Draft Report on National Perinatal Performance Measures: Highlights with Broad Relevance to Childbearing Women and Families

Childbirth Connection        National Partnership for Women and Families      

NOTE: Childbirth Connection (CC) and the National Partnership for Women and Families (NPWF) are jointly issuing this time-sensitive alert to update readers on important national maternity care quality issues and the opportunity for public comment. CC's Executive Director Maureen Corry co-chairs the Steering Committee for this project, and Lee Partridge from NPWF is a Committee member. An online letter from Maureen Corry and NPWF President Debra Ness, and the letter and content of this web page (PDF) are also available.

The National Quality Forum (NQF) has invited review and comment on its draft report, National Voluntary Consensus Standards for Perinatal Care, by June 18, 2008 (NQF members) or June 11, 2008 (general public). A multi-stakeholder Perinatal Care Steering Committee reviewed 33 performance measures, and recommended that 18 receive the "NQF-endorsed" designation. To address gaps in measures, the Steering Committee also developed 10 recommendations for further research and measure development. The full draft report, related documents and forms for providing comments are at  NQF's Perinatal Care Project web page.  Following the comment period, NQF members will vote on the measures and research and development recommendations, and NQF leadership will approve the final set.

This page highlights the report recommendations of broadest relevance to childbearing women and their families.

Measures Recommended for Endorsement

Five of the measures recommended for endorsement address important quality concerns for large segments of the population of childbearing women and newborns.

PN-007-07 Elective delivery prior to 39 completed weeks gestation
Why is this measure important? Most births in the United States now begin by medical intervention (labor induction or planned cesarean section) rather than spontaneous onset of labor. Many of these do not require urgent delivery and take place before 39 completed weeks of gestation, when the fetal brain, lungs and other organs are still developing. As earlier birth is associated with increased likelihood of newborn health problems, professional guidelines do not support "elective" delivery before 39 full weeks of gestation. Wide use of this performance measure could result in a very large number of newborns who are born later and healthier than at present.

How is the measure defined? This measure is the percentage of babies who are born before 39 full weeks of gestation, among single babies born after 37 weeks of gestation. The measure excludes babies with specific codes indicating that earlier delivery might have been appropriate. The information is available in medical records.

PN-013—07 Incidence of episiotomy
Why is this measure important? Episiotomy is a surgical cut into a woman's perineum to enlarge the opening of the vagina just before a vaginal birth. In 2005, about one quarter of women with vaginal births in U.S. hospitals experienced this procedure. However, the most recent systematic review of best evidence about effects of episiotomy reaffirmed that routine or liberal use of this procedure provides no benefit and increases risk of harm. Harm from liberal or routine episiotomy, as opposed to more limited episiotomy, may include increased injury to the perineum, need for stitches, experience of pain and tenderness, period of healing, incontinence of stool or gas, and pain with intercourse. There is great scope for improvement, as benchmark studies report good outcomes with episiotomy rates of 2% or less.

How is the measure defined? This measure is the percentage of women with an episiotomy, among women with vaginal births. The information is available in claims data, medical records, and some electronic health records.

PN-010-07 Cesarean rate for low-risk first birth women
Why is this measure important? The steadily climbing U.S. cesarean section rate has reached a record level each successive year in this century, and about 1 woman in 3 now gives birth by major abdominal surgery. By contrast, two large international studies recently reaffirmed earlier World Health Organization guidance that national cesarean section rates above 15% appear to do more harm than good. In comparison with vaginal birth, cesarean section is associated with increased risk for numerous shorter- and longer-term health problems in mothers (for example, blood clots and stroke, emergency hysterectomy, infection, more intense and longer-lasting pain, poorer overall functioning) and babies (for example, breathing problems, surgical injury, reduced breastfeeding, and asthma in childhood and adulthood). Of special concern are serious fertility and placenta problems that endanger mothers and babies in future pregnancies (such as ectopic pregnancy, placenta accreta, placental abruption). Risk for many of these increases with increasing number of prior cesareans, a special concern as access to VBAC (vaginal birth after cesarean) has sharply declined over the past decade in the U.S. Cesarean section has become the most common operating room procedure in U.S. hospitals and involves much greater cost than vaginal birth. Large improvement is within reach: high-quality care has resulted in benchmark cesarean rates of 7% in mixed risk and 4% in low-risk American women.

