Differences in the care received by women giving birth in hospitals across England are highlighted in a state of the nation report published by the Royal College of Obstetricians and Gynaecologists (RCOG) today.
The report, carried out in collaboration with the London School of Hygiene & Tropical Medicine, gives a national perspective on patterns of care during labour and delivery, enabling NHS trusts to examine their own practice in context and ensure their services meet the needs of women and their families.
For the first time, the information can be accessed in an interactive format on a new website launched today (https://indicators.rcog.org.uk).
Overall, 55% of all first-time mothers had some form of intervention during labour and delivery, and the report indicates considerable variation across maternity units in the types of intervention given and the outcomes these women experienced. For example, there was a 1.5 to two-fold difference between NHS trusts with the lowest and highest rates of emergency caesarean sections (8% and 15%). Among first-mothers who had vaginal delivery, a similar amount of variation was seen in the rates of instrumental delivery (19% and 29%) and episiotomy (29% and 44%).
Some variation in care is to be expected and may reflect a service that is tailored to the specific needs and preferences of individual patients or populations. The results have been adjusted to control for risk factors that are beyond the control of individual trusts, such as a woman’s previous birth history, age and level of social deprivation. However, the authors caution that some of the observed differences could be due to differences in the quality of the data submitted by trusts, as well as differences in patient characteristics that were not possible to control for, for example smoking and obesity. Nonetheless, the variation may also suggest that not all women are getting the best possible care across the country or that NHS resources are not being used in the most efficient way.
The report identifies that over 10% of hospital trusts failed all data quality checks and calls for greater NHS trust engagement in ensuring that IT systems are fit for purpose.
Dr David Richmond, President of the Royal College of Obstetricians and Gynaecologists (RCOG), said:
“We are concerned about the amount of variation identified in this report. Although the exact causes are difficult to establish, it is paramount that maternity units have information about their services, as well as the ability to compare themselves to the national average and to their peers.
“The RCOG is dedicated to creating a culture of openness and transparency within maternity and gynaecological care. With this information, maternity services, alongside commissioners, will be able to move towards identifying priority areas for reducing variation and further improving the safety and quality of care provided to women and their babies.”
Dr David Cromwell, co-author of the report and Reader in Health Services Research at the London School of Hygiene & Tropical Medicine, added:
"Despite a continued need for improvements in data quality across the NHS, the information provided to trusts within this report will help them to monitor local practice and deliver consistently good care throughout the country.
“Since we started sharing these findings in 2013, we have already seen excellent examples of trusts using the data to identify clinical issues and make improvements. Providing data to empower individual trusts to take action is exactly why we undertook this project.”
The RCOG, in partnership with the London School of Hygiene & Tropical Medicine, Royal College of Midwives and Royal College of Paediatrics and Child Health, will build on this work by leading the new National Maternity and Perinatal Audit, which will evaluate the quality of care received by women and newborns cared for by hospital services in England, Wales and Scotland.
For further information, please contact Rebecca Jones, RCOG Media and PR Manager on 020 7772 6444 or email firstname.lastname@example.org
The report uses data from the Health and Social Care Information Centre (HSCIC).
Further information about the RCOG Clinical Indicators Project.
Further information about the National Maternal and Perinatal Audit.
Case study information
The RCOG has identified some NHS trusts who have already started using the data to make improvements to their local maternity services.
Central Manchester University Hospitals NHS Foundation Trust
Using the Clinical Indicators data, the trust identified that it had a low caesarean section rate, low induction rate and more women delivering vaginally than most other hospitals in the country. However, it accepted that in order to achieve this, its rates of instrumental delivery and episiotomy were slightly higher than the national average.
Maternal readmission rates were also slightly higher than the national average. On conducting an internal audit, the trust identified the causes behind the readmission rates and are working to find ways of reducing wound infection and sepsis.
Dr Sarah Vause, Consultant in Fetal and Maternal Medicine and Deputy Clinical Head of Division St Mary's Hospital Manchester, said:
“These data have been extremely helpful in highlighting where we need to focus our attention and improve services. The ability to pinpoint how we are performing across all aspects of intrapartum care not only allows us to provide valuable feedback to our staff, but also to provide women with evidence-based information to help them make informed decisions about their care.”
University College London Hospitals NHS Foundation Trust
The trust identified that certain indicators relating to elective caesarean section and instrumental delivery have slightly higher rates than the national average due to the inclusion of high-risk deliveries as the tertiary referral unit for North Central London as well as nationally. Maternal readmission rates were also slightly higher as a result of a focus on early diagnosis and treatment of infection in secondary care following the recommendation from the latest MBRRACE-UK report into maternal mortality.
Mr Ruwan Wimalasundera, Consultant Obstetrician & Fetal Medicine Specialist and Lead for Obstetrics University College London Hospital, said:
“We welcome the publication of the RCOG data and the opportunity to benchmark against other similar organisations and learn from differences. This has helped us focus on our continued aim to offer the highest quality care and patient experience for our patients. We were very encouraged that our adjusted overall caesarean section rates were significantly below the national average, but we recognise that our planned caesarean section rates are higher than the national average. However, having examined the data more closely, we have found that women accessing our services have already made a decision about the type of birth they want and choose to book with us as they feel that we are the best place for them to have their elective caesarean. Reinforced by the recent NHS England National Maternity Review, patient choice is central to maternity care, however, it is our role to ensure that all of the correct pathways are put in place. Women are fully counselled about all of the risks and benefits of the different delivery options and we have appropriate levels of staffing to care for the women we serve.
“Despite our slightly higher instrumental delivery rate, we are reassured that our third and fourth degree tear rates are lower than the national average, indicating that our staff are well trained in performing these procedures when they are required. Overall our policy is to support women wishing to deliver in the midwifery-led birth centre and maintain normality as much as possible. However, we are also working with our midwifery and anaesthetic staff to maintain mobility in women who chose to have epidurals as this has been shown to reduce prolonged labour and the need for instrumental deliveries.”
 Comparing the 10% of hospitals with lowest rates with the 10% of hospitals with the highest rates.