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.

Executive summary

Introduction to the NMPA The National Maternity and Perinatal Audit (NMPA) is a large-scale project established to provide data and information to those working in and using maternity services. The NMPA helps us understand the maternity journey by bringing together information about maternity care and information about hospital admissions. This NMPA clinical audit report is an important step forward in understanding the way in which NHS maternity services care for women and birthing people, and it provides information on a number of measures, based on births in England and Wales from April 2018 to March 2019. This report follows on from the previous NMPA clinical audit reports and is one strategy used by the audit team to understand the care and outcomes experienced by women and birthing people, and to highlight areas of potential service improvement.

Data Data for births in England are provided by NHS Digital’s Maternity Services Data Set (MSDS) version 1.5 as well as by Hospital Episode Statistics (HES) records. Data for births in Wales are provided by Digital Health and Care Wales’s Maternity Indicators dataset (MIds), the Initial Assessment (IA) dataset, as well as Admitted Patient Care records from the Patient Episode Database for Wales (PEDW), and some data fields from the National Community Child Health Database (NCCHD). The NHS trusts and boards included in the audit provided maternity care at one or more hospital sites.* This report captures 89% of eligible births (88% in England and 97% in Wales). Data are included from over half a million women and birthing people, and their babies, born between 1 April 2018 and 31 March 2019 in England and Wales.

Key findings One-third of women and birthing people with singleton pregnancies at term in England and Wales underwent an induction of labour. Of all women and birthing people experiencing an instrumental birth by forceps, as many as 1 in 20 did so without an episiotomy; of these, 31% experienced a third- or fourth-degree tear. Of the women and birthing people opting for a vaginal birth after a previous caesarean birth, the proportion who experienced a vaginal birth was 61%. This is over 10 percentage points lower than overall proportions reported in national guidance (72–75%). Postnatal readmission rates were higher

• Where possible, site-level results are available on the NMPA website. Guidance on using the data on the NMPA website can be found on the Resources page and in the Frequently Asked Questions. A list of organisations and useful publications are also available within the NMPA Quality Improvement page to support those improving the quality of care locally. The NMPA is committed to engagement with anyone accessing the audit’s outputs and we welcome feedback on how these can be made more useful (contact nmpa@rcog.org.uk). ix following a caesarean birth compared with a vaginal birth in both England (4.3% vs 2.9%) and Wales (4.7% vs 3.3%). Of the women and birthing people experiencing their first birth, 23% had an instrumental birth, 23% had an emergency caesarean birth and 44% of those who had a vaginal birth had an episiotomy. Around half of babies born small for gestational age (SGA) were born after their due date. This is in contrast to national guidance recommending earlier induction be offered if there are concerns about a baby being small. Data completeness issues remain for many NMPA measures, especially for anaesthesia, augmentation (helping the progress of labour), labour onset, episiotomy, maternal ethnicity, body mass index (BMI) and smoking status at birth. From our dataset, it is not always possible to tell which type of pain relief a woman or birthing person received during labour or whether they had an epidural or spinal, or general anaesthetic. National datasets in both England and Wales under-report rates of pre-pregnancy conditions such as high blood pressure.

Recommendations R1 Improve the availability and quality of information about possible interventions during labour and birth, by offering individualised evidence-based information in a language and format which is accessible and tailored to each woman or birthing person’s circumstances. Consider using the IDECIDE decision-making and consent tool (when available).

R2 All women and birthing people should be routinely counselled and offered an episiotomy prior to experiencing a forceps-assisted birth, to reduce the chance of an OASI.

R3 Further information is required to better understand the underlying causes and patterns of variation in measures. Use local audit of measures to investigate differences in practice that may contribute to observed variation in rates.

R4 Review all cases of postnatal maternal readmission to understand common indications, and identify changes in practice that may decrease the chance of readmission, especially among those having a caesarean birth.

R5 Conduct reviews of data completeness, data capture software and practices including mandatory field requirements. Utilise user feedback to identify patterns in missing data and opportunities to support healthcare professionals to provide complete data without compromising clinical care.

R6 Amend data fields to: ● collect the availability and timeliness of epidural anaesthesia ● separate the recording of intrapartum analgesia by type for both England and Wales ● collect analgesia and anaesthesia into two separate fields and enhance anaesthesia coding granularity to capture epidural, spinal or general anaesthesia separately in Wales.

R7 Develop strategies to ensure harmonisation between national maternity datasets, in particular that data are collected to: ● record pre-existing conditions in the Welsh Initial Appointment dataset ● include a ‘number of infants’ variable in the English MSDS v2.0 ● prevent the under-reporting of all diagnoses within HES and PEDW.

R8 Review the appropriateness of routine perinatal and postnatal data to obtain a meaningful measure of care, such as duration of skin-to-skin, who with and reasons for non-occurrence