How is the measure defined? This measure is the percentage of women with cesareans in first-time mothers who are expected to be at low risk. This group is giving birth to single babies in a head-first position at or beyond 37 weeks of gestation. It is especially important to focus on first-time mothers because 1) about 4 in 5 women with one birth will have at least 1 and, more likely, 2 or more additional babies, 2) women who have had a first vaginal birth are highly likely to give birth vaginally in future births, 3) a cesarean section puts women at increased risk in future pregnancies, and 4) at present, many women in the United States do not have access to vaginal birth after cesarean (VBAC).

PN-021-07 Breastfeeding at hospital discharge
Why is this measure important? Consistent, high-quality evidence suggests that exclusive breastfeeding is the optimal way to feed nearly all infants for the first six months of life. Benefits include reduced childhood infectious disease, sudden infant death syndrome, obesity, type 2 diabetes, and blood pressure and cholesterol levels. Breastfeeding also has important health benefits for women, including reduced postpartum depression, type 2 diabetes, and breast and ovarian cancer. Leading professional organizations recommend exclusive breastfeeding during the first 6 months, but most mothers and babies in the United States do not achieve this standard. A large proportion of women who intend to exclusively breastfeed as they come to the end of pregnancy are not doing so a week after the birth, and this group experiences high rates of hospital practices that disrupt breastfeeding — for example, formula "supplements." Use of this measure in California resulted in notable improvement in exclusive breastfeeding at the time of hospital discharge, with important benefits extending to underserved women.

How is the measure defined? This measure is available through newborn screening data. The group of interest is live born babies who did not receive care in newborn intensive care units and experienced genetic screening. The measure is the percentage of that group that was fed by "breast only" at the time that babies go home from hospitals and birth centers.

PN-014-07 Newborn bilirubin screening prior to discharge
Why is this measure important?  Hyperbilirubinemia (high bilirubin level) in a newborn, if not detected and treated, can cause irreversible brain damage resulting in permanent visual, muscular or other disabilities and even death.  Failure to identify and treat hyperbilirubinemia in newborns is one of the NQF-endorsed measures of serious reportable hospital events. Unfortunately visual inspection of the baby for jaundice frequently fails to identify the presence of the condition, particularly if the infant is discharged after a very short inpatient stay. This measure would reinforce adherence to the recommended hospital protocol of universal screening, using either a blood or skin test, prior to discharge.

How is this measure defined? The measure is defined as the percentage of babies who are screened before hospital discharge for jaundice, among newborns born after 35 weeks of gestation. Screening is a blood test or a skin test, and babies who had care in newborn intensive care units or whose parents declined the test are excluded. The information can come from medical records, a clinical database, laboratories that process the tests or electronic health data.

Measures Not Recommended for Endorsement

Among measures not recommended for endorsement, two relate to vaginal birth after cesarean (VBAC), an important issue for the half million women with one or more previous cesareans who give birth annually in the United States.  Access to VBAC is declining sharply and is unavailable in many communities across the country, placing these women and their babies at elevated risk for many health problems. In its current guideline, the American College of Obstetricians and Gynecologists recommends that most women with a previous cesarean be counseled and offered VBAC. A large proportion of women with a previous cesarean are interested in the option of VBAC, but most of those do not have this option, primarily because their caregiver or hospital is unwilling to offer it. At this time, over 9 in 10 women in the United States with a previous cesarean have repeat cesareans. Incentives for hospitals and health professionals to offer this service to childbearing women are urgently needed.

NQF endorsed one of the two measures, PN-028-07 Risk-adjusted vaginal birth after cesarean, in 2003, and more than 700 hospitals currently report it. The NQF Perinatal Care Steering Committee reevaluated the measure as required by NQF policy, and a majority decided it does not meet NQF criteria for importance or usability, as there is no consensus on what the "ideal" VBAC rate would be.  An alternative measure, PN-020-07 VBAC availability, which is currently used in California, would define "access" as a VBAC rate of 5% of more.  It was also opposed by a majority of Steering Committee members for the same reason.  Supporters of these measures believe having public information about risk-adjusted VBAC rates and about availability of VBAC fosters health care quality by helping women with an interest in VBAC and purchasers identify supportive facilities and caregivers. Inclusion in the new measure set, which may be expected to receive more attention than previous maternity performance measures, may also encourage the health system to increase support for VBAC and stem loss of access. Although a majority of Steering Committee members voted not to recommend either measure, it is possible that their recommendations will be reconsidered as the NQF endorsement process goes forward.

