Browsing by Author "Relph, S."

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    National Maternity and Perinatal Audit. Ethnic and Socio-economic inequalities in NHS maternity and perinatal care for women and their babies. Assessing care using data from births between 1 April 2015 and 31 March 2018 across England, Scotland and Wales.
    (RCOG, 2021-11-18) NMPA Project Team; Webster, K.; Carroll, F.; Coe, M.; Dunn, G.; Fremeaux, A.; Gurol-Urganci, I.; Jardine, J.; Karia, A.; Muller, P.; Relph, S.; Waite, L.; Harris, Tina; Hawdon, J.; Oddie, S.; Khalil, A.; van der Meulen, J.
    Executive summary Introduction The purpose of this report is to describe inequalities in maternity and perinatal care for women and their babies in England, Scotland and Wales during the period 1 April 2015 to 31 March 2018. Using routinely collected data, care and outcomes experienced by women and babies using NHS maternity services are measured and stratified by ethnicity and by Index of Multiple Deprivation (IMD), a proxy for socio-economic deprivation. This report focuses on the following maternal measures: ● caesarean birth (presented as elective, emergency and both combined) ● birth without intervention ● major postpartum haemorrhage (1500 ml or more) and the following perinatal measures: ● an Apgar score of less than 7 at 5 minutes ● breast milk at first feed ● neonatal unit admission at term. Methods This report uses existing NMPA linked datasets. Ethnicity is coded using the Office for National Statistics (ONS) 2001 census categorisation of 16+1 codes for ethnicity,2 grouped into white, South Asian, Black and Other (comprising ‘Mixed’ and ‘Other’ combined). Socio-economic deprivation is measured using the Index of Multiple Deprivation (IMD), an area-based measurement of multiple deprivation calculated for each lower-layer super output area (LSOA) in England and Wales, and data zone in Scotland.3 IMD is based on residential postcode and grouped into quintiles of national distribution (quintile 1 = least deprived to quintile 5 = most deprived) for analysis. Results for each maternal and perinatal measure are reported by the mother’s ethnic group and IMD quintile. The results presented in this report are crude and therefore descriptive. The results do not take into account the interactions that contributory factors, such as parity, age, pre-existing co-morbidities, ethnicity and deprivation may have on each other, the complexities of which are not easily interpreted in an audit report such as this. An advisory group comprising professionals and a diverse range of service user representatives with experience of accessing maternity care was involved in the sprint audit. The advisory group was involved in the choice of measures for inclusion in this report, interpretation of results, identifying key messages, and reviewing the draft report and recommendations. Key findings Our results demonstrate differences in outcomes of maternity and perinatal care among women and birthing people, and their babies, via comparisons between those living in the most deprived and the least deprived areas in Great Britain, and in those from ethnic minority groups versus white ethnic groups. Women from South Asian and Black ethnic groups and those from the most deprived areas had higher rates of hypertension and diabetes when compared with women from white ethnic groups and those in the least deprived areas. Smoking was considerably higher among women and birthing people from white ethnic groups and those in the most deprived quintile. Women from Black ethnic groups had a higher rate of experiencing a birth without intervention. While this may be desirable in many situations, it may also represent circumstances where interventions are desired or indicated but do not occur. Rates of caesarean birth (both elective and emergency combined) and rates of emergency caesarean birth were highest for women from Black ethnic groups and higher for women from South Asian groups when compared with those from white ethnic groups. Women and birthing people from Black ethnic groups had higher rates of major postpartum haemorrhage (1500 ml or more) when compared with women and birthing people from white ethnic groups. In contrast to the usual association of increased deprivation with increased morbidity, a decreasing trend for major postpartum haemorrhage (1500 ml or more) was observed from the least to most deprived. Babies born to women from South Asian ethnic groups were less likely to have an Apgar score of less than 7 at 5 minutes but were more likely to be admitted to a neonatal unit at term when compared with babies born to women from white ethnic groups. Babies born to women from Black ethnic groups were more likely to be assessed as having an Apgar score of less than 7 at 5 minutes and were more likely to be admitted to a neonatal unit at term when compared with babies born to women from white ethnic groups. Rates of receiving breast milk at their first feed were significantly lower for babies born to white women and to those living in the most deprived areas. We also found areas of concern with regard to data completeness and rates of missing data by ethnic group and IMD. Our results show 1 in 10 women and birthing people in Great Britain (1 