currently underway and there are plans to include a sustainability strategy to ensure national data on maternity and perinatal services will be available long-term. There are exciting plans to not only enhance collaborative working with women and birthing people, and their families, but also to provide midwives and maternity services healthcare professionals with tools and data to improve care and outcomes. We are always happy to receive questions, comments and feedback to improve our outputs, email us at: firstname.lastname@example.org, and make sure you follow us on Twitter for news and updates @nmpa_audit.
Kirstin Webster, ANNP and NMPA Neonatal Clinical Fellow
Twitter: @nmpa_audit @NeonatalNurstin