Indicators of Treatment Quality for Women with Low-risk Pregnancies Who are Considering a Hospital Birth

Ali Yawar^*
*Correspondence: Ali Yawar, Department of Medical Area, University of Udine, Udine, Italy, Email:

Commentary

Practices for planned birth among women with low-risk pregnancies vary by birth setting, medical professional and organizational system. Appropriate monitoring is essential for quality improvement. Although sets of quality indicators have been developed, their applicability has not been tested. To improve the quality of childbirth care for low-risk mothers and infants in Japanese hospitals, we developed 35 quality indicators using existing clinical guidelines and quality indicators. We retrospectively analysed data for 347 women in Japan diagnosed with low-risk pregnancy in the second trimester, admitted between April 2015 and March 2016. We obtained scores for 35 quality indicators and evaluated their applicability, i.e., feasibility, improvement potential, and reliability (intra- and inter-rater reliability: kappa score, positive and negative agreement). The range of adherence to each indicator was 0–95.7%. We identified feasibility concerns for six indicators with over 25% missing data. Two indicators with over 90% adherence showed limited potential for improvement. Three indicators had poor kappa scores for intra-rater reliability, with positive/negative agreement scores 0.94/0.33, 0.33/0.95, and 0.00/0.97, respectively. Two indicators had poor kappa scores for inter-rater reliability, with positive/negative agreement scores 0.25/0.92 and 0.68/0.61, respectively. The findings indicated that these 35 care quality indicators for low-risk pregnant women may be applicable to real-world practice, with some caveats.

No serious differences in clinical outcomes such as infant mortality and morbidity have been reported among low-risk pregnant women giving birth at home, in a midwifery unit, or in an obstetrics unit. However, childbirth care practices for women with low-risk pregnancy vary according to birth setting, medical professional, and organizational system. Women with low risk who are planning a birth at home or in a midwifery unit are more likely to have a vaginal birth and to receive less unnecessary medical intervention than women with planned births in an obstetrics unit6. In addition, women receiving midwife-led continuous care by the same midwife or team of midwives from pregnancy until the early parenting period report greater satisfaction. In all cases, it is critical to refrain from unnecessary interventions, such as caesarean sections and episiotomies.

To improve quality of care, quality indicators have been widely used in many clinical fields. A quality indicator is defined as “a measurable element of practice performance for which there is evidence or consensus that it can be used to assess the quality, and hence change in the quality, of care provided” Quality indicators for maternal and perinatal hospital care have been developed mainly for high-risk pregnancy using the consensus method.

In Japan, 98% of women give birth in hospitals, where midwife-led continuous care for low-risk woman is monitored by obstetricians. Among midwives, 87% of midwives works at hospital and clinics18. Midwives in Japan are not legally allowed to perform interventions such as episiotomy, epidural anaesthesia, oxytocin infusion, and instrumental delivery. If necessary, obstetricians from the same hospital provide emergency care. Additionally, care for low-risk pregnancy and childbirth is not covered by insurance in Japan; thus, there are no healthcare claims issued for these types of care. Clinical practices that are covered by the national insurance system can be administratively monitored using claims data; however, data for these low-risk pregnancies are neither publicly accumulated nor evaluated. Types of care that are not included in a claims database have not been adequately investigated with respect to quality improvement. To improve this situation and make such care more accessible, we focused on the importance of clinical data that are available from medical records, as the best method for quality improvement in each medical ssssfacility. Under this background, to assess the quality of childbirth care provided for women with low-risk pregnancy who give birth in a hospital, we developed and updated care quality indicators using existing clinical practice guidelines and quality indicators. We aimed to demonstrate the applicability of care quality indicators for planned hospital births among women with low-risk pregnancies in Japan [1-5].

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