victorian perinatal services performance indicators 2012–13

8/20/2019 Victorian perinatal services performance indicators 2012–13

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© State of Victoria, Department of Health & Human Services, August 2015.

Available at www.health.vic.gov.au/CCOPMM

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Contents

List of tables and figures V

Acknowledgements VI

About this report 1

Methods 5

Changes for 2012–13 5

Using this report 7

Data and results 8

Statewide results and highlights 8

Indicators 1a, 1b and 1c: Outcomes for standard primiparae 19

Indicator 2: Term infants without congenital anomalies who require additional care 25

Indicator 3: Severe fetal growth restriction (FGR) in a singleton

pregnancy undelivered by 40 weeks 28

Indicators 4a and 4b: Vaginal births after primary caesarean section 31

Indicators 5a and 5b: Five-year (2008–2012) gestation standardised perinatal mortality ratio 35

Indicator 6: Referral to postnatal domiciliary care or Hospital in the Home 38

Indicator 7: Smoking during pregnancy 41

Indicators 8a, 8b and 8c: Breastfeeding 44

Indicator 9: Antenatal clinic services 49

Indicator 10: Term infants without congenital anomalies

with an Apgar score < 7 at five minutes 52

Appendix 1: Definitions and data sources 55

Indicator 1: Outcomes for standard primiparae 55

Indicator 2: Term infants without congenital anomalies who require additional care 57


pregnancy undelivered by 40 weeks 58

Indicator 4: Vaginal births after primary caesarean section 59

Indicator 5: Five-year gestation standardised perinatal mortality ratio (GSPMR) 60

Indicator 6: Referral to postnatal domiciliary care or Hospital in the Home 62

Indicator 7: Smoking during pregnancy 63

Indicator 8: Breastfeeding 64

Indicator 9: Antenatal clinic services 65

Indicator 10: Term infants without congenital anomalies withan Apgar score < 7 at five minutes 66


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Appendix 2: Manual data collection 67

Appendix 3: Total women and babies, 2012 68

Key terms 70

References 72

Further reading 74


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V

List of tables and figuresFigure 1: Schema of perinatal performance indicators 1

Table 1: Perinatal indicators and their desired outcomes 4

Table 2: Summary of results, 2012–13 9

Figure 2: Outcomes for standard primiparae, 2012 (Indicators 1a, b and c) 11

Figure 3: Breastfeeding in hospital, 2012 (Indicators 8a, b and c) 12

Figure 4: 32 week GSPMR with results for FGR and Apgar, 2012 13

Figure 5: Comparison of statewide performance over five years, from 2007-08 to 2012-13 14

Figure 6: Indicator 1a: Rate of inductions in standard primiparae in

Victorian public hospitals, 2012 22

Figure 7: Indicator 1b: Rate of caesarean section in standard primiparae

in Victorian public hospitals, 2012 23

Figure 8: Indicator 1c: Third- and fourth-degree perineal tears in standard primipara giving

birth vaginally in Victorian public hospitals, 2012 24

Figure 9: Indicator 2: Term infants without congenital anomalies who require additional

care in Victorian public hospitals, 2012–13 27

Figure 10: Indicator 3: Rate of severe fetal growth restriction (FGR) in a singleton

pregnancy undelivered by 40 weeks in Victorian public hospitals, 2012 30

Figure 11: Indicator 4a: Rate of women who planned for vaginal birth following

a primary caesarean section in Victorian public hospitals, 2012 33

Figure 12: Indicator 4b: Rate of women who achieved a planned vaginal birth

following a primary caesarean section in Victorian public hospitals, 2012 34

Figure 13: Indicator 5a and b: Perinatal mortality ratio for babies born at 22 weeks and 32 weeks

or more (gestation standardised, excluding all terminations of pregnancy and deaths due to

congenital anomalies) using five years pooled data in Victorian public hospitals, 2008-12 37

