Australasian Clinical Indicator Report 2003 – 2010 Obstetrics ...

The Australian Council on 

Healthcare Standards 

Australasian Clinical Indicator Report 

Acknowledgements: 

2003 – 2010 

12 th Edition 

Obstetrics, version 6 

Clinical Indicators 

Health Services Research Group 

University of Newcastle 

In 2010, this indicator set had been reported since 2003. 2008, 2009 and 2010 data drawn from a 

revised set of indicators. 

The Obstetrics Working Party is led by Dr Ted Weaver from Royal Australian and New Zealand 

College of Obstetricians and Gynaecologists 

Australasian Clinical Indicator Report 2003-2010 Page 1 

© ACHS. This work is copyright. Requests and inquiries concerning reproduction and rights should 

be addressed to pos@achs.org.au

Contents 

Obstetrics, v6 

Obstetrics, version 6 3 

Selected primipara - intervention 3 

1.1 Selected primipara - spontaneous vaginal birth (H) 3 

1.2 Selected primipara - induction of labour (L) 5 

1.3 Selected primipara - instrumental vaginal birth (L) 8 

1.4 Selected primipara - caesarean section (L) 11 

Vaginal birth after caesarean section (VBAC) 13 

2.1 Vaginal delivery following a previous primary caesarean section (N) 13 

Selected primipara – perineal injury 15 

3.1 Selected primipara - intact perineum (H) 15 

3.2 Selected primipara - episiotomy and no perineal tear (L) 18 

3.3 Selected primipara - perineal tear and NO episiotomy (L) 20 

3.4 Selected primipara - episiotomy and perineal tear (L) 23 

3.5 Selected primipara surgical repair of perineum for third degree tear (L) 24 

3.6 Selected primipara - surgical repair of perineum for fourth degree tear (L) 26 

Caesarean section – General anaesthetic 27 

4.1 General anaesthetic for caesarean section (L) 27 

Antibiotic prophylaxis 29 

5.1 Appropriate prophylactic antibiotic at time of caesarean section (H) 29 

Thromboprophylaxis 30 

6.1 High risk caesarean section - pharmacological thromboprophylaxis (H) 30 

Blood transfusion 32 

7.1 Vaginal birth - blood transfusion (L) 32 

7.2 Caesarean section - blood transfusion (L) 35 

Low birthweight 38 

8.1 Deliveries - birth weight

Obstetrics, version 6 

Selected primipara - intervention 

1.1 Selected primipara - spontaneous vaginal birth (H) 


Rationale 

The selected primipara represents an uncomplicated pregnancy whereby intervention and 

complication rates should be low and consistent across hospitals. Use of the selected 

primipara (rather than all women giving birth) controls for differences in case mix and 

increases the validity of inter-hospital comparisons of maternity care. 

Numerator Total number of selected primipara who have a spontaneous vaginal birth. 

Denominator Total number of selected primipara who give birth. 

Dimensions of care: Accessibility Appropriateness Continuity 

Effectiveness Efficiency Quality Improvement and Risk Safety 

Desirable level: Low High Not specified 

Type of Indicator: Process Outcome Structure 

No. Total Total 

Year HCOs numerator denominator Rate # 

Centile Stratum Outlier 

(20) (80) gains gains gains 

2008 139 17,724 38,294 46.3 36.7 57.7 4,374 1,999 1,277 

2009 155 21,852 48,465 45.1 37.3 55.9 5,222 2,411 1,347 

2010 165 23,873 52,147 45.8 36.4 57.7 6,241 3,335 1,783 

# per 100 selected primipara 

Rate # 

Rate # 

In 2010 there were 304 data submissions from 165 HCOs. The annual rate was 45.8 per 100 

selected primipara. 

Variation between strata 

Rates by Public / Private 

No. Total 

Total Stratum 

Year Stratum HCOs numerator denominator rate # 

Standard Stratum 

error gains 

2009 Private 58 7,561 20,297 38.2 0.84 2,411 

Public 97 14,291 28,168 50.0 0.72 

2010 Private 58 7,832 21,845 36.9 0.91 3,335 

Public 107 16,041 30,302 52.2 0.77 

#per 100 selected primipara 

Variation between HCOs 

In 2010 the potential gains totalled 6,242 more spontaneous births. 




Outliers 


In 2010 there were 31 outlier submissions from 19 HCOs whose combined excess was 1,783 

fewer spontaneous births. The outlier HCO rate was 25.1 per 100 selected primipara. 




1.2 Selected primipara - induction of labour (L) 


Rationale 





Numerator Total number of selected primipara who undergo induction of labour. 










2008 141 10,933 39,903 27.4 19.9 34.2 2,995 1,118 684 

2009 153 13,587 47,435 28.6 21.7 33.6 3,300 2,760 640 

2010 162 14,935 51,365 29.1 22.8 34.0 3,205 2,472 750 


Rate # 

Rate # 







Rates by State 


No. Total 

Total Stratum 



error gains 

2009 NSW 46 3,836 12,485 30.4 0.79 942 

Qld 20 2,272 7,918 28.5 1.00 447 

SA 15 1,559 4,808 31.9 1.28 438 

Tas 5 384 1,218 30.9 2.54 98 

Vic 44 3,348 13,313 25.7 0.77 387 

WA 15 1,633 5,118 31.6 1.24 446 

Other 8 555 2,575 22.8 1.74 

2010 NSW 46 3,997 13,532 29.3 0.78 674 

Qld 22 2,620 9,148 28.6 0.95 392 

SA 19 1,758 5,127 33.7 1.26 481 

Tas 5 358 1,125 31.2 2.70 78 

Vic 43 3,645 13,717 27.1 0.77 386 

WA 17 1,856 5,667 32.4 1.20 459 

Other 10 701 3,049 24.3 1.64 



In 2010 the potential gains totalled 3,205 fewer inductions, corresponding to a reduction by 

approximately one fifth. 

Outliers 

In 2010, there were 19 outlier submissions from 14 HCOs whose combined excess was 750 

more inductions. The outlier HCO rate was 42.6 per 100 selected primipara. 