Recommendations for Future Measurement Development and Research

In addition to evaluating existing performance measures, the Perinatal Care Steering Committee identified 10 areas in need of further measurement development and research. The following recommendations are exceptionally important for the population of childbearing women and newborns.

Vaginal birth after cesarean delivery rate (VBAC)
Although neither of the two VBAC candidate measures was recommended for endorsement, the Steering Committee was very concerned about the diminishing VBAC availability and stressed the importance of development of measures or composites that would help stem this tide. Suggested measures should include women’s need for high-quality information, counseling, and shared decision-making as well as access to safe supportive VBAC care if they make an informed decision to plan a vaginal birth after cesarean.  

Normal birth measure
Most childbearing women are healthy and have good reason to expect an uncomplicated birth, yet childbirth care in the United States often involves routine or liberal use of numerous interventions. About one-half of childbearing women support the concept that giving birth is a process that should not be interfered with unless medically necessary, while about one-quarter are uncertain and another quarter disagree. A normal birth measure would be of great value for women who wish to avoid routine interventions by providing information that can assist with choice of birth setting and caregiver.  A normal birth measure has been developed and used and reported throughout the United Kingdom for many years, but does not currently have a sponsor and developer in the United States.

Informed decision making
Studies suggest that the standard processes of informed consent frequently are not followed during maternity care. There are special challenges with informed decision making during labor when many tests and procedures are often undertaken. To improve the quality of maternity care, the Perinatal Care Steering Committee recommended the development of new performance measures relating to informed maternity decision making.

Smoking cessation
High-quality research clarifies the harm to the developing fetus and lifelong impact of smoking during pregnancy. Similarly, high-quality research identifies effective interventions for helping pregnant women quit smoking or reduce the amount of smoking. Effective smoking cessation interventions in pregnant women reduce preterm birth and increase average birth weight. Smoking cessation interventions are more effective in pregnant women than in non-pregnant populations. The Perinatal Care Steering Committee has recommended that measure developers identify a measure of actual smoking cessation rather than mere recommendation to quit or referral to help. Such a measure has the potential to improve the health of mothers, babies and families.

Patient experience
The CAHPS surveys (Consumer Assessment of Healthcare Providers and Systems) are increasingly used to assess the quality of care from the perspective of the person receiving care. These important surveys have been developed for use in diverse clinical areas, but there are some limitations when applied to the specific circumstances of maternity care. The Perinatal Care Steering Committee noted the absence of patient experience measures in the measures submitted for consideration, and recommended that the CAHPS tools be tailored specifically for use with the childbearing population, which would include accommodating the range of maternity care providers and birth settings, the range of approaches to labor pain relief and the range of routes of medication.

Transitions of care
As childbearing women move across providers and care settings before and during pregnancy, for childbirth, for postpartum care, and for continuing health care, there are numerous opportunities for continuity and care coordination to fall short and to adversely affect mothers and babies, as well as health care value. The Perinatal Care Steering Committee recommended the development of performance measures to strengthen care coordination for childbearing women and newborns.

"Value added"
A number of measures that the Perinatal Care Steering Committee recommended for NQF endorsement apply to rather small portions of mothers and babies among the more than four and one-quarter million births annually in the United States. To foster a smoothly functioning system of performance measurement, reporting and improvement, the Committee recommended ongoing assessment to ensure that the collection and use of Perinatal Care performance measures adds value for childbearing families, providers and payers, and leads to measured improvement in care and outcomes.

To learn more about this project, read the full draft report and offer comments, go to NQF's Perinatal Care Project web page.

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Childbirth Connection is a national not-for-profit organization founded in 1918 as Maternity Center Association. Our mission is to improve the quality of maternity care through research, education, advocacy and policy. Childbirth Connection promotes safe, effective and satisfying evidence-based maternity care and is a voice for the needs and interests of childbearing families.
Most recent page update: 6/6/2008