Browsing by Author "van der Meulen, Jan"

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    Authors Reply to "Induction of labour and emergency caesarean section in English maternity services: examining outcomes is needed before recommending changes in practice".
    (Wiley, 2022-12-27) Gurol-Urganci, Ipek; Jardine, Jennifer; Harris, Tina; Khalil, Asma; van der Meulen, Jan
    We thank Anna Seijmonsbergen-Schermers and colleagues for their interest in our paper in which we describe that there is considerable between-hospital variation in the use of induction of labour and emergency caesarean section in singleton term births that took place in the English National Health Service between April 2015 and March 2017.1 More importantly, we also show that hospitals with a higher rate of induction had slightly lower risks of adverse perinatal outcomes, whilst a similar association was not found for emergency caesarean section. In our paper, we suggest that the between-hospital variation observed in the induction of labour and emergency caesarean section rates may reflect differences in the ‘practice style’ of hospitals providing maternity services. Admittedly at the risk of over-interpreting our results, we conclude that a more proactive practice style with an increased use of induction of labour, rather than an increased use of caesarean section in emergency situations, seems to be linked to safer childbirth. Seijmonsbergen-Schermers and colleagues raise two issues. First, they argue that the range of outcome measures we use, i.e., antenatal and intrapartum stillbirth, neonatal unit admission, and mechanical ventilation, is too narrow. They argue that perinatal mortality should have been used instead of stillbirth, because induction of labour may in some cases only change the timing of birth without preventing a baby dying in utero or at a later stage. We could not agree more. Indeed, the ideal study would have used perinatal mortality. However, it is important to note that in our paper we also show associations of induction of labour with better postnatal outcomes, e.g., lower neonatal admission and mechanical ventilation, which are fully in line with the associations that we report for stillbirth. Second, Seijmonsbergen-Schermers and colleagues contrast our results with a population-based follow-up study they carried out using linked data reporting a range of outcomes in healthy women giving birth to a singleton term baby with and without induction of labour between 2000 and 2016 in New South Wales, Australia.2 They conclude that their results show that induction of labour for non-medical reasons was associated with more adverse perinatal outcomes. Here, we need to point out the fundamental difference between this study and the one that we report in our paper: we answer a different question with a different study design. We compare outcomes in hospitals with higher and lower rates of induction and emergency caesarean section; Our study does not directly compare a group of women who had induction of labour with a group of women who did not. Therefore, the studies are not directly comparable. Our study design, comparing perinatal outcomes according to hospital-level intervention rates, is likely to be less strongly affected by confounding by clinical indication than the population-based follow-up study by Seijmonsbergen-Schermers. Most importantly, we wholeheartedly support Seijmonsbergen-Schermers’ final plea: projects aiming to get a better understanding of how we can make childbirth safer should include a range of measures and indicators, ideally covering both maternal and neonatal outcomes beyond the intrapartum period.3 References 1. Seijmonsbergen-Schermers A, Peters LL, Downe S, Dahlen H, de Jonge A. Induction of labour and emergency caesarean section in English maternity services: Examining outcomes is needed be fore recommending changes in practice. BJOG. 2022. https://doi. org/10.1111/1471-0528.17359 2. Gurol-Urganci I, Jardine J, Carroll F, et al. Use of induction of labour and emergency caesarean section and perinatal outcomes in English maternity services: a national hospital-level study. BJOG. Vol 129, 11:1899-1906 3. Dahlen HG, Thornton C, Downe S, et al. Intrapartum interventions and outcomes for women and children following induction of labour at term in uncomplicated pregnancies: a 16-year population-based linked data study. BMJ Open. 2021;11(6):e047040. 4. NMPA Project Team. National Maternity and Perinatal Audit: Clinical Report 2022. Based on births in NHS maternity services in England and Wales between 1 April 2018 and 31 March 2019. London: RCOG;2022.
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    Maternity admissions to intensive care in England, Wales and Scotland in 2015/16: A report from the National Maternity and Perinatal Audit.
    (Royal College of Obstetrics and Gynaecology, 2019) Jardine, Jen; Aughey, Harriet; Blotkamp, Andrea; Carroll, Fran; Gurol-Urganci, Ipek; Harris, Tina; Hawdon, Jane; Knight, Hannah; Mamza, Lindsey; Moitt, Natalie; Pasupathy, Dharmintra; van der Meulen, Jan
    The National Maternity and Perinatal Audit (NMPA) is a national audit of the NHS maternity services across England, Scotland and Wales, commissioned in July 2016 by the Healthcare Quality Improvement Partnership (HQIP) on behalf of NHS England, the Welsh Government and the Health Department of the Scottish Government. 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 & Tropical Medicine (LSHTM). The overarching objective of the NMPA is to produce high-quality information about NHS maternity and neonatal services that can be used by providers, commissioners and users of the services to benchmark against national standards and recommendations where these exist, and to identify good practice and areas for improvement in the care of women and babies. This report focuses on maternal admissions to intensive care in England, Wales and Scotland. The NMPA, and the data it holds, offers a unique opportunity to link maternity data, which contain information about the mother, her pregnancy and her baby, to data from national data sets for intensive care admissions. The purpose of this report is to describe the feasibility of linking the NMPA’s maternity data to intensive care data and to evaluate the suitability of rates of maternal admission to intensive care as an indicator of care quality. It also describes the demographics of women admitted to intensive care and the reasons for admission.