1.3 Selected primipara - instrumental vaginal birth (L) 


Rationale 





Numerator The number of selected primipara who undergo an instrumental vaginal birth. 










2008 134 8,964 36,968 24.2 18.3 29.1 2,190 1,227 374 

2009 151 11,275 46,901 24.0 18.4 28.0 2,634 2,285 495 

2010 161 12,420 51,143 24.3 19.2 27.8 2,588 1,098 437 


Rate # 

Rate # 









No. Total 

Total Stratum 



error gains 

2009 Private 55 5,172 19,140 26.4 0.51 775 

Public 96 6,103 27,761 22.4 0.42 



No. Total 

Total Stratum 



error gains 

2009 NSW 47 3,021 12,368 24.4 0.63 663 

Qld 19 1,554 7,527 21.0 0.81 146 

SA 15 1,165 4,808 24.3 1.01 248 

Tas 5 264 1,218 22.2 2.01 

Vic 41 3,378 13,167 25.3 0.61 814 

WA 14 1,359 4,809 27.7 1.01 411 

Other 10 534 3,004 19.1 1.28 

2010 NSW 46 3,001 13,296 23.0 0.60 

Qld 21 1,927 9,011 21.8 0.73 

SA 19 1,241 5,127 24.5 0.97 137 

Tas 5 237 1,125 22.2 2.07 

Vic 41 3,636 13,607 26.0 0.60 568 

WA 17 1,649 5,523 28.9 0.93 393 

Other 12 729 3,454 22.0 1.18 



In 2010 the potential gains totalled 2,588 fewer instrumental vaginal births, corresponding to a 

reduction by approximately one fifth. 

Outliers 

In 2010 there were 12 outlier submissions from ten HCOs whose combined excess was 437 

more instrumental vaginal births. The outlier HCO rate was 34.9 per 100 selected primipara. 








1.4 Selected primipara - caesarean section (L) 


Rationale 



primipara (rather than all women giving birth) controls for differences in casemix and increases 

the validity of inter-hospital comparisons of maternity care. 

Numerator Total number of selected primipara undergoing caesarean section. 





Type of Indicator: 

Process Outcome 

Rate # 

Rate # 



be addressed to pos@achs.org.au 

Structure 





2008 134 11,004 38,748 28.4 22.4 35.0 2,318 1,773 695 

2009 149 13,007 46,642 27.9 22.3 32.7 2,595 1,912 908 

2010 160 14,455 51,616 28.0 22.4 33.9 2,873 2,316 1,203 






No. Total 

Total Stratum 



error gains 

2009 Private 55 6,635 18,896 33.9 0.51 1,912 

Public 94 6,372 27,746 23.8 0.42 


Public 104 6,853 30,095 23.5 0.47 



In 2010 the potential gains totalled 2,873 fewer caesarean sections, corresponding to a 

reduction by approximately one tenth.

Outliers 



more caesarean sections. The outlier HCO rate was 43.8 per 100 selected primipara. 




Vaginal birth after caesarean section (VBAC) 


2.1 Vaginal delivery following a previous primary caesarean section (N) 

Rationale 

With caesarean section rates continuing to increase to the highest level in history, the issue of 

whether it is safe to have a vaginal birth after caesarean section (VBAC) is of the highest 

importance. There is evidence that repeat caesarean section can be associated with 

significant morbidity for women but VBAC carries increased risks for the baby when compared 

with repeat elective caesarean section. 

Numerator Total number of women delivering vaginally following a previous primary caesarean 

section. 

Denominator Total number of women delivering who have had a previous primary caesarean 

section and no intervening pregnancies of more than 20 weeks gestation. 







(20) (80) 

2003 151 2,174 13,574 16.0 11.0 21.3 

2004 153 2,397 15,779 15.2 9.23 20.8 

2005 149 2,303 17,076 13.5 7.84 19.7 

2006 147 2,315 18,018 12.8 7.78 18.4 

2007 147 2,410 18,875 12.8 8.17 19.1 

2008 131 2,220 18,546 12.0 7.71 18.5 

2009 138 2,864 20,032 14.3 9.88 21.0 

2010 142 2,991 20,741 14.4 8.24 21.0 

Rate # 

Rate # 

*Centile 

gains 

#per 100 deliveries *Gains are not calculated when the desirable level is not specified. 




*Stratum 

gains 

*Outlier 

gains 


deliveries. 

Trends 

The fitted rate decreased from 14.5 to 13.2, a change of 1.3 per 100 deliveries. 

Rates and centiles by year 

Desirable rate unspecified 

x 

80 th centile rate 

Aggregate rate 

Fitted rate 

20 th centile rate


There were no significant stratum differences in 2009 and 2010. 


Outliers 


Since it has not been specified whether high or low rates are desirable, outlier HCOs are not 

reported. 




Selected primipara – perineal injury 

3.1 Selected primipara - intact perineum (H) 


Rationale 

Vaginal birth is the most common cause of anal sphincter injuries in women and as such 

obstetric anal sphincter injury is considered a major complication of vaginal birth – a 

complication that can have a significant impact on a woman’s quality of life. 

Numerator Total number of selected primipara with an intact perineum. 

Denominator Total number of selected primipara delivering vaginally. 









2008 141 5,602 27,598 20.3 11.9 33.6 3,676 1,121 

2009 151 6,073 34,243 17.7 10.2 29.9 4,179 4,787 1,012 

2010 162 6,348 35,935 17.7 10.2 29.6 4,295 2,940 920 


Rate # 

Rate # 









No. Total 

Total Stratum 



error gains 

2009 NSW 46 1,377 8,877 15.7 1.42 1,420 

Qld 19 1,298 5,725 22.5 1.77 528 

SA 15 537 3,679 14.6 2.20 629 

Tas 5 297 895 31.7 4.47 

Vic 41 1,235 8,980 14.0 1.41 1,588 

WA 16 799 3,812 20.7 2.16 418 

Other 9 530 2,275 22.9 2.80 201 

2010 NSW 47 2,413 9,153 25.8 1.48 

Qld 21 1,001 5,728 17.6 1.87 469 

SA 18 467 3,679 12.9 2.34 476 

Tas 5 225 807 26.6 4.99 

Vic 42 1,172 9,767 12.4 1.44 1,310 

WA 18 592 4,121 14.5 2.21 467 

Other 11 478 2,680 17.7 2.74 217 



In 2010 the potential gains totalled 4,296 more mothers having intact lower genital tract. 