in 5 in Scotland) did not have their ethnic group recorded, and IMD was missing for 6%. Recommendations R1 Target efforts for a life-course approach to improve the health of people, addressing the wider social determinants of health as well as specific health-related risk factors. Offer individualised preconception and antenatal information tailored to their circumstances, including BMI, smoking, pre-existing comorbidities (hypertension and type 2 diabetes) and whether this is their first birth or they have previously had a caesarean birth. (Audience: Healthcare professionals working in maternity services, maternity services providers, general practitioners, primary care providers, public health policy makers) R2 Target efforts to reduce smoking. Audit rates of carbon monoxide testing and referrals for smoking cessation for women during pregnancy, and audit compliance with monitoring for fetal growth restriction. (Audience: Healthcare professionals working in maternity services, maternity services providers, general practitioners, primary care providers, stop smoking services, public health policy makers) R3 Support research and investigation into why women from ethnic minority groups and more deprived areas have higher rates of stillbirth, taking into consideration differences in care, specific risk factors and the wider determinants of health. (Audience: National Institute for Health Research, Health and Care Research Wales and NHS Research Scotland in consultation with the Royal College of Obstetricians and Gynaecologists and policy makers, service planners/commissioners, service managers and healthcare professionals working for maternity services) R4 Improve availability and quality of information about choices during pregnancy and labour, with particular attention to the development of evidence-based shared decision-making tools for place, mode and timing of birth and pain relief options. Consider using the IDECIDE tool (when available). (Audience: Healthcare professionals working in maternity services, maternity services providers, NHS England, NHS Scotland, NHS Wales) R5 Avoid term admissions to a neonatal unit through improving transitional care provision, by establishing facilities where they are not currently available; or in hospitals that do have transitional care facilities, by expanding cot space availability and increasing numbers of appropriately trained staff. (Audience: Maternity and neonatal services providers) R6 Offer all women breastfeeding information and support, and target support in specific areas where breastfeeding rates are lowest (see also Priority 4c, intervention 3 of the Equity and Equality: Guidance for Local Maternity Systems). (Audience: Healthcare professionals working in maternity services, health visitors, primary care providers, maternity care services) R7 Review equality and diversity training provision and update to include the risks associated with deprivation, and how to recognise and avoid unconscious bias (see also Priority 4d, intervention 1 of the Equity and Equality: Guidance for Local Maternity Systems). (Audience: Local trusts and health boards, medical Royal Colleges, Royal Colleges of Nursing and Midwifery, General Medical Council, Nursing and Midwifery Council, Health and Care Professions Council, higher education institutions) R8 Ethnicity should be asked of and accurately recorded for all pregnant people using agreed ethnic group coding systems that should be updated regularly in accordance with the most current census groups. Consideration should be given to methods for self-reporting of ethnicity whenever possible (see also Priority 3, intervention 1 of the Equity and Equality: Guidance for Local Maternity Systems). (Audience: Healthcare professionals working in maternity services, maternity service providers, general practitioners, primary care providers, NHS England, NHS Scotland, NHS Wales) R9 Review the ethnic diversity and rates of socio-economic deprivation in the local area of each NHS trust or board and consider ways to reduce inequalities in healthcare outcomes (see also Priority 4, intervention 1 of the Equity and Equality: Guidance for Local Maternity Systems). (Audience: Local trusts and health boards, primary care providers, public health bodies, local government) R10 Prioritise further research in NHS maternity and perinatal care that could improve outcomes for women, and their babies, from ethnic minority groups and those in the most deprived areas. Undertaking quantitative analysis to investigate ethnic and socio-economic inequalities and report on the mediating factors and causal pathways; along with qualitative research to include exploring the experiences of people accessing maternity care. (Audience: National Institute for Health Research, UK Research and Innovation, Health and Care Research Wales and NHS Research Scotland in consultation with the Royal College of Obstetricians and Gynaecologists and policy makers, service planners/commissioners, service managers and healthcare professionals working for maternity services
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    NHS Maternity Care for Women with a Body Mass Index of 30 kg/m2 or Above: Births between 1 April 2015 and 31 March 2017 in England, Wales and Scotland.
