National Maternity and Perinatal Audit (NMPA) Context Page

The National Maternity and Perinatal Audit (NMPA) is a large-scale audit of the NHS maternity services across England, Scotland and Wales. The NMPA is led by the Royal College of Obstetricians and Gynaecologists (RCOG) in partnership with the Royal College of Midwives (RCM), the Royal College of Paediatrics and Child Health (RCPCH) and the London School of Hygiene and Tropical Medicine. Using timely, high-quality data, the audit aims to evaluate a range of care processes and outcomes in order to identify good practice and areas for improvement in the care of women and babies looked after by NHS maternity services.

Trusts are required to participate and report on all National Clinical Audit and Patient Outcomes Programme projects as part of their NHS Standard contract. All NHS maternity units in England, Scotland and Wales are therefore expected to participate in the NMPA.  149/155 Trusts/Health Boards in England, Scotland and Wales with a maternity service supplied data to the NMPA in the first year. The 6 trusts that were unable to supply data were unable to participate due to not having an electronic maternity record system that they could extract the required data from.

Metrics are shown across two slides and divided across the care pathway – antenatal (Metric 2), intrapartum (Metrics 3-7) and postpartum (Metric 8).

To view the full audit dataset visit www.maternityaudit.org.uk/Audit/Charting/Clinical

Metrics:

1. Case ascertainment

  • Rationale: This metric shows the proportion of eligible cases within the hospital that were submitted to the audit. The comparison is made against Hospital Episode Statistics data. Case ascertainment describes the proportion of births for which data were received, compared to the total number of births recorded through HES. This can sometimes be higher than 100% due to inconsistencies in local coding methodologies.
  • Guideline/mapping: Trusts are required to participate and report on all National Clinical Audit and Patient Outcomes Programme projects as part of their NHS Standard contract.
  • Graph/relative performance: Comparison to national standard pf 95%.
  • Quality improvement prompt question: Consider the other metrics in context of case ascertainment; particularly where ascertainment is low. If case ascertainment is low, this should prompt questions about coding practices, data collection and engagement with the audit.

2. Case-mix adjusted proportion of small-for-gestational-age babies (birthweight below 10th centile) who are not delivered before their due date

  • Rationale: Babies who are small for their age at birth are at increased risk of problems before, during and after birth. In recent years, there has been an increase in initiatives to improve detection of babies who are small at term, in order to enable these babies to be born before problems arise. A baby born small after their estimated due date can be considered to represent a failure of antenatal detection, as national guidance recommends that labour induction or caesarean section is offered before the estimated due date to women whose baby is thought to be small for their gestational age. If detection of these babies was perfect, we would expect the rate of babies born small after their estimated due date to be zero. However, tests such as scans have limitations, so we do not expect perfect detection.
  • Guideline/mapping: This metric maps to Section 11 of the RCOG Small-for-Gestational-Age Fetus, Investigation and Management Green-top Guideline No. 31.
  • Graph/relative performance: Risk-adjusted funnel-plot cross-section; this shows the position of the Trust relative to 99.8% control limits. The grey zone means that the hospital’s performance is not statistically significantly different to the national average. Outside the grey zone means the unit is an outlier and there is statistical evidence the performance is different to the national average.
  • Quality improvement prompt question: ‘ ‘red’ status should prompt questions about why the proportion of small-for-gestational-age babies not delivered before their due date is high what actions the unit has taken to reduce it.

3. Case-mix adjusted proportion of elective deliveries (caesarean or induction) between 37 and 39 weeks with no documented clinical indication for early delivery

  • Rationale: For babies with a planned (or elective) birth, being born before 39 weeks is associated with an increased risk of breathing problems. This can lead to admission to the neonatal unit. There is also an association with long-term health and behaviour problems. Therefore there should be a clinical indication for any elective birth before 39 weeks.
  • Guideline/mapping: This metric maps to 1.4.1.1 NICE Clinical guideline CG132-Caesarean Section and 1.2.5.1 of NICE Clinical guideline CG70-Inducing Labour.
  • Graph/relative performance: Risk-adjusted funnel-plot cross-section; this shows the position of the Trust relative to 99.8% control limits. The grey zone means that the hospital’s performance is not statistically significantly different to the national average. Outside the grey zone means the unit is an outlier and there is statistical evidence the performance is different to the national average.
  • Quality improvement prompt question: ‘red’ status should prompt questions about why either rates of elective deliveries between 37-39 weeks without clinical indication are high or why clinical indications are not being documented and what actions the unit has taken to reduce it.

4. Case-mix adjusted overall caesarean section rate for single, term babies

  • Rationale: Caesarean birth occurs for many reasons. Elective (planned) caesarean birth is offered for a range of conditions. Women with previous caesareans are offered the option of a caesarean birth. A caesarean may also be offered if the baby is not in the cephalic (head down) position, if there are concerns about the baby’s wellbeing or growth, or some maternal conditions including maternal mental health needs. A small number of caesarean sections occur due to mothers requesting this mode of birth. An emergency (unplanned) caesarean section may be performed when there are acute concerns about the baby’s or mother’s wellbeing or when labour is not progressing. As such both overly high and overly low rates may reflect inappropriate care.
  • Guideline/mapping: This metric relates to Sections 1.2 and 1.3 of NICE Clinical guideline CG132-Caesarean Section.
  • Graph/relative performance: Risk-adjusted funnel-plot cross-section; this shows the position of the Trust relative to 99.8% control limits. The grey zone means that the hospital’s performance is not statistically significantly different to the national average. Outside the grey zone means the unit is an outlier and there is statistical evidence the performance is different to the national average.
  • Quality improvement prompt question: ‘yellow’ (higher or lower than expected) status should prompt questions about whether elective caesarean rates may be either too high or too low and what actions the unit has taken to consider whether changes in practice are required.