Outliers 

In 2010 there were 29 outlier submissions from 17 HCOs whose combined excess was 920 

fewer mothers having intact lower genital tract. The outlier HCO rate was 6.0 per 100 selected 

primipara. 








3.2 Selected primipara - episiotomy and no perineal tear (L) 


Rationale 




Numerator Total number of selected primipara undergoing episiotomy and NO perineal tear while 

giving birth vaginally. 










2008 129 6,894 24,364 28.3 18.1 37.2 2,495 2,974 772 

2009 138 8,388 30,824 27.2 16.5 34.2 3,307 2,955 1,026 

2010 144 9,563 32,699 29.2 17.7 39.6 3,777 2,692 1,100 


Rate # 

Rate # 





No. Total 

Total Stratum 



error gains 

2009 Private 47 3,475 10,163 33.4 1.23 940 

Public 91 4,913 20,661 24.2 0.86 


Public 97 5,562 21,985 25.8 0.78 







No. Total 

Total Stratum 



error gains 

2009 NSW 44 2,251 7,856 28.7 1.32 879 

Qld 16 885 4,970 18.1 1.66 

SA 13 799 3,223 24.8 2.06 233 

Vic 41 3,029 9,003 33.3 1.23 1,422 

WA 14 1,024 3,358 30.1 2.02 420 

Other 10 400 2,414 17.5 2.38 


Qld 19 1,082 5,253 20.9 1.57 

SA 13 944 3,468 27.1 1.93 217 

Vic 40 3,512 9,611 36.0 1.16 1,460 

WA 16 1,135 3,785 29.8 1.85 339 

Other 12 621 2,868 22.6 2.12 



In 2010 the potential gains totalled 3,777 fewer perineal tears, corresponding to a reduction by 

approximately one third. 

Outliers 


more perineal tears. The outlier HCO rate was 46.0 per 100 selected primipara. 




3.3 Selected primipara - perineal tear and NO episiotomy (L) 


Rationale 




Numerator Total number of selected primipara sustaining a perineal tear and NO episiotomy. 










2008 128 11,175 24,402 45.8 36.9 51.1 2,177 1,193 494 

2009 137 14,087 30,566 46.1 39.8 50.7 1,916 1,178 448 

2010 147 15,339 32,551 47.1 38.9 50.5 2,672 1,529 810 


Rate # 

Rate # 









No. Total 

Total Stratum 



error gains 

2009 Private 47 4,187 10,129 42.2 0.90 

Public 90 9,900 20,437 48.0 0.63 1,178 



No. Total 

Total Stratum 



error gains 

2009 NSW 44 3,368 7,748 43.8 0.98 

Qld 16 2,585 4,988 50.9 1.22 420 

SA 13 1,721 3,223 52.3 1.51 317 

Vic 41 3,747 9,003 42.4 0.91 

WA 13 1,429 3,190 45.2 1.52 

Other 10 1,237 2,414 50.0 1.75 182 


Qld 20 2,943 5,462 52.9 1.37 573 

SA 13 1,841 3,468 52.7 1.72 357 

Vic 41 3,927 9,429 42.4 1.04 

WA 16 1,766 3,678 48.0 1.67 204 

Other 12 1,459 2,868 49.9 1.89 215 



In 2010 the potential gains totalled 2,673 fewer perineal tears, corresponding to a reduction by 

approximately one tenth. 

Outliers 










3.4 Selected primipara - episiotomy and perineal tear (L) 


Rationale 




Numerator Total number of selected primipara undergoing episiotomy AND sustaining a perineal 

tear while giving birth vaginally. 










2008 121 1,217 23,776 5.12 2.35 5.94 659 282 281 

2009 133 1,855 30,532 6.08 2.79 6.55 1,003 392 

2010 141 1,893 32,146 5.89 2.90 6.75 960 407 


Rate # 

Rate # 






In 2010 the potential gains totalled 961 fewer perineal tears, corresponding to a reduction by 

approximately one half. 

Outliers 







3.5 Selected primipara surgical repair of perineum for third degree tear 

(L) 

Rationale 




Numerator Total number of selected primipara undergoing surgical repair of 

the perineum for third degree tear. 










2008 145 1,162 28,816 4.03 2.62 4.82 407 318 64 

2009 151 1,420 33,210 4.28 2.62 4.99 548 371 135 

2010 159 1,565 34,826 4.49 2.72 5.15 617 499 170 


Rate # 

Rate # 





No. Total 

Total Stratum 



error gains 

2009 Private 54 332 11,518 3.16 0.20 

Public 97 1,088 21,692 4.87 0.15 371 

2010 Private 53 309 11,735 3.06 0.22 

Public 106 1,256 23,091 5.22 0.15 499 







No. Total 

Total Stratum 



error gains 

2010 NSW 49 329 8,343 4.04 0.27 51 

Qld 19 179 5,420 3.43 0.33 

SA 14 243 3,649 6.46 0.41 110 

Tas 5 24 807 3.55 0.87 

Vic 43 490 10,108 4.79 0.24 137 

WA 18 170 3,819 4.41 0.40 37 

Other 11 130 2,680 4.69 0.48 33 



In 2010 the potential gains totalled 617 fewer surgical repairs, corresponding to a reduction by 

approximately one third. 

Outliers 

In 2010 there were nine outlier submissions from seven HCOs whose combined excess was 

170 more surgical repairs. The outlier HCO rate was 10.7 per 100 selected primipara. 





3.6 Selected primipara - surgical repair of perineum for fourth degree 

tear (L) 

Rationale 




Numerator Total number of selected primipara undergoing surgical repair of the perineum for 

fourth degree tear. 