    (RCOG, 2021-05-13) Relph, S.; Coe, M.; Carroll, F.; Gurol-Urganci, I.; Webster, K.; Jardine, J.; Dunn, G.; Harvey, A.; Harris, Tina; Hawdon, J.; Khalil, A.; Pasupathy, D.; van der Meulen, J.
    Introduction This report focuses on the maternal and neonatal outcomes of pregnant women with body mass index (BMI) of 30 kg/m2 or above who gave birth between 1 April 2015 and 31 March 2017, compared with those of women with BMI in the range 18.5–24.9 kg/m2 . Methods This study uses existing NMPA linked datasets to explore the characteristics and outcomes of women and babies according to category of maternal BMI at booking with the maternity service provider. Women are grouped by BMI according to established World Health Organization (WHO) categories. The association between maternal BMI and each maternal or neonatal measure is represented using line graphs, stratified by maternal parity (nulliparous, multiparous with previous vaginal births only, multiparous with a previous caesarean birth). We also explored the feasibility of stratifying the outcomes according to the woman’s risk status at the time of labour and birth (as defined by the National Institute of Health and Care Excellence (NICE) Intrapartum Care for Healthy Women and Babies guideline). Finally, we described the type of maternity units in which the women gave birth, by maternal BMI. A lay advisory group was involved at all stages of this sprint audit, including discussing the choice of outcomes, interpreting the results, and reviewing the draft report and recommendations. Key findings For the period 1 April 2015 to 31 March 2017, we estimate that 21.8% of women giving birth had a BMI of 30 kg/m2 or above; however, 16.9% of women did not have a BMI (or height and weight) recorded. The likelihood of a woman experiencing an intrapartum intervention or adverse maternal outcome, or her baby experiencing very serious complications following birth, increases as BMI increases. We do not know whether this is because women with higher BMI are more likely to develop complications requiring intervention or because of differences in the clinicians’ threshold to intervene. However, those women with a BMI of 30 kg/m2 or above who have previously had at least one vaginal birth (and no caesarean births) are almost as likely to have another unassisted vaginal birth as multiparous women with a BMI in the range 18.5–24.9 kg/m2 who have also not previously had a caesarean birth. Babies born to women with a BMI of 30 kg/m2 or above are less likely to receive skin-to-skin contact within 1 hour of birth or breast milk for their first feed than babies born to women with a lower BMI. The proportion of women giving birth in a freestanding midwifery unit, or at home, decreases as BMI increases, although 1.7% of women with a BMI of 35.0–39.9 kg/m2 and 1.1% of women with a BMI of 40 kg/m2 or above did give birth in one of these settings. The lay advisory group requested that we also measure access to birth in water, monitoring of fetal growth by ultrasound, access to perinatal mental health services and prevention of venous thromboembolism in women with a BMI of 30 kg/m2 or above. We currently do not have sufficient information in the NMPA dataset to assess these. Presentation of maternal or neonatal outcomes by maternal BMI, parity and risk status (as assessed at admission for birth) is both feasible and likely to be useful to support informed decision making. It is limited by uncertainty with less common outcomes (particularly those indicating poor condition of the baby at birth), more so when these are estimated in smaller groups of women. Recommendations R1 Audit local rates of missing data on BMI (or height and weight) before the end of the 2021/22 reporting year, and commence local initiatives to improve electronic recording of this where it is low. (Audience: Maternity service providers) R2 Commence by the end of June 2023 the production of, or include in updates to existing documents, detailed guidance on the antenatal and intrapartum care offered to women who are suspected to have a large-for-gestational-age baby, including whether the guidance should differ for women with a BMI of 30 kg/m2 or above. (Audience: National organisations responsible for publishing guidance on maternity care) R3 Support research and investigation into why women with a BMI of 30 kg/m2 or above have a higher risk of stillbirth, in order to inform clinical care which aims to reduce this risk. (Audience: National Institute for