National Maternity and Perinatal Audit Report published on 9 November 2017
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What is the National Maternity and Perinatal Audit?
A new large scale audit of NHS maternity services across England, Scotland and Wales to evaluate a range of care processes and outcomes to identify good practice and areas for improvement for women and babies.
What are the key findings of the National Maternity and Perinatal Audit?
Availability of services and facilities
- Maternity and neonatal services are organised in many different ways and there is no ‘typical’ maternity unit. This may reflect services responding to local needs.
- Nearly all trusts and boards use an electronic maternity information system to record the care of women and babies but half report that this was not fully accessible to community midwives and only a tenth report that women themselves have access to their electronic maternity record.
- The number of planned community postnatal contacts for healthy women and babies ranges from 2 to 6 between different maternity services.
- Many services are taking measures to put women and their families at the centre of care, but these are not universal.
- Fewer than two thirds of sites with a neonatal unit provide transitional care for babies who need some additional support, either on a postnatal ward or on a dedicated transitional care ward.
Maternity and neonatal services staffing
- There is variation in staffing provision. This reflects differences in staffing models and the absence of clear national standards for midwifery and obstetric staffing across the care period.
- The level of carer continuity that maternity services perceive they provide is low, regardless of how midwifery care is organised.
- Only 15% of trusts and boards use care models for which they report that women see the same midwife for most care contacts in the antenatal, intrapartum and postnatal period. This includes care in labour from a known midwife. No Trusts use these care models for all women.
- Maternity services should work towards electronic recording of all maternity care contacts. This can help identify which care models are associated with the highest levels of continuity of carer and monitor progress towards this goal.
The NMPA organisational survey results shows which of the key themes of national policies have been implemented and more importantly, which have not. This initial survey is to be repeated in 2019.
It is hoped that this survey will:
- serve as a baseline to monitor progress against and provide an opportunity to identify barriers to the implementation of recommendations,
- examine organisational factors in association with clinical outcomes; and
- develop additional standards to benefit women and babies.
Working and learning together Networks
Clinical networks are linked groups of healthcare providers, aiming to enable sharing of expertise.. Neonatal networks were established following the 2003 review of neonatal intensive care by the Department of Health. A key recommendation of the English maternity review was that maternity care professionals set up a similar network for improved learning.
92% of trusts in England reported that they are engaged in both a maternity and a neonatal network, an increase from 2013, when 74% of English trusts were involved in a maternity network. One further trust reported involvement in a neonatal, but not a maternity, network. All trusts reported some referral of women between hospitals, for example for more specialist care. In Wales, six of the seven health boards (86%) reported engagement in both a maternity and a neonatal network.
Electronic information sharing
Information sharing between professionals, organisations and with the women using the maternity services is vital to provide safe and effective care. A key aim of maternity providers in England is to develop a digital maternity tool and achieve women-held digital maternity records.
97% of trusts reported using an electronic maternity information system to record the care of women and babies. However, even among the 133 services (86%) which reported full access to electronic maternity records for maternity clinicians in hospital, access was limited off-site and in particular for women themselves. See below:
Care models and continuity
Midwifery staffing was organised in different ways; some services had separate staff in the community and in hospital, while others had integrated staff, who worked across antenatal, intrapartum and postnatal care in the community and in hospital. 10% of trusts reported that all midwives worked in an integrated way, with a further 34% having some integrated midwives.
Only 3% of trusts reported that all their midwives carried a caseload (and hence provided continuity), defined as a primary midwife providing care during pregnancy, birth and postnatally with back-up provided by another known midwife when necessary.
In addition, a further 35% of trusts reported having some midwives who carried a caseload, but this was most commonly for women with particular needs.
58% of trusts operated more than one care model and 92% had community midwives organised into teams. 36% of these reported that the majority of their teams had 4 to 6 midwives (as recommended by Better Births), but over half mostly had larger teams than this (again reducing the possibility of continuity).
Delivering Continuity of Maternity Care
The need for continuity of carer is among the most prominent of recommendations resulting from the national maternity reviews. The only way to see how many care providers seen in any one pregnancy is to have electronic recording of all contacts during pregnancy, birth and the postnatal period. This would require sustained adequate IT provision.
Currently the majority of trusts rely on time-consuming audit of paper records but 40% of maternity services do not monitor continuity of carer at all.
The 2016 RCOG report “Providing quality patient care – obstetrics and gynaecology workforce” describes many challenges facing obstetric staffing one of which is a significant shortage of middle grade doctors in the UK.
