In this article Kirstin Webster, ANNP and NMPA Neonatal Clinical Fellow, presents an overview of the recently published National Maternity and Perinatal Audit State of the Nation report, highlighting key findings and recommendations for improvements in clinical care and data quality. She also provides an update on other recent activities and developments within the audit.
The latest State of the Nation report published last week by the National Maternity and Perinatal Audit (NMPA) for births in NHS maternity units across England, Scotland and Wales, presents results for over half a million women and birthing people who gave birth in 2023.
This report, capturing 94% of eligible births, finds variation in care and outcomes between trusts and boards and highlights key messages with respect to data quality and completeness. Country-level results are summarised in a State of the Nation report, with interactive data tables and funnel plots available at trust/board-level.
This is the first report the audit has published since 2022, when we published a report on 18/19 births. This is due to delays we experienced in receiving data from NHS England in their updated Maternity Services Data Set v2.0 (MSDS v2.0). During the period between the reports, we reviewed and revised the measures we include in our results with the help of our Clinical Reference Group (CRG) and Women and Families Involvement Group (WFIG). The measures review process is published on our website, along with methods and technical specifications outlining the NMPA approach to data collection and data sources. We have changed our reporting period from financial years to calendar years, a decision that was made to align our reports with those of complementary audits such as the National Neonatal Audit Programme (NNAP) and the Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK’s (MBRRACE-UK) maternal programme of work and perinatal programme of work.
With the intention of providing annual clinical results for the most up-to-date data years available to us, we made the decision to publish the latest State of the Nation (SON) report for births that occurred in 2023. We will publish results for the interim years (2019–2022) on our website in due course, with an aim to publish the next SON and annual clinical report data for births occurring in 2024 early next year.
For births in 2023, we are reporting for the first time rates of late booking, that is women and birthing people having their first appointment with a midwife (booking appointment) after 10+o weeks of gestation. We found that just over one quarter of women and birthing people across Great Britain booked after 10+o weeks of gestation, with a wide variation in rates between maternity care providers IQR 16.7–30.2% (Interquartile Range (IQR) shows the middle 50% of results giving a sense of the data values around the median value). The reasons for late booking are varied and may include maternal age, ethnicity, socioeconomic deprivation, language barriers and previous experiences of maternity care. This is an important metric to measure because late booking may delay commencement of antenatal care, which in turn may impact the timing of the dating scan, reduce the accuracy of fetal anomaly screening and estimated due date (EDD) calculation, all of which may have implications for intrapartum care. We recommend that Government health departments across England and the devolved nations should work with stakeholders to develop initiatives at local and national levels to target an improvement in timely pregnancy booking. These should include engaging with service users, representative groups and charities to ensure information and access to services are appropriate and work to overcome existing barriers to pregnancy booking.
In reporting mode of birth, we found that just under half (49.4%) of women and birthing people gave birth vaginally without the use of instruments. Of those giving birth with the use of instruments (11.1%), 7.0% gave birth with the use of forceps and 4.1% by ventouse. Of those giving birth vaginally, 3.29% experienced a third- or fourth-degree perineal tear and 24.4% had an episiotomy.
For the first time, we are reporting caesarean birth by selected Robson Group Classification (Robson Groups 1, 2 and 5 are the same as those that are report on the NHS England Maternity Dashboard). Caesarean birth rates have increased considerably since our previous report (Unplanned caesarean birth: 2018/19, 15.5%; 2023, 23.1%. Planned caesarean birth: 2018/19, 12.1%; 2023, 16.4%). It is important to note there is no ‘ideal’ rate for caesarean births, all modes of birth carry their own risks and benefits and a woman or birthing person’s individual circumstances should be taken into consideration when counselling to inform their decision-making process.
Rates of induction of labour (IOL) have been increasing, 33.9% of women and birthing people experienced an IOL in 2023 compared with 28.5% in our first report on births in 15/16, with considerable variation in rates between trusts and boards in 2023 (IQR 29.6%–39.0%). An IOL specific snapshot audit is underway and is due to be published later this year. This snapshot audit will include more information about the mode of birth experienced by women and birthing people following an induction of labour, and their baby’s 5-minute Apgar score. The report makes recommendations for clinical practice and data quality and capture.
Our results show the landscape of maternity care is changing, perhaps in response to national initiatives such as Saving Babies Lives Care Bundle v3 (SBLCB v3), Better Births, Maternity and Neonatal Safety Improvement Programme; independent investigation reports that include Morecambe Bay, East Kent, Shrewsbury and Telford, the ongoing Nottingham investigation and recently announced maternity and neonatal investigation, along with changes to national guidelines for example those from NICE, Intrapartum Care, Inducing Labour, Caesarean Birth.
We report an increase in interventions such as induction of labour and caesarean birth, and a decrease in rates of vaginal birth without the use of instruments and vaginal birth after caesarean (VBAC). We have previously reported overall rates for VBAC of 22.5% in 2018/19, the rate in 2023 was 14.2%. These changes in mode of birth lead to not only an increased demand on maternity services, on both workforce (midwifery, obstetric, theatre and anaesthetic staffing groups) and resources (theatres and postnatal bed pressure due to increased length of stay) but also for the women and birthing people who access maternity services. An increase in interventions may impact postpartum recovery times and lead to either an increased length of stay following birth or an unplanned readmission. With this in mind, we have made a recommendation that commissioners of maternity services and maternity networks should use the evidence of variation in care processes and outcomes that we have demonstrated in our results to work with their constituent units, for example when planning service provision and to identify opportunities for quality improvement. This may also include trusts and boards reviewing their own results from the NMPA and local audit to explore differences in practice that may contribute to the observed variation in rates.