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    National Maternity and Perinatal Audit: Clinical report 2019. Based on births in NHS maternity services between 1 April 2016 and 31 March 2017
    (Royal College of Obstetricians and Gynaecologist, 2019-09-12) Aughey, Harriet; Blotkamp, Andrea; Carroll, Fran; Geary, Rebecca; Gurol-Urganci, Ipek; Harris, Tina; Hawdon, Jane; Heighway, Emma; Jardine, Jen; Knight, Hannah; Mamza, Lindsey; Moitt, Natalie; Pasupathy, Dharmintra; Thomas, Nicole; Thomas, Louise; van der Meulen, Jan
    In the wake of national maternity and neonatal reviews and other improvement initiatives, changes are being implemented in the delivery of care to mothers and their babies in England, Scotland and Wales. Use of electronic records for maternity care is constantly developing, and provides a rich source of data to understand and evaluate these changes. The National Maternity and Perinatal Audit (NMPA) uses these data to produce information that can usefully support the improvement of maternity and perinatal care. This report presents measures of maternity and perinatal care based on births in English, Welsh and Scottish NHS services between 1 April 2016 and 31 March 2017. The report also provides contextual information describing the characteristics of women and babies cared for by NHS maternity services during this time period. The majority of the measures presented in this report are the same as presented in our previous report on 2015/16 data. One measure has been removed: early elective delivery without documented clinical indication. Four measures have been added. The first is birth without intervention, a composite measure to describe births that start and proceed spontaneously. The other new measures relate to babies admitted to a neonatal unit following birth: the proportions of term and late preterm babies who are admitted to a neonatal unit; the proportion of term babies who receive mechanical ventilation in the first 72 hours of life; and the proportion of babies who develop an encephalopathy in the first 72 hours of life. The results in this report are presented at trust/board level, rather than by site with an obstetric unit, as was the case for most measures in the previous report. This follows feedback from clinical services to the NMPA team,* and enables a more balanced inclusion of births in freestanding midwifery units and at home, as these can be included in trust level results but not as individual sites owing to low numbers.† The majority of trusts have a single obstetric unit and for those trusts this reporting change makes little difference. Site level results continue to be reported on the NMPA website.
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    National Maternity and Perinatal Audit: Organisational Report 2019
    (Royal College of Obstetrics and Gynaecology, 2019-07-11) Blotkamp, Andrea; Aughey, Harriet; Carroll, Fran; Gurol-Urganci, Ipek; Harris, Tina; Hawdon, Jane; Heighway, Emma; Jardine, Jennifer; Knight, Hannah; Mamza, Lyndsey; Moitt, Natalie; Pasupathy, Dharmintra; Thomas, Nicole; Thomas, Louise; van der Meulen, Jan
    Maternity and neonatal services in England, Scotland and Wales are going through an eventful time. Wide-ranging transformation plans are being implemented as a result of the English national maternity services review and the Scottish maternity and neonatal services review,1,2 and an updated Welsh vision for maternity care is in preparation at the time of writing. Services are being reconfigured and changes made to ways of working across the three countries. The second organisational survey of the National Maternity and Perinatal Audit (NMPA) maps current service provision as of January 2019 across England, Scotland and Wales. This report describes how services have changed since the last survey in January 2017, where service provision has improved and where further improvement is still needed in order to meet recommendations. It is hoped that this report will help inform the transformation and other improvement initiatives which are underway.
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    NHS Maternity Care for Women with Multiple Births and Their Babies A study on feasibility of assessing care using data from births between 1 April 2015 and 31 March 2017 in England, Wales and Scotland.
