- A large evaluation of NHS services that looked after over 700,000 women and 720,000 babies show improvements in care
- Findings also show where action is needed from services, commissioners and policy makers
- Royal Colleges commend progress, but highlight where services need to be made safer, more personalised and offer greater choice
The National Maternity and Perinatal Audit (NMPA) is a major analysis of NHS maternity and neonatal services in Britain. Launched in 2016, it uses data collected by hospitals to evaluate a range of care processes and outcomes, and produces high-quality information about services.
The second clinical report, published today, continues to show considerable wide variation in care and outcomes for women and babies. Some of this variation is inevitable and may reflect meeting the local needs of women and babies or variable data quality, but all maternity services need to ensure that care being delivered is of the highest standard, concludes the report.
The findings present a national picture of maternity and perinatal services in 149 of 151 trusts and boards across England, Scotland and Wales that provided care to 717,529 women who gave birth to 728,620 babies born between April 2016 March 2017.
Key findings include:
- Induction of labour rate increased slightly from 27.9% to 29.2%, while babies born small after 40 weeks decreased from 55.3% to 52.3% in England compared with 2015/16. This coincides with the introduction of the Saving Babies’ Lives Care Bundle that aims to reduce stillbirth.
- However, the number of small babies born after 40 weeks is still high, and the induction of labour rate varied from 16.1% to 43% among individual maternity units.
- Third and fourth degree perineal tears – a major complication of vaginal birth – were broadly similar between all countries, with an overall rate of 3.5% across Britain, but the reported rate varied widely among maternity services from 0.7% to 6.4%.
- Obstetric haemorrhage of 1500 ml or more – major bleeding after childbirth which remains an important cause of maternal morbidity and mortality – had a rate of 2.8% in England and 3.5% in Wales, with wide variation among maternity units with reported rates from 0.7% to 5.4%.
- Rates of an Apgar score of less than 7 at 5 minutes – a measure of the baby’s condition after birth – also varied from 0.4% to 3.6% among maternity services.
- For the first time, over half (50.4%) of women were recorded as overweight or obese at the time of booking – this is up from 47.3% in 2015/16.
- 22% of women were over the age of 35, and 4.1% were over the age of 40, at the time of giving birth, reflecting the ongoing rise in maternal age.
Substantial variation in the different types of birth exists and these measures should be considered together:
- The spontaneous vaginal birth rate among women having a single term baby was 61.9% in England, 57.1% in Scotland and 64.5% in Wales, with variation from 54.1% to 68.5% among maternity services.
- The rate of overall caesarean birth (including elective and emergency) was 25.5% in England, 30.5% in Scotland, 24.1% in Wales, with an overall rate of 25.8% across Britain, and a range of 19.2% to 32.8% among maternity services.
- The rate of instrumental births (assistance of forceps or ventouse during a vaginal birth) was 12.6% in England, 12.3% in Scotland, 11.4% in Wales, with an overall rate of 12.5% across Britain, with variation from 6.8% to 18.4% among maternity services.
- The proportion of women who gave birth to a single baby at term, and who had a spontaneous onset of labour and a spontaneous vaginal birth without epidural, spinal/general anaesthesia or an episiotomy was 41.5% in England, 34.2% in Scotland and 41.1% in Wales. This ranged from 29% to 54% among maternity services.
New neonatal care measures being reported for the first time include:
- 5.8% of babies born between 37 and 42 weeks, and 41.9% of those born between 34 and 36 weeks were admitted to a neonatal unit.
- 5.8 in 1000 babies born between 37 and 42 weeks received mechanical ventilation in the first 3 days of life.
- 1.7 in 1000 babies born between 35 and 42 weeks developed an encephalopathy, a marker of potential brain injury, within the first 3 days of life.
The report makes a number of key recommendations to drive improvements for those providing, commissioning, funding and using maternity services.
Professor Lesley Regan, President of the Royal College of Obstetricians and Gynaecologists (RCOG), said:
“All women should expect to receive the best possible care during pregnancy and childbirth. National initiatives to improve maternal and neonatal care are making impressive headway to ensure services are as safe and personalised as possible for women, the vast majority of whom have a safe birth.
“But we must not be complacent since this report highlights marked variation in standards of care persist, particularly around birth complications, such as severe perineal tearing and obstetric haemorrhage. These findings will enable maternity staff, healthcare commissioners, policy makers and women to evaluate maternity and perinatal care provided locally and nationally, and to make further improvements in the quality of services.”
Professor Russell Viner, President of the Royal College of Paediatrics and Child Health (RCPCH), said:
“For the first time, over half of women are being recorded as overweight or obese during pregnancy. Every parent wants to give their baby the best start in life, however this raises several red flags for both women’s and children’s health.
“For mothers, being overweight during pregnancy comes with significant risks including gestational diabetes, pre-eclampsia, miscarriage and postpartum haemorrhage. Meanwhile, babies born to overweight parents are much more likely to become overweight children and are more likely to suffer from life-long conditions such as type 2 diabetes.