Health Research, Health and Care Research Wales and NHS Research Scotland in consultation with the Royal College of Obstetricians and Gynaecologists and policy makers, service planners/commissioners, service managers and healthcare professionals working for maternity services) R4 Ensure that women with a BMI of 30 kg/m2 or above are given preconception and antenatal information tailored to their individual circumstances (including their BMI and whether this is their first birth or they have previously had a caesarean birth). To support women in their decision making, this should include information from this report on their risk of the following: ● birth interventions ● major postpartum blood loss ● postnatal readmission to hospital ● very serious complications for their baby following birth. (Audience: Healthcare professionals working in maternity services, general practitioners) R5 Identify common causes for readmission to the maternity unit following birth specifically for women with a BMI of 40 kg/m2 or above, and commence local quality improvement initiatives to reduce the risk of readmission. (Audience: Maternity service providers) R6 Support all women and babies to experience skin-to-skin contact with one another within 1 hour of birth should they choose to and regardless of the woman’s BMI, unless it is unsafe to do so because either the woman or baby requires immediate medical attention. (Audience: Healthcare professionals working in maternity services) R7 Offer all women breastfeeding information and support during pregnancy and again shortly after the birth. Women with a BMI of 30 kg/m2 or above may require support to be tailored to their specific needs and to be provided by a healthcare professional who is trained to adapt breastfeeding techniques for women with a higher BMI. (Audience: Healthcare professionals working in maternity services) R8 Incorporate information on antenatal assessment of fetal growth status (suspected SGA or LGA) and on venous thromboembolism risk scores and prophylaxis in future trust/board and national maternity dataset specifications. (Audience: Maternity service providers, the Data and Intelligence Division of Public Health Scotland, the National Welsh Informatics Service) R9 Assess the quality of data on labour or birth in water, and where completeness is low, commence initiatives to improve it. (Audience: Maternity service providers)
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    Use of induction of labour and emergency caesarean section and perinatal outcomes in English maternity services: a national hospital-level study
    (Wiley, 2022-04-21) Gurol-Urganci, I.; Jardine, J.; Carroll, F.; Dunn, G.; Fremeaux, A.; Muller, P.; Relph, S.; Waite, L.; Webster, K.; Oddie, S.; Hawdon, J.; Harris, Tina.; Khalil, A.; van der Meulen, J.
    ABSTRACT Objectives – To assess the association between hospital-level rates of induction of labour and emergency caesarean section, as measures of “practice style”, and rates of adverse perinatal outcomes. Design – National study using electronic maternity records. Setting – English National Health Service. Participants – Hospitals providing maternity care to women between April 2015 and March 2017. Main outcome measures – Stillbirth, admission to a neonatal unit, and babies receiving mechanical ventilation. Results – Among singleton term births, the risk of stillbirth was 0.15%; of admission to a neonatal unit 5.4%; and of mechanical ventilation 0.54%. There was considerable between-hospital variation in the induction of labour rate (minimum 17.5%, maximum 40.7%) and the emergency caesarean section rate (minimum 5.6%, maximum 17.1%). Women who gave birth in hospitals with a higher induction of labour rate had better perinatal outcomes. For each 5%-point increase in induction, there was a decrease in the risk of term stillbirth by 9% (OR 0.91; 95% CI 0.85 to 0.97) and mechanical ventilation by 14% (OR 0.86; 95% CI 0.79 to 0.94). There was no significant association between hospital-level induction of labour rates and neonatal unit admission at term (p>0.05). There was no significant association between hospital-level emergency caesarean section rates and adverse perinatal outcomes (p always >0.05). Conclusions – There is considerable between-hospital variation in the use of induction of labour and emergency caesarean section. Hospitals with a higher induction rate had a lower risk of adverse birth outcomes. A similar association was not found for caesarean section.