Centile Stratum 

(20) (80) gains gains 

2008 143 97 28,687 0.34 0.26 0.40 21 

2009 148 114 33,178 0.34 0.32 0.36 6 5 

2010 158 120 34,759 0.35 0.31 0.38 12 


Rate # 

Rate # 




Outlier 

gains 






In 2010 the potential gains totalled 12 fewer surgical repairs, corresponding to a reduction by 

approximately one tenth. 

Outliers 

There were no outlier HCOs in 2010.

Caesarean section – General anaesthetic 

4.1 General anaesthetic for caesarean section (L) 


Rationale 

There is now evidence that women who are having a caesarean section should be offered 

regional anaesthesia rather than general anaesthesia because it is safer and results in less 

maternal and neonatal morbidity. 

Numerator Total number of women having a general anaesthetic for a caesarean section 

Denominator Total number of women having a caesarean section. 









2008 130 2,701 44,669 6.05 3.55 9.38 1,113 1,101 391 

2009 142 3,698 56,734 6.52 3.45 10.1 1,742 1,803 511 

2010 148 3,665 59,617 6.15 3.60 9.48 1,521 1,703 480 

# per 100 caesareans 

Rate # 

Rate # 


caesareans. 



No. Total 

Total Stratum 



error gains 

2009 Private 48 717 23,509 3.34 0.35 

Public 94 2,981 33,225 8.77 0.29 1,803 


Public 102 2,932 35,120 8.14 0.23 1,703 

#per 100 caesareans 


In 2010 the potential gains totalled 1,522 fewer general anaesthesia, corresponding to a 

reduction by approximately one third. 




Outliers 



more general anaesthesias. The outlier HCO rate was 12.6 per 100 caesareans. 




Antibiotic prophylaxis 


5.1 Appropriate prophylactic antibiotic at time of caesarean section (H) 

Rationale 

An appropriate prophylactic antibiotic at the time of caesarean section, both elective and 

emergency, significantly reduces maternal post-operative infectious morbidity. 

Numerator Total number of women who receive an appropriate prophylactic antibiotic at the time 

of caesarean section. 

Denominator Total number of women undergoing caesarean section. 









2008 68 11,796 18,443 64.0 36.1 96.0 5,901 4,399 2,718 

2009 88 25,032 31,507 79.4 57.7 98.2 5,897 2,485 

2010 84 29,864 35,010 85.3 75.6 97.8 4,360 1,875 


Rate # 

Rate # 


caesareans. 




In 2010 the potential gains totalled 4,360 more mothers receiving appropriate antibiotic 

prophylaxis. 

Outliers 


fewer mothers receiving appropriate antibiotic prophylaxis. The outlier HCO rate was 62.2 per 

100 caesareans. 




Thromboprophylaxis 


6.1 High risk caesarean section - pharmacological thromboprophylaxis 

(H) 

Rationale 

Thromboembolism is a major cause of maternal morbidity. Pregnancy is a risk factor for VTE 

and the risk is higher if birth is by caesarean section, especially emergency caesarean section. 

Numerator Total number of high risk women undergoing caesarean section who receive 

appropriate pharmacological thromboprophylaxis. 

Denominator Total number of high risk women undergoing caesarean section. 









2008 40 1,049 1,698 61.8 19.1 85.6 405 309 217 

2009 56 1,456 2,814 51.7 26.4 88.7 1,038 848 378 

2010 58 2,960 4,275 69.2 36.5 90.1 893 516 


Rate # 

Rate # 


caesareans. 



No. Total 

Total Stratum 



error gains 

2009 NSW 8 32 171 21.4 13.7 106 

SA 7 69 212 33.4 12.3 105 

Vic 26 736 1,645 44.7 4.41 636 

WA 7 315 373 83.4 9.26 

Other 8 304 413 73.2 8.80 


There were no significant stratum differences in 2010. 


In 2010 the potential gains totalled 893 more mothers at risk having appropriate 

pharmacological thromboprophylaxis. 

Outliers 


fewer mothers at risk having appropriate pharmacological thromboprophylaxis. The outlier 

HCO rate was 20.8 per 100 caesareans. 








Blood transfusion 

7.1 Vaginal birth - blood transfusion (L) 


Rationale 

Postpartum haemorrhage (PPH) is a potentially life threatening complication of birth that 

occurs in about 3-5% of vaginal births. The condition remains a leading cause of maternal 

morbidity and mortality. 

Numerator Total number of women who give birth vaginally who receive a blood transfusion 

during the same admission. 

Denominator Total number of women who give birth vaginally. 









2008 125 1,044 88,624 1.18 0.52 1.38 578 216 217 

2009 145 1,268 113,835 1.11 0.73 1.35 439 415 51 

2010 155 1,599 127,362 1.26 0.78 1.57 610 610 64 

# per 100 vaginal births 

Rate # 

Rate # 

In 2010, there were 286 data submissions from 155 HCOs. The annual rate was 1.3 per 100 

vaginal births. 



No. Total 

Total Stratum 



error gains 

2009 Private 51 206 35,437 0.75 0.046 

Public 94 1,062 78,398 1.28 0.031 415 


Public 104 1,394 91,766 1.44 0.033 610 

#per 100 vaginal births 






No. Total 

Total Stratum 



error gains 

2009 NSW 39 144 20,223 0.83 0.067 

Qld 20 245 20,388 1.20 0.067 74 

SA 15 155 11,185 1.36 0.090 58 

Tas 6 31 4,110 0.87 0.15 

Vic 39 399 34,800 1.10 0.051 94 

WA 18 173 15,271 1.13 0.077 44 

Other 8 121 7,858 1.41 0.11 45 

2010 NSW 43 306 26,871 1.18 0.068 

Qld 20 301 23,796 1.27 0.072 50 

SA 14 191 11,489 1.62 0.10 64 

Tas 5 28 3,298 1.02 0.19 

Vic 43 403 35,513 1.15 0.059 

WA 19 163 15,970 1.06 0.088 

Other 11 207 10,425 1.75 0.11 71 

#per 100 vaginal births 


In 2010 the potential gains totalled 611 fewer mothers requiring blood transfusion, 

corresponding to a reduction by approximately one third. 