    (Royal College of Obsstetricians and Gynaecologists, 2020-08-21) Relph, Sophie; Gurol-Urganci, Ipek; Blotkamp, Andrea; Dunn, George; Harris, Tina; Hawdon, Jane; Pasupathy, Dharmintra; van der Meulen, Jan
    Introduction This report focuses on the maternity care for women with multiple births during the period 1 April 2015 to 31 March 2017 and their babies. The purpose of this report is to describe the feasibility of assessing maternity care for women with multiple births and their babies, using routinely collected data. Methods This study examines the feasibility of using existing data sources and linkages within NMPA to report the characteristics and outcomes of twin pregnancy and birth and to assess the care of women with multiple birth. National guidelines from the National Institute for Health and Care Excellence (NICE) and the Royal College of Obstetricians and Gynaecologists (RCOG) and recommendations from Twins Trust and the Multiple Births Foundation were consulted in the development of audit measures. Maternal outcomes were reported per pregnancy. Perinatal outcomes were reported per pregnancy or per baby, as appropriate. The characteristics and outcomes of higher order births were assessed and reported separately from those of twins. Given that many of the national guidelines referred to local service configuration, an evaluation of the availability of specific services for women with multiple birth was conducted, by linking the results of the NMPA Organisational Survey 2017 with the location of birth of the women with multiple pregnancy.2 Key findings We have demonstrated that an audit of maternity and neonatal care for women and babies affected by multiple birth is feasible using NMPA methodology and data sources, but such an audit will be limited by data availability and quality issues. We identified 41608 babies born from multiple pregnancies in 20 655 women from England, Scotland and Wales. When compared with the number of multiple births reported in data from the Office for National Statistics, this represented an estimated case ascertainment of 89.5%, compared with case ascertainments of 92% in 2015/16 and 97% in 2016/17 for singleton births. Case ascertainment is affected by inaccuracies in the recorded number of infants born to each woman and by unavailability of data on the number of fetuses identified in the first trimester of pregnancy. Only two of 174 clinical guideline statements can be directly assessed using NMPA methods. These relate to recommendations that mothers should be supported to breastfeed and that neonatal networks should aim to reduce term neonatal admissions. The most common reason that recommendations or clinical guideline statements cannot be assessed isthe absence of information on chorionicity and amnionicity in the data. This information is not routinely collected in maternity datasets. Challenges were also identified in classifying caesarean section into categories according to whether the procedure was planned or the procedure was urgent or an emergency, particularly in the context of risk of spontaneous preterm labour in multiple pregnancies in women with planned caesarean birth. It is also not possible to assess provision of specialist services for twin babies with fetal complications (e.g. twin-to-twin transfusion syndrome) because these diagnoses and related therapeutic procedures are poorly recorded in the data. Assessing maternity care for women with multiple births: feasibility study viii Case mix adjustment using standard NMPA methods is more complex for women with twin births, compared with those with singleton births. For each pregnancy, a choice has to be made which of the two birthweights need to be included in the case mix adjustment. There is also a small number of women affected by less common comorbidities (e.g. hypertension) and antenatal complications (e.g. placenta praevia), usually included in the established NMPA adjustment method. A study of variation in measures of maternity care between NHS trusts or boards, or between hospital sites, is only possible for measures where the outcome is common (e.g. prelabour caesarean birth). When relevant features of care or outcomes are rare, maternity and neonatal care can only be assessed at regional or national level. For the evaluation of maternity and neonatal care that is specific to those babies admitted to a neonatal unit, successful linkage of NMPA maternity data with the NNRD was slightly lower for twin births before 32+0 weeks of gestation than the existing linkage of singleton neonates. For example, the linkage rate at 30+0 to 31+6 weeks of gestation was 87.7% for liveborn twins compared with 94.9% for all liveborn babies. This was particularly noted at gestations less than 28+0 weeks. The most likely explanation for this lower linkage rate is less complete and maybe less accurate data entry, including possible errors or omissions with neonatal NHS numbers. It is possible to assess the availability of specialist services at the level of NHS trust or board, or hospital site, for women giving birth following multiple pregnancy. However, this can currently only be studied according to the place of birth, as information on where antenatal care was received is not available. It should be noted that a similar problem exists for singleton births. Recommendations R1 Maternity service providers should consider the local reasons for inaccuracies in the recording of ‘number of infants’ at birth and work to correct these by the end of the 2020/21 reporting year. This might require auditing local data, mandating the ‘number of infants’ data item and checking data download reports for national datasets to ensure that ‘birth order’ has not been mislabelled as ‘number of infants’. R2 Maternity service providers and national organisations responsible for collating and managing maternity datasets should request/record data on the number of fetuses in the first trimester of pregnancy, in addition to number at birth, for women with multiple pregnancy, and should plan to be compliant with this for the next version of the national data specification. R3 Maternity service providers and national organisations responsible for collating and managing maternity datasets should make chorionicity and amnionicity a compulsory data item in maternity information systems and national datasets for women with multiple pregnancy. This should be implemented in the next version of the national data specification. R4 Maternity service providers who offer specialist fetal procedures, such as intrauterine fetal laser therapy, should work with their coding departments to ensure that the fetal complications and procedures are properly coded into HES, SMR and PEDW by the end of the 2020/21 reporting year. R5 Maternity service providers and national organisations responsible for collating and managing maternity datasets should work to include a compulsory field on planned mode of birth, to enable distinction between those women who have an urgent caesarean birth following labour onset for new clinical reasons and those who have planned caesarean birth. This should be implemented in the next version of the national data specification. R6 Maternity service providers should put local systems in place by the end of the 2020/21 reporting year to ensure that the NHS number for every newborn baby is stored in the maternity information system and linked to the mother’s number. Particular care must be taken to ensure that the baby’s NHS number is not linked to the baby record of the other twin.
