News

Report shows wide variation in intrapartum care in England

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f2844 (Published 02 May 2013) Cite this as: BMJ 2013;346:f2844
  1. Jacqui Wise
  1. 1London

Some English maternity units have double the instrumental delivery rate of others, says a new report that shows widely varying practices and outcomes among units.

The report, from the Royal College of Obstetrics and Obstetricians, concludes that the wide variation in intrapartum care is more than would be expected from random fluctuation.1 The college says that this is a cause of concern as it indicates that not all women are getting the best possible care. The report is the first of what will be an annual survey that will eventually cover the whole of the United Kingdom.

The college, in collaboration with the London School of Hygiene and Tropical Medicine, used hospital episode statistics from all maternity units in England for 2011-12 (covering 644 248 deliveries) to produce a series of 11 risk adjusted indicators. These included emergency readmission of the mother within 30 days of delivery, numbers of third and fourth degree perineal tears in unassisted and assisted vaginal delivery, and the proportion of elective caesarean sections. The researchers controlled for factors such as mothers’ medical history.

Among primiparous women who underwent induced labour the mean proportion of emergency caesareans was 30.2%. After risk adjustment the proportion in individual hospitals ranged from 15.6% to 45.6%. There was a twofold difference in the proportion between the top 10% of hospitals and the bottom 10% (20.4% and 40.3% respectively). Among multiparous women whose labours were induced the mean proportion of emergency caesarean section was 13.2%. There was almost a fourfold difference between the rates of hospitals that were in the top 10% and those in the bottom 10%.

The report found that in women giving birth for the first time the mean proportion of instrumental deliveries was 24.2%. After adjustment for risk factors, the proportion in individual hospitals ranged from 13.2% to 35.1%. There was an almost twofold difference in the proportion between the top 10% of hospitals and the bottom 10% (16.4% and 31.8% respectively).

Nationally, the mean proportion of attempted instrumental deliveries resulting in emergency caesarean section was 3.1%, but in individual hospitals the failure rate ranged from 1% to 9.3%. In seven hospitals the rate was above 6%.

The authors said that their findings should be interpreted with caution because of limitations in the currently available data. They said that the introduction of a national maternity dataset for England from April 2013 should mean a more accurate source of information for future reports.

The researchers also said that there is still work to be done on identifying the most robust and appropriate indicators for monitoring the quality of maternity care. In future reports the number of indicators will be expanded to cover other areas, such as neonatal outcomes and patients’ experience.

One of the report’s recommendations is that clinicians take ownership of their own data to help improve its quality. It also calls for maternity units to use the results to examine their own practice.

David Richmond, vice president (clinical quality) at the Royal College of Obstetrics and Obstetricians, said, “There is a need to improve the completeness and consistency of routine maternity data, and we hope that this report will act as a stimulus for clinicians and units to improve their data collection activity, which will ultimately lead to improving the quality of patient care.”

Notes

Cite this as: BMJ 2013;346:f2844

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