Outliers 

In 2010 there were five outlier submissions from four HCOs whose combined excess was 64 

more mothers requiring blood transfusion. The outlier HCO rate was 3.0 per 100 vaginal 

births. 








7.2 Caesarean section - blood transfusion (L) 


Rationale 

Postpartum haemorrhage (PPH) is a potentially life threatening complication of birth that 

occurs in about 3-5% of vaginal births. The condition remains a leading cause of maternal 

morbidity and mortality. 

Numerator Total number of women who undergo caesarean section who receive a blood 

transfusion during the same admission. 

Denominator Total number of women who undergo caesarean section. 









2008 119 724 41,802 1.73 0.55 2.24 493 419 211 

2009 140 814 54,645 1.49 0.73 2.09 412 334 97 

2010 147 996 60,710 1.64 1.02 2.27 376 419 131 


Rate # 

Rate # 


caesareans. 



No. Total 

Total Stratum 



error gains 

2009 Private 52 183 24,787 0.88 0.099 

Public 88 631 29,858 2.00 0.090 334 


Public 97 809 34,987 2.15 0.065 419 







No. Total 

Total Stratum 



error gains 

2009 NSW 38 84 10,553 0.97 0.16 

Qld 20 162 10,140 1.58 0.16 61 

SA 15 125 5,576 2.18 0.22 67 

Tas 6 65 1,651 2.98 0.41 33 

Vic 36 199 15,540 1.31 0.13 52 

WA 17 112 8,077 1.43 0.18 37 

Other 8 67 3,108 2.01 0.30 32 

2010 NSW 41 169 13,619 1.34 0.12 

Qld 19 213 11,126 1.88 0.13 60 

SA 14 117 5,546 2.10 0.19 42 

Tas 5 25 1,304 1.90 0.39 

Vic 39 219 16,214 1.38 0.11 

WA 19 123 8,635 1.43 0.15 

Other 10 130 4,266 2.71 0.21 58 



In 2010 the potential gains totalled 376 fewer mothers requiring blood transfusion, 

corresponding to a reduction by approximately one third. 

Outliers 

In 2010 there were 11 outlier submissions from nine HCOs whose combined excess was 131 

more mothers requiring blood transfusion. The outlier HCO rate was 4.2 per 100 caesareans. 








Low birthweight 



APGAR scores 

9.1 Term babies - Apgar score of




No. Total 

Total Stratum 



error gains 

2009 Private 55 346 60,604 0.69 0.046 

Public 101 1,573 105,865 1.42 0.035 774 


Public 110 1,665 116,684 1.36 0.028 687 

#per 100 term babies 


In 2010 the potential gains totalled 746 fewer low APGAR scores, corresponding to a 

reduction by approximately one third. 

Outliers 

In 2010 there were six outlier submissions from five HCOs whose combined excess was 105 

more low APGAR scores. The outlier HCO rate was 2.3 per 100 term babies. 




Transfer to NICU / special care 


10.1 Term babies - transferred / admitted to NICU / special care (except 

congenital abnormality) (L) 

Rationale 

Inborn term infants without birth defects are not normally expected to be admitted to a special 

care nursery (SCN) or neonatal intensive care nursery (NICN). The indicator focuses on all 

admissions of term infants (without a birth defect), resulting from adverse events occurring in 

labour or the immediate neonatal period, which require the facilities of SCN or NICN. 

Numerator Total number of inborn term babies transferred / admitted to a neonatal intensive care 

nursery or special care nursery for reasons other than congenital abnormality. 

Denominator Total number of inborn term live babies.. 









2008 140 11,886 131,680 9.03 1.23 13.6 10,263 3,437 

2009 150 15,124 157,441 9.61 2.10 13.8 11,819 3,595 

2010 156 16,332 162,681 10.0 2.22 12.5 12,727 3,701 

# per 100 term babies 

Rate # 

Rate # 


live births. 




In 2010 the potential gains totalled 12,727 fewer term babies requiring special care, 

corresponding to a reduction by approximately three quarters. 

Outliers 


more term babies requiring special care. The outlier HCO rate was 18.6 per 100 live births. 




Review of adverse events 


11.1 Serious adverse events addressed within peer review process (H) 

Rationale 

Serious unanticipated or unusual adverse events occur in healthcare settings which result in 

maternal or perinatal mortality or morbidity. A peer review process ensures that incidents are 

reviewed and the outcome evaluated with the aim of improving the safety and quality of 

obstetric care. 

Numerator Total number of serious adverse events that are addressed within a peer review 

process. 

Denominator Total number of serious adverse events. 









2008 24 187 233 80.3 60.2 95.1 34 21 16 

2009 42 542 1,053 51.5 94.5 99.2 502 492 222 

2010 41 643 764 84.2 94.6 99.1 114 106 77 

# per 100 specified adverse events 

Rate # 

Rate # 


adverse events. 





Rates by Metro / Non metro 


No. Total Total Stratum 



error gains 

2009 Metropolitan 24 324 833 39.1 5.39 492 

Non metro 18 218 220 98.3 10.5 



No. Total 

Total Stratum 



error gains 

2010 Private 20 427 434 98.1 3.78 

Public 21 216 330 65.9 4.34 106 







No. Total 

Total Stratum 



error gains 

2009 NSW 10 167 210 79.7 8.18 37 

Qld 8 84 85 97.6 12.9 

SA 8 94 545 17.5 5.08 436 

Vic 7 51 55 92.0 16.0 

Other 9 146 158 92.0 9.44 

2010 NSW 12 165 168 97.7 5.03 

Qld 5 120 121 99.0 5.93 

SA 7 95 196 48.9 4.66 98 

Vic 5 54 57 94.2 8.64 

WA 6 70 77 92.6 7.43 

Other 6 139 145 95.4 5.42 

#per 100 specified adverse events 


In 2010 the potential gains totalled 114 more adverse events addressed. 

Outliers 

In 2010 there were three outlier submissions from two HCOs whose combined excess was 77 

fewer adverse events addressed. The outlier HCO rate was 26.6 per 100 adverse events. 




