Background and Indicator development

The foundation of the National Core Maternity Indicators

The Douglas Inquiry into obstetric and gynaecological services carried out between 1990 and 2000 at the King Edward Memorial Hospital (KEMH) for Women in Perth, Western Australia, recommended that Australia establish an enquiry process with annual benchmarking and/or reporting of performance indicators for obstetric and gynaecological practice and outcomes (Fahy et al. 2001). In 2002, Australian Health Ministers agreed to support a collaborative project coordinated by the Department of Health, Western Australia (Department of Health Western Australia 2007) to enable the analysis of comparative clinical performance data from tertiary obstetric and gynaecological hospitals in Australian jurisdictions (WHA 2007). In 2003, DoHWA conducted a 3-month pilot project of maternity data benchmarking. This ‘proof of concept’ project demonstrated the potential to improve the quality of maternity care through benchmarking.

In 2005, the National Maternity Services Collaboration on Health Policy (then Maternity Services Inter-Jurisdictional Committee (MSIJC)) noted to the Australian Health Ministers’ Advisory Council (AHMAC) that it would be necessary to identify and develop a set of national performance indicators with a view to aligning service and clinical indicators (WHA 2007).

Under a grant from the Australian Council on Safety and Quality in Health Care (now the Commission), the DoHWA consulted with a number of agencies, establishing the Core Maternity Indicators Project (CMIP) to develop a national set of risk-adjusted maternity performance indicators. Women’s Healthcare Australasia managed the Project Plan developed by this group. This extensive body of work aimed to ‘measure and evaluate safe and effective maternity care in a timely fashion’ (Women’s Healthcare Australasia 2007).

In late 2008, the Australian Health Ministers’ Advisory Council transferred responsibility for the management and continuation of CMIP from the Australian Commission on Safety and Quality in Health Care to the MSIJC. The MSIJC’s role was to provide consistency on national reporting of core maternity indicators. This project was also needed to identify an appropriate national repository for this information for ongoing coordinating, reporting and analysis.

The development of core maternity indicators aligns with the first recommendation of the National Review of Maternity Services undertaken by the Chief Nursing and Midwifery Officer on behalf of the Australian Government in 2008 which states:

That the Australian Government, in consultation with states and territories and key stakeholders, agree and implement arrangements for consistent, comprehensive national data collection, monitoring and review, for maternal and perinatal mortality and morbidity (Commonwealth of Australia 2009).

The MSIJC established an Expert Working Group in 2009 to reaffirm the core maternity indicators. A list of 20 National Core Maternity Indicators (NCMIs) was proposed by the Expert Working Group in early 2010 and funded by AHMAC in 2015–16, this formed the basis for the work undertaken by the Australian Institute of Health and Welfare (AIHW) (see Table 1).

National Core Maternity Indicator Development Project

For the first phase of the project a report on 10 of the 20 proposed NCMIs was produced using the AIHW National Perinatal Data Collection (NPDC) with clinical commentary from an Expert Commentary Group (ECG) (AIHW NPESU & AIHW 2013).

For more details see Table 1 and the report: Foundations for enhanced maternity data collection and reporting in Australia: National maternity data development project - Stage 1.

In 2012–13, the project explored the validity and feasibility of a possible 8 additional NCMIs to be added to the current set of 10 NCMIs. Clinical advice and input was provided by an ECG.

In consultation with key stakeholders and experts, definitions and technical specifications were developed for the 8 additional NCMIs, and existing and potential data sources for reporting were investigated. Further, an additional indicator (Indicator 21) was proposed during the consideration and development of the abovementioned 8 additional indicators. Recommendations for next steps were then made for each proposed NCMI. 