In our previous report, we found that around half 48.9% of babies born small-for-gestational-age (SGA) were born at or after their due date (40+0 weeks of gestation). Small-for-gestational-age is defined as a birthweight below the 10th centile, for NMPA data this is according to the British 1990 growth reference centiles. The rate has fallen to 42.6% in our latest report and is down from 55.4% in our first report. National guidance from the Royal College of Obstetricians and Gynaecologists and SBLCB v3 recommend an earlier birth be offered if there are concerns about a baby’s growth. Our finding may indicate an improvement in instances of SGA being appropriately detected, or that birth was expedited due to other decision-making in line with national maternity safety initiatives.
We have identified some potential issues with data quality and capture. For example, data quality (completeness and/or distribution) for postpartum haemorrhage (PPH) ≥1500 ml was insufficient for us to be able to report this measure for almost one quarter (27/120) of trusts in England. The data suggests that a number of trusts may report high-volume blood loss only, whilst others appear to report estimated blood loss volumes, a practice which has been shown to be highly inaccurate. In practice, the ability to make a rapid visual assessment of high volumes of blood loss is necessary to facilitate timely intervention, however standardised, objective and accurate measuring and reporting of all blood loss volumes is crucial to reporting comparable rates of PPH across maternity care providers.
The challenges encountered in providing early neonatal care for ethnic minority babies was highlighted in the NHS Race Health Observatory 2023 report, in particular when applying the Apgar scoring tool. We have also had responses from a number of units who were found to have triggered alarm-level outlier status for a high rate of babies being assigned an Apgar score of less than seven at five minutes. Upon interrogating their data, these units found instances of the tool being incorrectly applied in the scoring of babies who had established a regular respiratory pattern but required facial continuous positive airway pressure (CPAP) to assist them through their transition at birth. A number of these babes were scored a 1 when in fact, they should have scored 2, this had an impact on their overall 5-minute Apgar score and the trust rate.
Skin-to-skin contact was not available as a variable in the Scottish or Welsh datasets, and there was striking variation in the rates between English trusts (IQR 68.3%–84.1%). In our previous report, we commented on skin-to-skin contact as a meaningful measure of early postnatal care. There is a discrepancy between the UNICEF Baby Friendly definition of skin-to-skin contact “the practice where a baby is dried and laid directly on the mother’s bare chest after birth, and left for at least an hour or until after the first feed” and the MSDS definition, which lists the data item name as “skin-to-skin contact indicator (within one hour)” and the description “Whether or not baby had skin-to-skin contact with mother in the first hour of life.”. The wide variation we found between maternity care provider rates may reflect uncertainty around what constitutes meaningful skin-to-skin contact in the context of these two definitions. NICE Intrapartum Care guideline has recommended encouraging skin-to-skin contact as soon as possible after birth since 2007. This was updated in 2023 to encourage skin-to-skin with a “birth companion” if the mother is not well enough, yet no information is available in the datasets on reasons for non-occurrence or if skin-to-skin occurred with someone other than the mother.
It is reported that the UK has some of the lowest breastfeeding rates in the world. A national infant feeding survey conducted every 5 years between 1975 and 2010, most recently reported breast milk given at first feed for 81% of babies across the United Kingdom (UK) (83% in England, 74% in Scotland and 71% in Wales). We report that rates of breast milk at first feed were higher in England (72.6%) than in Scotland (63.1%) or Wales (65.8%). However, without longer-term breast milk feeding rates, it is difficult to interpret how meaningful breast milk at first feed is as a measure for influencing longer-term breast milk feeding rates. In October 2023 the Government commissioned Ipsos to carry out a new infant feeding survey, the results of which are not yet available.
The updated MSDS v2.0 makes use of Systemized Nomenclature of Medicine – Clinical Terms (SNOMED CT) clinical coding system, a system that was devised in 1999 and recommended for use by NHS England in 2014, who remain responsible for maintaining and releasing a UK edition of the coding system. As with all changes to clinical coding and data recording, it takes time for the processes to be adopted and embedded into daily practice. We have found coding issues specifically in relation to SNOMED CT coding in the maternity data and urge for greater interoperability and integration between clinical systems and coding to align with the Digital Maternity Records Standard (DMRS).
The NMPA has been extended to continue the audit’s activities, annual clinical reports, State of the Nation summary reports and a schedule of topic specific snapshots audit reports until at least December 2027. We have been working tirelessly to establish a link between maternity data and the data collected and reported by the NNAP. The two audits have support from our respective Clinical Reference Groups (CRG) and have received approvals from the Confidential Advisory Group (CAG). A collaboration between the audits offers an opportunity for more detailed reporting of neonatal outcomes of maternity care and support amongst others, the NHS England’s Maternity Transformation initiatives. A snapshot audit of maternity outcomes for multiple births is expected to be published in early 2026 and we are exploring relevant and appropriate topics for publication later in 2026 and 2027.
National audit data and results such as those reported in NMPA outputs and online offer an opportunity for maternity care providers to reflect on the care they provide. By interrogating their own practice and by sharing good practice examples from others, they may initiate quality improvement processes to enhance care and outcomes. We are planning an opportunity for maternity care providers to share examples of quality improvement projects and other relevant examples of barriers and enablers of providing quality care that may be of benefit to others. This may be via posters/reports or video recordings in space on our website, or live webinars with Q&A (recordings of which could be uploaded to our website). We welcome expressions of interest in taking part and suggestions of the most useful format.
We are always happy to receive questions, comments and feedback to improve our outputs. Email us at: nmpa@rcog.org.uk
Kirstin Webster, ANNP and NMPA Neonatal Clinical Fellow
nmpa@rcog.org.uk
September 2025