Clinical Significance of these results 

The clinical indicators in this set are: 

Selected primipara - intervention 

1.1 Selected primipara - spontaneous vaginal birth (H) 

1.2 Selected primipara - induction of labour (L) 

1.3 Selected primipara - instrumental vaginal birth (L) 

1.4 Selected primipara - caesarean section (L) 

VBAC 

2.1 Vaginal delivery following a previous primary caesarean section (N) 


3.1 Selected primipara - intact perineum (H) 

3.2 Selected primipara - episiotomy and no perineal tear (L) 

3.3 Selected primipara - perineal tear and NO episiotomy (L) 

3.4 Selected primipara - episiotomy and perineal tear (L) 

3.5 Selected primipara - surgical repair of perineum for third degree tear (L) 

3.6 Selected primipara - surgical repair of perineum for fourth degree tear (L) 

Caesarean section – general anaesthetic 

4.1 General anaesthetic for caesarean section (L) 


5.1 Appropriate prophylactic antibiotic at time of caesarean section (H) 


6.1 High risk caesarean section - pharmacological thromboprophylaxis (H) 


7.1 Vaginal birth - blood transfusion (L) 

7.2 Caesarean section - blood transfusion (L) 




• 31.8% and the public rate was 26.1% 

• instrumental vaginal birth (CI 1.3) – the private rate was 27.0% and the public rate was 22.2% 

• caesarean section (CI 1.4) – the private rate was 

• 35.4% and the public rate was 23.0%. 

CI 1.1: Selected primipara – spontaneous vaginal birth (H) 

In 2010, there were 52,147 selected primipara reported from 165 HCOs. The annual rate of 

spontaneous vaginal birth was 45.8 per 100 selected primipara. In 2010, there were 19 outlier 

HCOs whose combined rate was 25.1%. 

CI 1.2: Selected primipara – induction of labour (L) 


induction of labour was 29.1 per 100 selected primipara. 

CI 1.3: Selected primipara – instrumental vaginal birth (L) 


instrumental vaginal birth was 24.3 per 100 selected primipara. 

CI 1.4: Selected primipara – caesarean section (L) 


caesarean section was 28.0 per 100 selected primipara. 

Vaginal birth after caesarean 

This indicator has been collected since 2003. The apparent trend is small and the 20 th and 

80 th centile rates have remained close to 7.5% and 20% respectively, indicating that there is 

considerable variation between HCOs. Since 2004, the private rate has been approximately half 

the public rate. 

CI 2.1: Vaginal delivery following a previous primary caesarean section (N) 

In 2010, there were 20,741 deliveries reported from 142 HCOs. The annual rate was 14.4 per 

100 deliveries. The fitted rate decreased from 14.5 to 13.2, a change of 1.3 per 100 deliveries. 


These six indicators have been collected since 2008. There are public / private differences in 

CIs 3.2 and 3.5. When the three years of data are combined, the private rate of episiotomy and 

no perineal tear was 35.6% and the public rate was 24.5%, and the private rate of surgical 

repair of perineum for fourth degree tear was 2.7% and the public rate was 5.2%. 

CI 3.1: Selected primipara – intact perineum (H) 


intact perineum was 17.7 per 100 selected primipara. In 2010, there were 17 outlier HCOs 

whose combined rate was 5.97%. 

CI 3.2: Selected primipara – episiotomy and no perineal tear (L) 


episiotomy and no perineal tear was 29.2 per 100 selected primipara. 




CI 3.3: Selected primipara – perineal tear and NO episiotomy (L) 



perineal tear and no episiotomy was 47.1 per 100 selected primipara. 

CI 3.4: Selected primipara – episiotomy and perineal tear (L) 


episiotomy and perineal tear was 5.89 per 100 selected primipara. 

CI 3.5: Selected primipara – surgical repair of perineum for third degree tear (L) 


surgical repair of perineum for third degree tear was 4.49 per 100 selected primipara. 

CI 3.6: Selected primipara – surgical repair of perineum for fourth degree tear (L) 


surgical repair of perineum for fourth degree tear was 0.35 per 100 selected primipara. 

Caesarean section – general anaesthetic 

The public rate for a general anaesthetic in caesarean section is more than twice the private 

rate, 8% and 4% respectively. 

CI 4.1: General anaesthetic for caesarean section (L) 

In 2010, there were 59,617 caesareans reported from 148 HCOs. The annual rate was 6.15 per 

100 caesareans. 


More than one fifth of submitting HCOs have compliance rates in excess of 95%, however one 

in five HCOs have rates less than 75%. 

CI 5.1: Appropriate prophylactic antibiotic at time of caesarean section (H) 


100 caesareans. In 2010, there were 21 outlier HCOs whose combined rate was 62.2%. 


CI 6.1: High risk caesarean section – pharmacological thromboprophylaxis (H) 


100 caesareans. In 2010, there were 12 outlier HCOs whose combined rate was 20.8%. 

Differences between HCOs are not well explained by strata differences. 


In both of these indicators, the public rate was more than twice the private rate, when the three 

years are combined. 

CI 7.1: Vaginal birth – blood transfusion (L) 




In 2010, there were 127,362 vaginal births reported from 155 HCOs. The annual rate of 

transfusion was 1.26 per 100 vaginal births. 

CI 7.2: Caesarean section – blood transfusion (L) 


In 2010, there were 60,710 caesareans reported from 147 HCOs. The annual rate of transfusion 

was 1.64 per 100 caesareans. 


CI 8.1: Deliveries – birth weight

Expert commentary 


Royal Australian and New Zealand College of Obstetricians and 

Gynaecologists (RANZCOG) 

Selected primipara – intervention 

The strata differences for CI 1.1: Selected primipara – spontaneous vaginal birth in 

relation to private and public continue to widen in 2010, compared with 2009. This is 

multifactorial, and represents the recognised / acknowledged difference in delivery mode 

between private and public settings. The demographics of the two populations vary widely, 

and RANZCOG does not envisage / plan any specific action(s) to change this disparity. 

Strategies which try to alter clinical decision making, with the primary aim of changing 

numbers, have significant risks in terms of unwanted adverse events and outcomes. 