The 9 potential additional indicators developed and investigated were:

  • NCMI 11—High risk women undergoing caesarean section who receive appropriate pharmacological thromboprophylaxis. Following investigation, it was recommended that this indicator should not be further developed or added to the current set of NCMIs at this stage.
  • NCMI 12—Babies born at or after 37 completed weeks gestation admitted to a neonatal intensive care nursery or special care nursery for reasons other than congenital anomaly. Following investigation, it was recommended that this indicator required further data development, and this development should be undertaken to enable future reporting against this indicator.
  • NCMI 13—Third and fourth degree tears for (a) all first births and (b) all births. Following investigation, it was recommended that this indicator be added to the current set of 10 NCMIs for reporting using the NPDC.
  • NCMI 14—Blood loss of (i) greater than 1,000 mL and less than 1,500 mL, and (ii) 1,500 mL or more during first 24 hours after the birth of the baby (that is, major primary postpartum haemorrhage) for (a) vaginal births and (b) caesarean sections. Following investigation, it was recommended that this indicator be aligned with items on postpartum haemorrhage in the 2014–15 Perinatal Data Set Specification (lower limit now to include 1,000 mL blood loss and be reflected in the Indicator title); and added to the current set of 10 NCMIs for reporting.
  • NCMI 15—Women having their second birth vaginally whose first birth was by caesarean section. Following investigation, it was recommended that this indicator be added to the current set of 10 NCMIs for reporting using the NPDC.
  • NCMI 16—Separation of baby from the mother after birth for additional care. Following investigation, it was recommended that this indicator should not be further developed or added to the current set of NCMIs at this stage.
  • NCMI 17—One-to-one care in labour. Following investigation, it was recommended that this indicator should not be further developed or added to the current set of NCMIs at this stage.
  • NCMI 18—Caesarean sections at less than 39 completed weeks gestation (273 days) without obstetric/medical indication. Following investigation, it was recommended that this indicator be added to the current set of 10 NCMIs for reporting using the NPDC.
  • NCMI 21 — Skin-to-skin contact between mother and baby after birth. During consideration and development of the 8 additional indicators, the ECG suggested the inclusion of this indicator. Following investigation, it was recommended that this indicator required further data development, and this development should be undertaken to enable future reporting against this indicator.

For more details see Table 1 and the report: National core maternity indicators—stage 2 report: 2007–2011.

In 2015, the AIHW undertook further work on the NCMI’s which included finalising 2 indicator specifications for reporting, data development, finalising the scope for 1 indicator based on the recommendations of the validity and feasibility work undertaken previously, and facilitating the revised data resupply from Victoria for 2009–2011.

The 2 additional indicators reported:

  • NCMI 13—Third and fourth degree tears for (a) all first births and (b) all births. This was introduced into the NCMI suite of indicators and reported using 2013 data onwards. Noting that a nationally standardised data item for this indicator was included in the 2013–14 Perinatal National Minimum Data Set (NMDS).
  • NCMI 15—Women having their second birth vaginally whose first birth was by caesarean section. This was introduced into the NCMI suite of indicators and reported using 2007 data onwards.  Noting that a nationally standardised data item for this indicator was included in the 2014–15 Perinatal NMDS.

Specifications were developed for NCMI 18: Caesarean section <39 weeks (273 days) without obstetric/ medical indication and NCMI 21: Skin-to-skin contact between mother and baby after birth. These specifications received support from the ECG, and have yet to be referred to the National Perinatal Data Development Committee (NPDDC) or tabled for endorsement by National Health Data and Information Standards Committee (NHDISC), formerly National Health Information and Performance Principal Committee (NHIPPC).

Specifications were developed for NCMI 12: Babies born at or after 37 completed weeks gestation admitted to a neonatal intensive care nursery or special care nursery for reasons other than congenital anomaly. Following consultation, development work still needs to be conducted and this specification has not yet been supported by the ECG.

For more details see Table 1 and the report: National Core Maternity Indicators stage 3 and 4 results from 2010–2013.

The AIHW will endeavour to undertake further development of the current, proposed and any additional NCMIs in the future, particularly in response to changes in evidence, policy, service provision or clinical practice.

