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Sentinel Audit - Update May 2001

Introduction: There is no 'correct' rate for caesarean section but there is concern that the rate is rising in England and Wales (1989-90 11.3%, 1994-95 15.5% and preliminary estimates for 1997-98 suggest 17%, DoH 1999). The variations in caesarean section rate between units are not accounted for by differences in casemix.

The National Sentinel Caesarean Section Audit represents a unique collaboration between The Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives, the Royal College of Anaesthetists and the National Childbirth Trust. It is funded by the Department of Health through NICE.

Aim

To evaluate the current role of caesarean sections in maternity care.

Objectives

• To determine the frequency of caesarean sections in all maternity units in England, Wales, Northern Ireland, the Channel Islands and the Isle of Man.
• To determine the factors associated with variations in the rates of caesarean section. The focus will be on the circumstances of delivery, the decision-making process and women's choice.
• To determine whether these factors are associated with the rising caesarean section rate.
• To assess the quality of clinical care against agreed standards, derived from current literature.
• To determine the extent to which maternal request for caesarean section:
  a) Contributes to the elective caesarean section rate.
  b) And how frequently patient and clinician reports of maternal request concord.
• To determine the influence of the following on caesarean section rates:
  a) Facilities/Equipment
  b) Staff on Delivery Suite
  c) Clinicians' threshold in relation to performing a caesarean section
  d) Policies on Delivery Suite

Methods

• At a national level, the audit has been run by RCOG CESU. Locally, every maternity unit has a nominated facilitator/co-ordinator who received ENB-approved training in audit methodology.
• To determine the frequency of caesarean sections, denominator data on all deliveries was collected in every maternity unit on Denominator Data Forms.
• More detailed information on all women having a caesarean section was collected on Clinical Data Forms. The focus of enquiry was on the decision-making process and aspects of the quality of care.
• At a unit level, information on staffing (midwifery, obstetric and anaesthetic), facilities and equipment was collected. Staffing levels were verified by diaries kept at intervals during the study.
  
• Local audit facilitators validated the data they sent against a local source (e.g. labour ward/theatre register) and returned data weekly to RCOG CESU.
  
• The returned data was checked and discrepancies in numbers of Clinical Data Forms returned or queries regarding missing denominator data have been followed up with audit facilitators in the respective units. All data entry and analysis is being performed centrally.

Update on Phase One

• Data collection for Phase One is complete (1 May - 31 July 2000). There has been an excellent response rate from the 236 NHS units and 4 private sector units taking part in England and Wales.
• One unit had to be excluded due to failure to collect data prospectively.
  
• Denominator Data feedback to all participating units has now been verified locally and analysis of the dataset is underway. Twenty-two units highlighted some discrepancies with the data they received, which have now been resolved. Amended results were sent back to them during December and January.
  
• During February, the eight hospitals with midwifery-led units that feed into them were sent summaries of their denominator data which also included deliveries in the midwifery-led units in the denominator.
  
• Clinical Data Forms: data entry was completed in December 2000. Cleaning and analysis is in progress. Following this process, we hope to send you summaries of your clinical data in May.
  
• External validation against birth registration statistics for England and Wales for the study period will be undertaken. The percentage of births included in the data and the ascertainment of stillbirths will be validated.
  
• Data entry for the supplementary surveys is complete. The response rates were as follows:
  95% (N=223) Labour ward staffing and facilities
  98% (N=232) Staffing diaries
  94% (n=204) Anaesthetic questionnaires
  Data cleaning and descriptive analysis of both the maternity unit and anaesthetic surveys is in progress.
  
• A facilitators' questionnaire was sent out to all facilitators during December 2000. This provided an opportunity for them to share their views on the experience of facilitating the audit, helping to build a picture of what areas worked well and if any problems were encountered.
  With all the postal difficulties being experienced around the Christmas period, we are pleased to have received a response rate of 79%.
  

Update on Phase Two

• 42 units were invited to take part in Phase Two. These were randomly selected in England, Wales and Northern Ireland, stratified by their caesarean section rates, geography and type of hospital (DGH, Teaching Hospital).
  
• One unit declined to take part and another failed to authorise their participation in time, giving a final sample of 40 units.
  
• Data collection took place between 1 December 2000 and 28 February 2001.
  
• Simultaneously, all maternity units in Northern Ireland, the Channel Islands and the Isle of Man ran the audit for the first time, including completion of the supplementary surveys.

Phase Two has three components:

Data Collection

• The 39 hospitals from England and Wales who participated in Phase Two responded admirably to the task of filling in Denominator Data and Clinical Data Forms for a further three month period, and once again the quality of the data and the commitment shown by staff has been high.
  
• Similarly, the 16 units in Northern Ireland, the Channel Islands and the Isle of Man who were collecting data for the first time also did a great job.
  
• Complete Phase Two data has now been received back from all units

Survey of Women's Views in Relation to Mode of Delivery

• This was a postal survey using a semi-structured questionnaire of women over 32 weeks gestation who had an EDD in January 2001.
  
• MREC approval was granted in August 2000. Forty units in England, Wales and Northern Ireland took part in the maternal survey as part of Phase Two. They were granted local ethical approval between 13th September and 8th December 2000. All LRECs gave approval to the study.
  
• The questionnaire was piloted on volunteers (all pregnant women), recruited thanks to media publicity, local facilitators and National Childbirth Trust (NCT) teachers.
  
• Training days for the facilitators of Phase Two took place in October 2000.
  Once ethical approval was received, invitations to all women in the participating units who had an EDD in January
• 2001 were despatched by the local facilitators between 27.11.00 and 15.01.01. A total of 7,873 invitations were sent out.
  
• Women who were willing to receive a questionnaire were asked to return a reply slip to RCOG CESU, who then despatched a questionnaire to the women. All women who replied were sent a questionnaire within a maximum of 2-3 working days of CESU receiving the reply slip.
  
• CESU received 2,942 reply slips back from women - a response rate of 37.4%.
  
• 2,506 completed questionnaires were returned - a response rate of 85%.
  
• Overall 32% of all women invited to participate responded.

Survey of Clinicians' Attitude Towards, and Threshold For, Performing a Caesarean Section

• The aim of the Clinicians' Survey was to examine senior clinicians' attitudes towards, and threshold for, performing a caesarean section. Development and piloting of this questionnaire took place during November-January.
  
• Clinicians in the participating units were invited to complete a structured questionnaire about their policies and attitude relating to performing a caesarean section.
  
• A database of Consultants practising obstetrics in the 40 Phase Two hospitals was compiled during the first two weeks of January by telephoning each unit and then verifying this information on the RCOG database of Fellows and Members.
  
• Printing of the survey was carried out in-house and it was despatched to a total 226 clinicians at the end of January.
  
• The response rate was 77% (n=174) and there has been some response from all units.

Launch Meeting

Regional and national data analysis, along with the audit report, will be published to coincide with the launch meeting being held on 26th October 2001 in London.

We would like to sincerely thank everyone who has contributed to both phases of this audit, including all those who have filled in forms, local facilitators and those who have enabled and encouraged their hospital to take part.

If you have any queries or questions please contact:
Jane Thomas, Shantini Paranjothy or Caroline Clark
RCOG CESU, 27 Sussex Place, Regent's Park, London NW1 4RG
T: 020 7772 6342 F: 020 7772 6390 E: cclark@rcog.org.uk