The rates for CI 1.2 : Selected primipara – induction of labour remain higher for SA and 

WA, while the rates for CI 1.3: Selected primipara – instrumental vaginal birth remain 

higher for WA and Vic. RANZCOG does not view these differences as ‘major’, and so offers 

no causative factors. 

In relation to CI 1.4: Selected primipara – caesarean section, the stratum rate for private 

healthcare organisations (HCOs) is much higher than for public HCOs, and there are 19 

outlier HCOs with an outlier rate of 43.8 per 100 selected primipara. The comments about 

spontaneous vaginal birth rates provided above apply to this indicator. The higher caesarean 

rates in private HCOs are likely to remain, maintained by multiple factors related to the 

demographic of the patient population, greater autonomy and patient choice in delivery 

mode, individual practitioner preference and training, among other factors. RANZCOG does 

not have an objective which includes changing clinical practice unless evidence-based 

studies indicate that outcomes are worse as a direct result of differences. Published data 

suggesting that overall obstetric outcomes are better in private HCOs compared with public 

HCOs would suggest change in practice should be evidence-driven only. 


The rate for CI 3.1: Selected primipara – intact perineum has decreased since 2008, with 

Vic and SA having the lowest rates in 2009 and 2010 and Tas having the highest rates in 

those years. Additionally, all states recorded lower strata rates in 2010 compared to 2009, 

apart from NSW where the rate has significantly increased from 15.7 to 25.8. There were 17 

HCOs with an outlier rate of 6.0 per 100 selected primipara. RANZCOG considers it overly 

simplistic to equate ‘intact perineum’ with lack of pelvic floor injury, either short or longer 

term. The change in the numbers likely represents (at least in part) better reporting of 

injuries, rather than any specific change in rate. Studies using endo- anal ultrasound and 

anal manometry increasingly show that occult anal sphincter injury occurs with significant 

frequency in situations where ‘intact’ or ‘first degree only’ is reported on the perinatal data. 1 





RANZCOG objectives in relation to perineal injury are: 

• accurate reporting of perineal injury; 

• accurate recognition of the degree of the injury, including partial or complete external 

anal sphincter (EAS) disruption; and 

• better teaching to all maternity intrapartum care providers on the correct techniques for 

repair of injuries, thereby reducing short and long term morbidity. 

In reviewing the results for CI 3.2: Selected primipara – episiotomy and no perineal tear, 

Vic continues to have very high results, and 21 HCOs are responsible for an outlier HCO rate 

of 46.0 per 100 selected primipara. The rates for CI 3.3: Selected primipara – perineal tear 

and no episiotomy identify SA and Qld as continuing to have high rates, with ten HCOs 

responsible for an outlier HCO rate of 66.4 per 100 selected primipara. It is difficult to 

speculate on differences between states, other than that caused by different reporting of the 

same event. Obstetric practice and demographic spread of patients should not vary 

significantly for these indicators. CI 3.2 (episiotomy and no perineal tear) is likely to contain 

considerable reporting error and therefore ascertainment bias in results, particularly as most 

perinatal data are entered retrospectively by non-medical staff, and the clinician responsible 

for dealing with the perineal injury in question is no longer present / available to clarify true 

findings. RANZCOG would support review of the usefulness and accuracy of CI 3.2 and CI 

3.3. 

Of particular interest in the results of CI 3.5: Selected primipara – surgical repair of 

perineum for third degree tear is the significant difference between public and private 

rates, with the latter being the better performing stratum (fewer third degree tears). 

RANZCOG believes that higher degrees of perineal injury (all third degree and fourth degree 

tears) have historically been under-reported, and this is now supported by research using 

anal ultrasound and manometry, showing unrecognised and unreported injury in significant 

rates above the 4%CI 3.5 rate. 1 


The rate for CI 5.1: Appropriate prophylactic antibiotic at time of caesarean section has 

been improving significantly since 2008 to its highest rate of 85.3%, and the rate of the 

poorest 20% of HCOs has increased in this time from 36.1% to 75.6%. This improvement is 

likely to be multifactorial, and probably an excellent example that demonstrates: 

• interdisciplinary cooperation between infectious disease clinicians and their hospital-wide 

education and audit practices; 

• awareness amongst obstetricians of the benefits of chemoprophylaxis (everybody hates 

a wound infection as 

• a very visible and long-term complication); and 

• affirmative cooperation from anaesthetic colleagues who administer intraoperative 

antibiotic cover. 






The rate for CI 6.1: High risk caesarean section – pharmacological 

thromboprophylaxis has slightly improved to its highest rate of 69.2, however only 58 

HCOs report on this indicator. The poorest 20% HCO rate has increased significantly from 

19.1% to 36.5%, but the best 20% HCO rate has only increased from 85.6% to 90.1%. 

Lastly, 12 HCOs are responsible for an outlier rate of 20.8 per 100 caesareans. Publication 

on VTE prophylaxis in surgery in general, and specifically in obstetric practice, and 

promotion in clinical guidelines has helped improve compliance and lift the rates of this 

indicator. Also, recognition of VTE as a leading cause of maternal morbidity in developed 

nations, such as Australia and New Zealand, has driven the compliance with 

thromboprophylaxis. RANZCOG will continue to support education and audit in this area 

amongst Fellows and GP Obstetricians. 


The rate for CI 7.2: Caesarean section – blood transfusion has increased in 2010, with the 

private and public rates both increasing; the public rate is twice as high as the private HCO 

rate. 

Additionally, the rate for SA HCOs remains high. The difference between states may not 

reflect any specific factor, given that in 2009 Tas was the outlier, however in 2010, their data 

have normalised. 

The public versus private differences in rates of blood transfusion at caesarean may reflect 

two factors: firstly, the different demographics, with higher acuity patients in the public 

sector more likely to need transfusion, and secondly, less experienced operators (more 

trainees, junior staff after hours) who may have higher transfusion rates. 