Figure 14: Indicator 6: Rate of women referred to postnatal domiciliary care

or Hospital in the Home in Victorian public hospitals, 2012-13 40

Figure 15: Indicators 7a and b: Rate of women smoking during pregnancy(before 20 weeks and after 20 weeks’ gestation) in Victorian public hospitals, 2012 43

Figure 16: Indicator 8a: Rate of breastfeeding initiation for babies born at 37+ weeks


Figure 17: Rate of use of infant formula by breastfed babies born at 37+ weeks


Figure 18: Indicator 8c: Rate of final feed being taken exclusively and directly from the

breast by breastfed babies born at 37 weeks’ gestation in Victorian public hospitals, 2012 48

Figure 19: Indicator 9: Rate of women attending their first antenatal visit prior to

12 weeks’ gestation in Victorian public hospitals, 2012 51

Figure 20: Indicator 10: Rate of term infants without congenital anomalies with an

Apgar score < 7 at five minutes in Victorian public hospitals, 2012 54


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VI

Acknowledgements

This report was developed by the Department of Health & Human Services with expert advice from

the Perinatal Safety and Quality Committee, a subcommittee of the Victorian Ministerial Perinatal

Services Advisory Committee.

Perinatal Safety and Quality Committee members

Associate Professor Rod Hunt (Chair) The Royal Children’s Hospital

Ms Laura Bignell The Royal Women’s Hospital

Dr Mary Anne Biro Monash University

Dr Melissa Coulson Consumer representative

Dr Mary-Ann Davey Department of Health & Human Services

Dr Jim Holberton Mercy Hospital for Women

Ms Lauren Newman Portland District Health

Professor Jeremy Oats Chair, Consultative Council on Obstetric

and Paediatric Mortality and Morbidity

Associate Professor Scott Simmons Mercy Hospital for Women

Dr David Simon West Gippsland Healthcare Group

Dr Christine Tippett Maternity and Newborn Clinical Network,Department of Health & Human Services

Professor Euan Wallace Monash Health, Monash University

Appreciation is also extended to the Consultative Council on Obstetric and Paediatric Mortality and

Morbidity (CCOPMM) for permission to use data from the Victorian Perinatal Data Collection (VPDC).


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About this report

Monitoring and reporting on the outcomes and experiences of women and babies during pregnancy

and childbirth in Victorian health services is a key commitment of the Victorian Government.

The Victorian perinatal services performance indicators 2012–13 (‘the report’) is provided to

help improve outcomes for Victorian women and their babies. The report contains data on 10

performance indicators of perinatal care in Victorian health services. The indicators span the

antenatal, intrapartum and postnatal period (Figure 1) and are measured at the statewide public and

private hospital level and the individual public hospital level. All Victorian public hospitals providing

birthing services are required to report accurate data against the perinatal performance indicators.

These indicators are regarded as key areas for assessing the quality of care provided to mothers

and their newborns and consumer information is included for each indicator presented.

Figure 1: Schema of perinatal performance indicators

Antenatal Intrapartum Postnatal

Apgar score

Fetal growth restriction

Smoking in pregnancy

First antenatal visit

Five-year gestation standardised perinatal mortality ratio (GSPMR)

Term infants needing additional care

Vaginal birth after

caesarean section

Outcomes for primiparae Domiciliary care

Breastfeeding


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Benchmark for key performance indicators

Although the report does not set targets for the indicators, it does provide a level of benchmarking

for health services to compare their results and monitor variation against peer group hospitals.

The statewide public hospital rate, and where possible a statewide private hospital rate, is provided

for each indicator. It is important to note, however, that the statewide rates do not represent the

desired target or expectation. In most cases, further improvements in performance are achievable

and expected (Table 1). For the first time, outlier services are presented using an interquartile range

approach, with results in the lower and upper quartiles highlighted in either red (for least favourable

results) or green (for most favourable results) depending on whether the result is expected to be

low or high. Results presented within the interquartile range are left orange and are not consideredto be outlying.

For the first time in this report, the GSPMR is presented with results for indicators relating to

fetal growth restriction (FGR) and Apgar score to highlight potential areas for improvement

across the indicators that represent baby outcomes.

