The National Maternity Mölndals Sjukhus March 2017 Perinatal audit – what is the purpose? Michael Robson The National Maternity Hospital Dublin, Ireland Mrobson@nmh.ie 1

Key issues in the Maternity Services Safety, consistency and quality

Key issues in the Maternity Services How do we assess quality in the Maternity Services?

Assessing Quality Structure (resources) Building Equipment Staff

Assessing Quality Processes (guidelines)

Assessing Quality Organisation Philosophy Leadership Truly multidisciplinary approach Good communication Key decision making Fail safe mechanisms

Assessing Quality Outcome Events and outcomes (including complications) Complaints, adverse events, medico-legal cases (incidents) Professionals knowledge of information Ability to respond and change as a result of information Ability to perform and continuously reassess information

Assessing Quality Women, healthcare professionals and governments are interested in safety and quality Safety and quality are ultimately related to outcome and outcome guides processes

Perinatal Audit - what is the purpose? The first measure of quality in any organisation is knowing what your results are

Perinatal Audit - what is the purpose? Safety and quality of care provided by a labour and delivery unit should be assessed in terms of available validated perinatal audit and only then ultimately in appropriate outcomes when all the necessary information is available

Perinatal Audit - what is the purpose? The second measure of quality is enabling the ability to understand the results, compare them with other delivery units and use them to improve quality of care

Evidence based medicine Competing Philosophies Process driven (Randomised trials) Outcome driven (Perinatal audit)

Randomised trials depend on relative outcomes over a limited period of time while perinatal audit concentrates on absolute outcomes over an indefinite period of time

As randomised trials continue to ascend in the evolution of evidence based medicine, we must recognise and respect their limitations when examining complex phenomena in heterogeneous populations Andrew Kotaska BMJ 2004

Perinatal Audit - why is it so difficult? Not recognised as an entity, specialist area or even at all useful (poor relation of randomised controlled trials) Collection of routine quality data is resource dependent, requiring total organisational commitment No accepted classification, principles or training programmes

Perinatal Audit - what is the purpose? In theory at least, it should be simpler to standardise measurement of outcomes rather than processes

Perinatal Audit - what is the purpose? If standardising measurement of outcome is established and accepted, a greater degree of comparison, learning and communication can and will take place It might then be reasonably expected that processes would gradually merge over time

Perinatal Audit - what is the purpose? Embrace different ways of care and rather than concentrating on standardising processes standardise the way we carry out perinatat audit so greater learning and comparison can take place between delivery units

Perinatal Audit – collection of routine quality data is resource dependent, requiring total organisational commitment Few delivery units, regions, countries have committed to routine quality data collection

Perinatal audit starts at the individual unit level with Perinatal Audit – collection of routine quality data is resource dependent, requiring total organisational commitment Perinatal audit starts at the individual unit level with The Clinical Report

Perinatal Audit The current challenges Routine data collection Classification of data

The Maternal and Newborn Clinical Managment System (MN-CMS) - routine data collection A means of clinical communication Concept of a virtual record and clinical care Storage of information Access to and the use of additional resources to improve care Information available for analysis

Perinatal Audit - classification of data Unless we classify data in a systematic and consistent way the more confused we will become

Perinatal audit – no accepted classification, principles or training We need to classify all perinatal outcome so that objective comparisons can be made of fetal and maternal outcomes over time in one unit and between different units both nationally and internationally

But to do that We need a consistent, objective and overarching structure (classification) within which we can examine fetal and maternal outcomes

Labour and delivery events and outcomes (including “interventions” and complications) Any intrapartum event, on its own insignificant to the mother, midwife, obstetrician or neonatologist but may influence one of the labour outcomes Outcomes Any outcome thought by the mother, midwife, obstetrician or neonatologist to affect the health and satisfaction of either mother or baby Robson MS. Labour Ward Audit. In: Management of Labour and Delivery. Ed. R.Creasy, 1997 Blackwell Science pp. 559-570

Is a Caesarean Section an event or an outcome?

Principles of Perinatal Audit Overall rates of any events or outcomes are on their own meaningless

Principles of Perinatal Audit No perinatal event or outcome (including CS) should be considered in isolation from other events, outcomes and organisational issues But it is important to acknowledge immediately that a caesarean section rate cannot be considered in isolation and we need to consider other outcome criteria. The perinatal morbidity and mortality, the maternal morbidity and mortality, maternal and indeed paternal satisfaction, complaints, medicolegal cases, resources and even staff satisfaction. All these criteria can be affected in different directions by changes in the caesarean section.

No perinatal event or outcome should be considered in isolation from other events and outcomes Risk-Benefit Calculus Perinatal morbidity and mortality Maternal morbidity and mortality Labour and delivery events and outcomes Complaints, adverse incidents and medico-legal cases Maternal satisfaction and staff satisfaction But it is important to acknowledge immediately that a caesarean section rate cannot be considered in isolation and we need to consider other outcome criteria. The perinatal morbidity and mortality, the maternal morbidity and mortality, maternal and indeed paternal satisfaction, complaints, medicolegal cases, resources and even staff satisfaction. All these criteria can be affected in different directions by changes in the caesarean section.