Table 1: National Core Maternity Indicator Status
Indicator Indicator specifications approved by NHIPPC* Status as at June 2018
Antenatal Indicators

 

 

 

1. Smoking in pregnancy for all women giving birth Yes Published 2011 to 2017
2. Antenatal care in the first trimester for all women giving birth Yes Published 2011 to 2017
20. Models of care No Referred for further work elsewhere(a)
Labour and Birth Indicators    
Selected women    
5. Induction of labour for selected women giving birth for the first time

Yes

Published 2004 to 2017

6. Caesarean section for selected women giving birth for the first time

Yes

Published 2004 to 2017

7. Unassisted (non-instrumental) vaginal birth for selected women giving birth for the first time

Yes

Published 2004 to 2017

8. Assisted vaginal birth for selected women giving birth for the first time

Yes

Published 2004 to 2017

All women

 

 

3. Episiotomy for women having their first baby and giving birth vaginally

Yes

Published 2011 to 2017

9. General anaesthetic for women giving birth by caesarean section

Yes

Published 2007 to 2017

11. High-risk women undergoing caesarean section who receive appropriate pharmacological thromboprophylaxis

No

Not to be reported(b)

15. Women having their second birth vaginally whose first birth was by caesarean section

Yes

Published 2007 to 2017

17. One-to-one care in labour

No

Not to be reported(c)

18. Caesarean sections at less than 39 completed weeks gestation (273 days) without obstetric/medical indication

No

Further development required(d)

Birth outcome Indicators

 

 

4. Apgar score of less than 7 at 5 minutes for births at term

Yes

Published 2004 to 2017

10. Small babies among births at or after 40 weeks gestation

Yes

Published 2004 to 2017

12. Babies born at or after 37 completed weeks gestation admitted to a neonatal intensive care nursery or special care nursery for reasons other than congenital anomaly

No

Further development work done in 2015-16

13. Third and fourth degree tears for (a) all first births and (b) all births

Yes

Published 2013 to 2017

14. Blood loss of (1) >1,000 mL and < 1,500 mL and (ii) ≥1,500 mL during first 24 hours after the birth of the baby (i.e. primary PPH) for (a) vaginal births and (b) caesarean sections No

Further development required(d)

16. Separation of baby from the mother after birth for additional care No Not to be reported(c)
19. Supporting breastfeeding No Referred for further work elsewhere(e)

21. Skin-to-skin contact after birth

No

Further development work done in 2015–16

* National Health Information and Performance Principal Committee (NHIPPC) is now retired and has been replaced by the National Health Data and Information Standards Committee (NHDISC).

  1. Work on this indicator will be covered by the National Maternity Data Development Project.
  2. The AIHW ECG recommended in 2013 that further development not be progressed. All jurisdictions agreed with this recommendation. This related to significant data quality issues.
  3. Maternity Services Inter-Jurisdictional Committee (MSIJC) recommended that further development of this indicator not be progressed.
  4. The data item underlying this indicator began to be reported voluntarily in 2014. National data is anticipated by 2018–19, prior to which indicator specifications will need to be sent for approval.
  5. Work on this indicator was referred to the National Child Health and Wellbeing subcommittee of the Australian Population Health Development Principal Committee of the Australian Health Ministers’ Conference (AHMC).

References

  • AIHW NPESU (Australian Institute of Health and Welfare National Perinatal Epidemiology and Statistics Unit) & AIHW 2013. National core maternity indicators. Cat. no. PER 58. Canberra: AIHW.
  • Commonwealth of Australia 2009. Improving maternity services in Australia: report of the maternity services review. Canberra: Commonwealth of Australia.
  • DoHWA (Department of Health, Western Australia) 2007. Improving maternity services: working together across Western Australia: a policy framework. Perth: Government of Western Australia, Department of Health.
  • Fahy K, Robinson J, Douglas NF & KEMH (King Edward Memorial Hospital) 2001. Inquiry into obstetric and gynaecological services at King Edward Memorial Hospital 1990–2000: final report 2001. Perth: Government of Western Australia, Department of Health.
  • WHA (Women’s Healthcare Australasia) 2007. Supporting excellence in maternity care: the core maternity indicators project: findings from the core maternity indicators project. Canberra: WHA.