“Women must be supported before conception, during pregnancy and after birth to ensure the healthiest possible outcome for both themselves and their child. With the right support, it is possible to stop this dangerous cycle from being repeated.”
Zeenath Uddin, Head of Quality and Safety at the Royal College of Midwives (RCM) said:
“The RCM is pleased to see that maternity services are making continuous and considerable efforts to improve and implement recommendations from recent reviews and initiatives.
“The results suggest that maternity and neonatal service provision is improving in a number of important areas as well as facing ongoing challenges, particularly around unwarranted variation.
“It’s disappointing that the data collected around smoking at time of birth and during pregnancy is inconsistent and this is concerning. We know smoking can increase the risk of miscarriage, placental abruption and eclampsia. A recent RCM survey revealed that almost 70 % of Heads of Midwifery reported they do not have a smoking cessation specialist midwife in their maternity team. Evidence show that stopping smoking early in pregnancy can almost entirely prevent adverse effects and we need to be doing all we can to support women and their families to stop smoking.
“Overall the audit findings present a valuable national snapshot of maternity and perinatal services and where there is unwanted variation is some areas, there are also areas where good practice has been identified and this is an opportunity for learning which will ultimately improve the care that women and their babies receive.”
Dr Ipek Gurol-Urganci, Lead Methodologist of the NMPA Project Team and Assistant Professor at the London School of Hygiene and Tropical Medicine wrote:
“This second clinical report from the National Maternity and Perinatal Audit demonstrates the importance of having complete and accurate information about where and how women give birth. However, NHS providers of maternity services and national data providers need to further improve the data that they collect and the flow from local systems to central datasets because many maternity services are still excluded from one or more measures because of incomplete data.”
Mrs Emma Crookes, NMPA Women and Families Involvement Group and RCOG Women’s Network member, wrote:
“The way the National Maternity and Perinatal Audit measures processes and outcomes of individual trusts and boards against their peers opens up local as well as national conversations between providers and service users. This means that open and honest conversations can take place to co-design services, co-produce care plans and co-create trusting and honest partnerships between healthcare professionals and service users. All maternity units should use the NMPA as a measuring tool in order to gain momentum and confidently move into more personalised and assured care for all women and their families.”
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The report is available on the NMPA website. Local and national results are available on an interactive website: www.maternityaudit.org.uk
The report includes approximately 97% of all births during the time period.
The findings include skin-to-skin contact after birth, breastfeeding, smoking in pregnancy, and maternal re-admission to hospital among other measures.
Of the 128 Trusts, 13 boards in Scotland, and 6 boards in Wales with at least one obstetric unit and among women having a term singleton baby:
- Rate of elective caesarean was 11.1% in England, 13.3% in Scotland, 10.9% in Wales, and 11.3% across Britain; the rate of emergency caesarean was 14.3% in England, 16.8% in Scotland, 13.3% in Wales, and 14.5% across Britain
- Rate of forceps during childbirth was 7.1% in England, 9.3% in Scotland, 8.1% in Wales, with a rate of 7.3% across Britain
- Rate of ventouse was 5.5% in England, 3.0% in Scotland, 3.3% in Wales, with an overall rate of 5.2% across Britain.
The first clinical report was published in 2018 and can be viewed on the NMPA website.
The clinical report published today should be evaluated together with the 2019 NMPA organisational report.
About the NMPAThe NMPA is a large evaluation of NHS maternity and neonatal services in Britain. Launched in 2016, it uses timely, high quality data to evaluate a range of care processes and outcomes and produces high-quality information about NHS maternity and neonatal services. It benchmarks against national standards and recommendations where these exist, and to identify good practice and areas for improvement in the care of women and babies.
Funded by HQIP, NMPA is a joint collaboration between the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives, the Royal College of Child Health and Paediatrics, and the London School of Hygiene & Tropical Medicine.
About the RCOG
The Royal College of Obstetricians and Gynaecologists (RCOG) is a medical charity that champions the provision of high-quality women’s healthcare in the UK and beyond. It is dedicated to encouraging the study and advancing the science and practice of obstetrics and gynaecology. It does this through postgraduate medical education and training and the publication of clinical guidelines and reports on aspects of the specialty and service provision. www.rcog.org.uk
About the Royal College of Midwives
The Royal College of Midwives (RCM) is the only UK professional organisation and trade union dedicated to serving midwifery and the whole midwifery team. The RCM has a vital role in disseminating information about professional midwifery practice, and in ensuring that there is a recognised UK-wide platform for sharing good practice. This includes professional and clinical guidance and information, online resources, reports on service provision, and conferences and events. www.rcm.org.uk
About the Royal College of Paediatrics and Child Health
The mission of the Royal College of Paediatrics and Child Health (RCPCH) is to transform child health through knowledge, innovation and expertise. The RCPCH aims to improve outcomes through research, standards, quality improvement and policy, in the UK and globally, and to ensure the voice of children, young people and families in its programmes. The RCPCH is responsible for the postgraduate training of paediatricians in the UK and provides access to multidisciplinary educational programmes. www.rcpch.ac.uk