5. Case-mix adjusted proportion of single, term infants with a 5-minute Apgar score of less than 7

  • Rationale: The Apgar score is a five component score used to summarise the condition of a newborn baby, typically at 1, 5 and 10 minutes of age. A 5 minute Apgar score of less than 7 has been associated with an increased risk of problems for the baby. The Apgar score of a newborn is not always a direct consequence of the care given to the mother during pregnancy and birth; babies with pre-existing illnesses are, for example, more likely to have a low Apgar score at birth. Case-mix adjustments attempt to take this into account but are not perfect.
  • Guideline/mapping: There is no specific national guideline relating to improving Apgar scores as there are a wide range of possible contributory factors within antenatal and intrapartum care periods. This measure was subject to formal outlier notification.
  • Graph/relative performance: Risk-adjusted funnel-plot cross-section; this shows the position of the Trust relative to 99.8% control limits. The grey zone means that the hospital’s performance is not statistically significantly different to the national average. Outside the grey zone means the unit is an outlier and there is statistical evidence the performance is different to the national average.
  • Quality improvement prompt question: ‘red’ (alarm) outlier status should prompt questions about why the proportion of 5 minute Apgar score of less than 7 is high and what actions the unit has taken to reduce it.

6. Case-mix adjusted proportion of vaginal births with a 3rd/4th degree perineal tear

  • Rationale: Vaginal birth may be accompanied by tearing of the vaginal skin and muscle; 85% of women giving birth for the first time will sustain a tear. However, few will extend beyond the vaginal tissue. These more severe tears are known as “third degree” (extending into the anal sphincter) and “fourth degree” (anal mucosa) tears. They are a major complication of vaginal birth.
  • Guideline/mapping: This metric maps to Section 5 of the RCOG The Management of Third- and Fourth-Degree Perineal Tears Green Top Guideline No. 29. This measure was subject to formal outlier notification.
  • Graph/relative performance: Risk-adjusted funnel-plot cross-section; this shows the position of the Trust relative to 99.8% control limits. The grey zone means that the hospital’s performance is not statistically significantly different to the national average. Outside the grey zone means the unit is an outlier and there is statistical evidence the performance is different to the national average. Please note, that the audit has identified challenges around detection and particularly low rates may reflect poor detection.
  • Quality improvement prompt question: ‘red’ (alarm) outlier status should prompt questions about why the proportion of vaginal births with a 3rd/4th degree perineal tear is high and what actions the unit has taken to reduce it.

7. Case-mix adjusted proportion of women with severe postpartum haemorrhage of greater than or equal to 1500 ml

  • Rationale: Obstetric haemorrhage is a major source of ill health after childbirth and can cause serious illness for the mother or, rarely, death. The most common cause of any postpartum haemorrhage (PPH) is failure of the womb to contract down after birth; this is more likely in women who are obese, have a multiple birth or large baby, have a prolonged labour or caesarean section, or have had a haemorrhage before. A threshold of 1500ml of blood loss is used as this is associated with longer stays in hospital, and a higher chance of needing a blood transfusion, a further operation or intensive care.
  • Guideline/mapping: This metric relates to the RCOG Postpartum Haemorrhage, Prevention and Management Green Top Guidelines No. 52. This measure was subject to formal outlier notification.
  • Graph/relative performance: Risk-adjusted funnel-plot cross-section; this shows the position of the Trust relative to 99.8% control limits. The grey zone means that the hospital’s performance is not statistically significantly different to the national average. Outside the grey zone means the unit is an outlier and there is statistical evidence the performance is different to the national average. Please note, that the audit has identified challenges around detection and particularly low rates may reflect poor detection.
  • Quality improvement prompt question: ‘red’ (alarm) outlier status should prompt questions about why incidence of severe postpartum haemorrhage is high and what actions the unit has taken to reduce it.

8. Proportion of live born babies who received breast milk for the first feed

  • Rationale: Breastfeeding is associated with significant benefits for mothers and babies. For the baby, there is protection against childhood infections, diabetes and obesity, along with an increase in measured intelligence. For the mother, breastfeeding offers protection against breast cancer and weight gain, along with probable protection against ovarian cancer and type two diabetes. Where postnatal care is provided in hospital, attention should be paid to facilitating an environment conducive to breastfeeding. In the first 24 hours after birth, women should be given information on the benefits of breastfeeding, the benefits of colostrum and the timing of the first breastfeed. Support should be culturally appropriate. Initiation of breastfeeding should be encouraged as soon as possible after the birth, ideally within 1 hour.
  • Guideline/mapping: This metric relates to Sections 1.3 of NICE Clinical guideline CG37 – Postnatal care up to 8 weeks after birth.
  • Graph/relative performance: percentile RAG scale; hospitals have been graded according to whether their outcomes fall in the top 25%, bottom 25%, or in the middle range of trusts nationally.
  • Quality improvement prompt question: If the unit is in the bottom 25% this should prompt questions about why the levels of babies receiving breast milk for the first feed are low and what actions the unit has taken to increase it.