The report also concludes that recommendations about hours of consultant presence on labour ward based on number of births, as in previous service standards, are no longer appropriate. Instead, the focus should be on ensuring adequate levels of cover at all times.
98% of sites with an obstetric unit reported consultant presence on labour ward during the daytime
from Monday to Friday. All units, except one very small rural unit, reported that a middle grade obstetrician was present on labour ward at all times, however maternity services are not a day time only service and provision at night and at weekend/ bank holiday varies significantly (see below).
Assessment of maternity care in the South West.
Appendix one shows clinical audit review results published as part of the National Maternity and Perinatal Audit for key maternity service hospitals in the South West. There are some concerning outliers:
- A measure of foetal wellbeing at delivery is the APGAR score. A poor Apgar score can be linked to long term problems for the baby.
Musgrove Park Hospital in Taunton has a worryingly high percentage of babies who have a poor APGAR score 5 minutes after delivery as does Torbay Hospital in Devon which has the highest percentage of term babies with poor Apgar scores across all trusts.
In contrast, Southmead Hospital in Bristol has a very low and commendable record of low APGAR scores as does University of Wales hospital in Cardiff.
- 3rd and 4th degree tears can cause a mother significant long term problems with prolapse and continence.
Southmead Hospital in Bristol has a worryingly high percentage of 3rd and 4th degree tears which could be as a result of its slightly higher than average number of instrumental deliveries.
St Michael’s Hospital in Bristol similarly has a raised percentage of deliveries resulting in 3rd and 4th degree tears.
- Babies who are small for gestational age born at or beyond 40 weeks could suggest a problem with blood supply to the baby in the later stages of labour which has not been identified on in utero monitoring. This in turn could have long term implications for that baby.
Royal Cornwall Hospital has a worryingly high percentage of babies who fall into this category.
- Obstetric haemorrhage following a delivery can lead to problems (and even death) for a mother.
Royal Cornwall Hospital as a fabulously low percentage of cases where this risk materialises.
St Michael’s Hospital in Bristol also shows a lower than average number of cases with obstetric haemorrhage.
In contrast, Southmead Hospital in Bristol, which has a very good record on foetal wellbeing has the highest rate of obstetric haemorrhage across all Trusts.
- Unplanned maternal readmission within 42 days of giving birth can be an indication of missed problems prior to discharge or poor postpartum management.
Royal Cornwall Hospital has a poor rate of unplanned maternal re-admissions as does Torbay Hospital in Devon.
- Caesarean births can be as a result of planned delivery due to anticipated complications or result from foetal distress during labour. A high caesarean birth rate suggests a pro-active approach to managing the risk of damage to the baby from the labour process.
Southmead hospital has a relatively high caesarean birth rate which is likely to explain, at least in part, its very low percentage of babies with a poor Apgar score (see above).
In contrast, University of Wales hospital in Cardiff has one of the lowest percentage of caesarean births across all trusts which in turn reflects a very high number of spontaneous vaginal births and a high percentage of instrumental delivery births. Their low use of caesarean section interestingly does not result in poor outcomes for babies at birth as shown by their wonderfully low percentage of term babies with a poor Apgar score at 5 minutes.
- Aiming for a vaginal delivery following a caesarean section can increase the risk of uterine rupture and damage to mother and baby. There is always a balance to be addressed. A low rate of vaginal birth after caesarean section can suggest a low threshold for advising / advocating a further caesarean section in this situation.
St Michael’s Hospital in Bristol has a very low percentage of mothers who have a vaginal delivery following a primary caesarean section. This could explain in part the low obstetric haemorrhage rate. No Apgar score rates have been provided for this hospital so it is not possible to see whether this step is reflected in a better than average percentage of babies with good Apgar scores.
Similarly Yeovil Maternity Unit has a low percentage of births falling into this category.
- Instrumental delivery can be necessary to achieve delivery of a baby which is starting to show signs of distress but it can also result from a failure to recognise those problems in a timely manner and can result in significant damage to a mother leading to potential incontinence and prolapse issues.
Plymouth Hospital has a worryingly high number of instrumental deliveries and a number of babies with poor Apgar scores at birth being towards the higher end of the distribution of results across trusts.
Hospital specific data for SW hospitals
The dark grey line is the mean across all hospitals and the x marks the individual hospital position on the range of results across all hospitals. Results in blue or purple suggest a particularly good or poor result depending upon the measure.
Royal Cornwall Hospital
St Michael’s Hospital Bristol
University of Wales, Cardiff
Yeovil Maternity Unit
North Devon Hospital
Derriford Hospital, Plymouth