Lastly, the decision to transfuse may vary depending on the clinician’s estimate of 

compliance with conservative therapy (oral haematinics). Where a clinician feels confident 

that oral haematinics have been taken in the lead up to birth and will be continued 

postnatally, transfusion may be avoided. Compliance will likely be better in private obstetric 

settings, as most private patients have a formal postnatal assessment with an obstetrician 

when haemoglobin can be checked. 

This would be a valuable small research project which RANZCOG will look to progress. 

Peer review of serious adverse events 

The rate for CI 11.1: Serious adverse events addressed within a peer review process 

has increased to its highest level at 84.2%, with the poorest 20% HCO rate increasing from 

60.2 to 94.6 and the best 20% HCO rate from 95.1 to 99.1. The public rate is much higher 

than the private rate, and SA remains much lower than all other states. 

RANZCOG is a very strong supporter of this indicator, and the process it measures – peer 

review of adverse events. Promotion of peer-review activities in both public and private 

sectors is part of the core business of RANZCOG’s Standing Committee for Continuing 




Professional Development (CPD). As one of the colleges with compulsory CPD which 


contains a mandatory proportion of risk management and practice improvement activities, 

RANZCOG remains committed to working with ACHS to improve these activities, particularly 

in the private sector, where rates for CI 11.1 are acknowledged to be lower rates for CI 11.1 

are acknowledged to be lower than desired. 

Participation rates 

In relation to how representative of Australian and New Zealand obstetric units these data 

are, it is difficult to comment without an awareness of which units reported for each clinical 

indicator, or more importantly, which HCOs did not report, particularly for those indicators 

with significant outliers and potential gains. 

For clinical indicators with over 100 reporting HCOs, however, RANZCOG would feel the 

results are representative to the degree that those results can be used by RANZCOG and its 

Fellowship to make changes and drive improved outcomes in maternity care. 

RANZCOG is very supportive of having ongoing input into the ACHS indicator review and 

development, particularly as models of care evolve and change under recent Maternity 

Reform Legislation.* 

References 

1. Andrews V, Sultan A, Thakar R and Jones P. Occult anal sphincter injuries – myth or 

reality? BJOG 2006; 113(2): 195–200 




Australian College of Midwives (ACM) 



In reviewing the strata differences for CI 1.1: Selected primipara – spontaneous vaginal 

birth, more women are accessing private health care and accessing private obstetricians as 

they are perceived to provide the best maternity care. If women were able to access models 

that provided continuity of midwifery care – all pregnant and birthing women need a midwife – 

but not all women need a doctor, there may be a decrease in the interventions and 

improvement in outcomes. 

Higher rates in SA and WA for CI 1.2: Selected primipara – induction of labour and higher 

rates for WA and Vic for CI 1.3: Selected primipara – instrumental vaginal birth are noted. 

There are significantly more private maternity beds per capita in WA than any other state, and 

WA also has a higher number of women requesting social induction of labour (IOL) because of 

the ‘fly in, fly out’ workforce. The medical model is dominant in both SA and WA, and dictates 

the provision of maternity care. Additionally, there are no consistent standards between the 

jurisdictions and this may be reflected in Vic policies around prolonged second stage labour 

and the timing of intervention. 

In reviewing the rates for CI 1.4: Selected primipara – caesarean section, primary 

caesarean sections are at an all-time high in Australia. This relates specifically to the 

predominance of the medical model and the lack of continuity of midwifery care models. 


The rate for CI 3.1: Selected primipara – intact perineum has decreased since 2008. From 

ACM’s perspective, women are not encouraged to use the birth positions they are shown 

during antenatal education, and more women are having epidurals which means they are 

usually in lithotomy position when it comes time to birth. Evidence has shown that this 

position will increase perineal trauma. Some maternity services still use the hands-on 

technique to support the perineum, which can actually increase perineal damage. 

When reviewing the results of CI 3.2: Selected primipara – episiotomy and no perineal 

tear, ACM is aware that there are a number of maternity units that do not have the resources 

or skilled, competent staff to provide episiotomy. Vic does not have a Service Capability 

Framework that is in line with other jurisdictions, which would dictate what services must be 

available to provide the service, and this may be a reason for the continuance of their high 

results. 

* Health Legislation Amendment (Midwives and Nurse Practitioners) Act 2010; Midwife 

Professional Indemnity (Commonwealth Contribution) Scheme Act 2010; Midwife Professional 

Indemnity (Run-off Cover Support Payment) Act 2010. 

There could be a number of reasons for strata differences of CI 3.3: Selected primipara – 

perineal tear and no episiotomy and CI 3.5: Selected primipara – surgical repair of 

perineum for third degree tear. These include birthing positions, big babies, policies around 

management of the perineum during birth, however the strongest cause is birth positions. 






In reviewing the improved rate for CI 5.1: Appropriate prophylactic antibiotic at time of 

caesarean section, ongoing education about the use of prophylactic antibiotics, and 

ensuring it becomes mandated in policy will lead to continuing compliance and 

improvements. Health services need to regularly audit this part of their quality processes. 


Whilst ACM acknowledges that the rate for CI 6.1: High risk caesarean section – 

pharmacological thromboprophylaxis has slightly improved, VTE prophylaxis needs to be 

mandated in policy in all maternity units. This should be endorsed by the Health Ministers 

from each jurisdiction as an operational directive. 


In reviewing the strata differences for CI 7.2: Caesarean section – blood transfusion, there 

are inconsistent policies across jurisdictions as to when a blood transfusion is given. Some 

sites use a haemoglobin level, while others base it on clinical compromise. Public maternity 

units generally have easy access to blood and blood products compared to some of the 

private units. There is also better access to haematology, so blood results are more readily 

available. Women can take a long time to recover if their haemoglobin is borderline, and they 

are trying to breastfeed and care for a new baby. This can be deleterious to their physical, 

mental and emotional health. 

Review of adverse events 

The rate for CI 11.1: Serious adverse events addressed within a peer review process is 

noted and, again, ACM considers this to be a process that should be mandated in policy in all 

maternity units. 

Participation rates 

The number of reporting HCOs appears to be fairly representative of the Australian maternity 

environment.

Australasian Clinical Indicator Report 2003 – 2010 Obstetrics ...

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