Perinatal Mortality Rate NMH 2005-2014 (88,005 deliveries >24/40 and/or weighing >500g including congenital anomalies) Groups   SB IPD NND (per 1000) 1 & 2 83/35406 0/35406 19/35406 (2.3) (0) (0.5) 3 & 4 46/35317 0/35317 17/35317 (1.3) 5 13/8682 0/8682 6/8682 (1.5) (0.7) 8 27/3294 0/3294 53/3294 (8.3) (16.1) 6,7,9 & 10 192/6953 2/6953 126/6953 (27.6) (0.3) (18.1)

HIE NMH 2005-2014 (88,005 deliveries >24/40 and/or weighing >500g including congenital anomalies) Group HIE (per 1000) 1 & 2 50/35406 (1.4) 3 & 4 25/35317 (0.7) 5 5/8682 (0.6) 8 2/3294 6,7,9 & 10 0/6953 (0)

Principles of Perinatal Audit Classification must be able to incorporate other variables related to perinatal events and outcome But it is important to acknowledge immediately that a caesarean section rate cannot be considered in isolation and we need to consider other outcome criteria. The perinatal morbidity and mortality, the maternal morbidity and mortality, maternal and indeed paternal satisfaction, complaints, medicolegal cases, resources and even staff satisfaction. All these criteria can be affected in different directions by changes in the caesarean section.

Classification must be able to incorporate other variables related to perinatal events and outcome Significant epidemiological factors Age, BMI, Fetal weight, Casemix Data collection must be aligned Organisational systems Staff and infrastructure resources Economics of childbirth

Principles of an ideal classification system Simple, easy to implement, informative and useful Robust, self validating and universal Prospectively determined, clinically relevant, identifiable, totally accountable and replicable The groups must be objectively not subjectively defined, mutually exclusive and totally inclusive Remove variables, but interpret accordingly

Classifying Perinatal Events and Outcome – the 10 Groups, Obstetrical Concepts and their Parameters Previous Obstetric Record Nulliparous Multiparous without a scar, Multiparous with a scar Category of pregnancy Single cephalic Single breech Multiple pregnancy Single transverse or oblique lie Course Spontaneous labour Induced labour Prelabour caesarean section Gestation The number of completed weeks at delivery

The 10 Group Classification - and the advantage of standardisation Any differences in sizes of groups or events and outcomes in the groups are either due to Poor data quality Differences in significant epidemiological factors Differences in practice

Philosophy of the 10 Group Classification Based on the premise that all information (epidemiological, maternal and fetal events, outcomes, cost and organisational) will be more clinically relevant by stratifying them using the 10 groups

Perinatal Audit - what is the purpose? To record and understand what we do in order to improve maternity care

Quality of maternity care Will not improve until we all continuously audit events and outcomes in a standardised way and understand their relationships MRobson@nmh.ie But it is important to acknowledge immediately that a caesarean section rate cannot be considered in isolation and we need to consider other outcome criteria. The perinatal morbidity and mortality, the maternal morbidity and mortality, maternal and indeed paternal satisfaction, complaints, medicolegal cases, resources and even staff satisfaction. All these criteria can be affected in different directions by changes in the caesarean section. 46

Classifying Perinatal Outcome – the 10 Group classification system (TGCS) The Ten Groups Have Been Created From the Previous Obstetric Record, Course, Category and Gestation Robson MS. Classification of Caesarean Sections. Fetal and Maternal Review 2001; 12:23-39. Cambridge University Press

National Maternity Hospital, Dublin Caesarean Sections - the 10 Groups 2015 1 Nullip single ceph >=37 wks spon lab 2 Nullip single ceph >=37wks ind. or CS before lab 3 Multip (excl prev caesarean sections) single ceph >=37 wks spon lab 4 Multip (excl prev caesarean sections) single ceph >=37wks ind. or CS before lab 5 Previous caesarean section single ceph >= 37 wks 6 All nulliparous breeches 7 All multiparous breeches (incl previous caesarean sections) 8 All multiple pregnancies (incl previous caesarean sections) 9 All abnormal lies (incl previous caesarean sections) 10 All single ceph <= 36 wks (incl previous caesarean sections)

National Maternity Hospital, Dublin Caesarean Sections - the 10 Groups 2015 Total number of caesarean sections over the overall total number of women 2015 2379/9180 25.9% 1 Nullip single ceph >=37 wks spon lab 178/2043 2 Nullip single ceph >=37wks ind. or CS before lab 585/1490 3 Multip (excl prev caesarean sections) single ceph >=37 wks spon lab 41/2525 4 Multip (excl prev caesarean sections) single ceph >=37wks ind. or CS before lab 142/1041 5 Previous caesarean section single ceph >= 37 wks 816/1118 6 All nulliparous breeches 193/200 7 All multiparous breeches (incl previous caesarean sections) 120/129 8 All multiple pregnancies (incl previous caesarean sections) 119/190 9 All abnormal lies (incl previous caesarean sections) 35/35 10 All single ceph <= 36 wks (incl previous caesarean sections) 150/409 Number of caesarean sections over the total number of women in each group