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    Risk of complicated birth at term in nulliparous and mutiparous women using routinely collected maternity data in England: cohort study
    (BMJ, 2020-10-01) Jardine, Jennifer; Blotkamp, Andrea; Gurol-Urganci, Ipek; Knight, Hannah; Harris, Tina; Hawdon, Jane; van der Meulen, Jan; Walker, Kate; Pasupathy, Dharmintra
    Abstract Objectives To determine the rate of complicated birth at term in women classified at low risk according to the National Institute for Health and Care Excellence guideline for intrapartum care (no pre-existing medical conditions, important obstetric history, or complications during pregnancy) and to assess if the risk classification can be improved by considering parity and the number of risk factors. Design Cohort study using linked electronic maternity records. Participants 276 766 women with a singleton birth at term after a trial of labour in 87 NHS hospital trusts in England between April 2015 and March 2016. Main outcome measure A composite outcome of complicated birth, defined as a birth with use of an instrument, caesarean delivery, anal sphincter injury, postpartum haemorrhage, or Apgar score of 7 or less at five minutes. Results Multiparous women without a history of caesarean section had the lowest rates of complicated birth, varying from 8.8% (4879 of 55 426 women, 95% confidence interval 8.6% to 9.0%) in those without specific risk factors to 21.8% (613 of 2811 women, 20.2% to 23.4%) in those with three or more. The rate of complicated birth was higher in nulliparous women, with corresponding rates varying from 43.4% (25  805 of 59 413 women, 43.0% to 43.8%) to 64.3% (364 of 566 women, 60.3% to 68.3%); and highest in multiparous women with previous caesarean section, with corresponding rates varying from 42.9% (3426 of 7993 women, 41.8% to 44.0%) to 66.3% (554 of 836 women, 63.0% to 69.5%). Conclusions Nulliparous women without risk factors have substantially higher rates of complicated birth than multiparous women without a previous caesarean section even if the latter have multiple risk factors. Grouping women first according to parity and previous mode of birth, and then within these groups according to presence of specific risk factors would provide greater and more informed choice to women, better targeting of interventions, and fewer transfers during labour than according to the presence of risk factors alone.
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    Technical Report: linking the National Maternity and Perinatal Audit Data Set to the National Neonatal Research Database for 2015/16
    (Royal College of Obstetrics and Gynaecology, 2019) Aughey, Harriet; Blotkamp, Andrea; Carroll, Fran; Cromwell, David; Gurol-Urganci, Ipek; Harris, Tina; Hawdon, Jane; Jardine, Jen; Knight, Hannah; Mamza, Lindsey; Moitt, Natalie; Pasupathy, Dharmintra; van der Meulen, Jan
    The National Maternity and Perinatal Audit (NMPA) is a national audit of the NHS maternity services across England, Scotland and Wales, commissioned in July 2016 by the Healthcare Quality Improvement Partnership (HQIP) on behalf of NHS England, the Welsh Government and the Health Department of the Scottish Government. 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 & Tropical Medicine (LSHTM). The overarching aim of the NMPA is to produce high-quality information about NHS maternity and neonatal services which can be used by providers, commissioners and users of the services to benchmark against national standards and recommendations where these exist, and to identify good practice and areas for improvement in the care of women and babies. This short report from the NMPA explores the feasibility of linking the NMPA data set, which contains data relating to the majority of women who give birth, to the National Neonatal Research Database (NNRD), which contains detailed information about the majority of babies admitted to a neonatal unit. This feasibility study is limited to linkage between neonatal records and maternity records in England, as a pilot for developing this linkage across England, Scotland and Wales. The linkage of neonatal data to maternity data offers many potential advantages. In particular, it allows the exploration of associations between maternal antenatal and intrapartum factors and neonatal outcomes. It also offers the potential to use one or more neonatal outcomes, such as admission to neonatal care, as an outcome measure of maternity care, and to explore variation in neonatal outcomes between maternity settings. The purpose of this report is to describe the feasibility of linking the NMPA data set with the NNRD data set. It describes the technical process of linking these data sets and explores whether this linked data set can be used on an annual basis to construct clinically relevant measures of maternity care.