Size of each group is the total number of women in each group divided by the overall total number of women National Maternity Hospital, Dublin Caesarean Sections - the 10 Groups 2015 2015 2379/9180 25.9% Size of group % 1 Nullip single ceph >=37 wks spon lab 178/2043 22.2 2 Nullip single ceph >=37wks ind. or CS before lab 585/1490 16.2 3 Multip (excl prev caesarean sections) single ceph >=37 wks spon lab 41/2525 27.5 4 Multip (excl prev caesarean sections) single ceph >=37wks ind. or CS before lab 142/1041 11.3 5 Previous caesarean section single ceph >= 37 wks 816/1118 12.2 6 All nulliparous breeches 193/200 2.2 7 All multiparous breeches (incl previous caesarean sections) 120/129 1.4 8 All multiple pregnancies (incl previous caesarean sections) 119/190 2.1 9 All abnormal lies (incl previous caesarean sections) 35/35 0.4 10 All single ceph <= 36 wks (incl previous caesarean sections) 150/409 4.5

CS rate in each group is worked out for each group by dividing the number of caesarean sections by the total number of women in each group National Maternity Hospital, Dublin Caesarean Sections - the 10 Groups 2013 2015 2379/9180 25.9% Size of group % C/S rate in gp % 1 Nullip single ceph >=37 wks spon lab 178/2043 22.2 8.7 2 Nullip single ceph >=37wks ind. or CS before lab 585/1490 16.2 39.3 3 Multip (excl prev caesarean sections) single ceph >=37 wks spon lab 41/2525 27.5 1.6 4 Multip (excl prev caesarean sections) single ceph >=37wks ind. or CS before lab 142/1041 11.3 13.6 5 Previous caesarean section single ceph >= 37 wks 816/1118 12.2 73.0 6 All nulliparous breeches 193/200 2.2 96.5 7 All multiparous breeches (incl previous caesarean sections) 120/129 1.4 93.0 8 All multiple pregnancies (incl previous caesarean sections) 119/190 2.1 62.6 9 All abnormal lies (incl previous caesarean sections) 35/35 0.4 100 10 All single ceph <= 36 wks (incl previous caesarean sections) 150/409 4.5 36.7

Absolute contribution of each group to the overall CS rate is worked out by dividing the number of CS in each group by the overall population of women This will depend on the size of the group as well as the CS rate in each group National Maternity Hospital, Dublin Caesarean Sections - the 10 Groups 2013 2015 2379/9180 25.9% Size of group % C/S rate in gp % Contr of each gp 25.9 % 1 Nullip single ceph >=37 wks spon lab 178/2043 22.2 8.7 1.9 2 Nullip single ceph >=37wks ind. or CS before lab 585/1490 16.2 39.3 6.4 3 Multip (excl prev caesarean sections) single ceph >=37 wks spon lab 41/2525 27.5 1.6 0.5 4 Multip (excl prev caesarean sections) single ceph >=37wks ind. or CS before lab 142/1041 11.3 13.6 5 Previous caesarean section single ceph >= 37 wks 816/1118 12.2 73.0 8.9 6 All nulliparous breeches 193/200 2.2 96.5 7 All multiparous breeches (incl previous caesarean sections) 120/129 1.4 93.0 1.3 8 All multiple pregnancies (incl previous caesarean sections) 119/190 2.1 62.6 9 All abnormal lies (incl previous caesarean sections) 35/35 0.4 100 10 All single ceph <= 36 wks (incl previous caesarean sections) 150/409 4.5 36.7

Groups 1,2 and 5 contribute to two thirds of all caesarean section rates and are the source of biggest variation between units 17.2% National Maternity Hospital, Dublin Caesarean Sections - the 10 Groups 2013 2015 2379/9180 25.9% Size of group % C/S rate in gp % Contr of each gp 25.9 % 1 Nullip single ceph >=37 wks spon lab 178/2043 22.2 8.7 1.9 2 Nullip single ceph >=37wks ind. or CS before lab 585/1490 16.2 39.3 6.4 3 Multip (excl prev caesarean sections) single ceph >=37 wks spon lab 41/2525 27.5 1.6 0.5 4 Multip (excl prev caesarean sections) single ceph >=37wks ind. or CS before lab 142/1041 11.3 13.6 5 Previous caesarean section single ceph >= 37 wks 816/1118 12.2 73.0 8.9 6 All nulliparous breeches 193/200 2.2 96.5 7 All multiparous breeches (incl previous caesarean sections) 120/129 1.4 93.0 1.3 8 All multiple pregnancies (incl previous caesarean sections) 119/190 2.1 62.6 9 All abnormal lies (incl previous caesarean sections) 35/35 0.4 100 10 All single ceph <= 36 wks (incl previous caesarean sections) 150/409 4.5 36.7