An objective of the Department of Health’s Victorian health service performance monitoring

framework 2014–2015 is to improve the quality, effectiveness and efficiency of health services

for Victorians. Under Victoria’s governance arrangements, health services are responsible for

ensuring that the care provided to all patients is of a safe and high standard. This responsibility

includes understanding the reasons behind their results and improving care and systems where

avoidable or contributing factors have been identified. An assessment of service capacity is integralto the capability of the service and where hospitals identify capacity constraints, these should be

addressed at the local level or in partnership with the Department of Health & Human Services

and other service providers.

Reports such as the Victorian perinatal services performance indicators report are another way

in which health services can use data to improve service quality and safety. The Department of

Health & Human Services will work with health services that are outliers to understand the drivers

for the reported performance and the opportunities for improvement.

Program managers and clinicians can use this report to implement local performance improvement

measures and quality activities for hospitals. Health services should use this report to:

• track their own performance and trends, using raw local data more frequently if required

• compare results with services of a similar profile

• identify priority areas for focus

• regularly review and plan for performance improvement within a continuous quality framework

• evaluate improvement programs and provide feedback to relevant stakeholders

• provide education and support to staff and local communities.


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Outlier services will need to also undertake:

• an assessment of their local capability and the processes to support regular clinical

audits and the provision of performance data feedback to clinicians

• a multidisciplinary review of local clinical practice guidelines and protocols to ensure

they are based on current evidence and research

• a review of organisational barriers that constrain continual practice improvement

• benchmarking with peer group services and engage with hospitals achieving better

outcomes to support local and regional improvement.

Hospitals should also consider doing further local analysis of specific groups or cohorts

of cases such as age profiles.

Performance indicator information is also of interest to consumers and a summary of each

indicator’s purpose and outcomes is included to assist consumers to become better informed

about the safety and quality of Victorian maternity services.

Table 1 provides an overview of the indicators and the desired outcomes.


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Indicator Description Desired outcome

Table 1: Perinatal indicators and their desired outcomes

• Rates should be low and consistent for this low-risk group

of women.

• Variation in rates may indicate that clinical practice and/or

system processes (and/or ascertainment for third- and

fourth-degree perineal tears) may not be supported by

evidence for best clinical practice.

• Rates should be low for this cohort.

• Variation should be low and consistent across peer group

hospitals, reflecting differing case mix.

• High rates may indicate quality of care issues during labour

and childbirth or suboptimal identification and/or management

of complications during pregnancy.

• Rates should be low and overall rates should decrease

considerably over time.

• Heath services should aim to improve methods for identifying

and managing severe FGR.

• Rates should be moderately high with little variation across

peer group hospitals.

• Unless contraindicated, women should be provided with

the opportunity for vaginal birth after caesarean (VBAC)

and information to support decision making.

• Less favourable outliers must understand the extent

of suboptimal performance issues and address these.

• Variation among peer group hospitals is expected to be small.

• Rates should continue to remain high and hospitals with

poorer results should plan for improved performance.

• Rates should be low.

• Services should ensure the data submitted against this

indicator is reliable.

• Hospitals achieving improved rates may be a potential

resource for services wishing to improve rates.

• Results for Indicator 8a (breastfeeding initiation) and 8c

(final hospital feed from the breast) should be high.

• Results for Indicator 8b should be low.• Rates should be consistent among peer group hospitals.

• Rates should be high.

• Services should ensure the data submitted against this

indicator is reliable.

• The large variation among Victorian hospitals should be a

focus for improvement at the local, regional or system level.

• Rates should be low for this lower risk cohort. Variation should

be low and consistent across peer group hospitals, reflecting

differing case mix.• This is an important indicator for longer term infant outcomes

and poorer results should be a priority area for performance

improvement.

Indicator 1a Rate of inductions in standard primiparae

Indicator 1b Rate of caesarean section in standard

primiparae

Indicator 1c Rate of third- and fourth-degree perineal

tears in standard primiparae

giving birth vaginally

Indicator 2 Rate of term infants without congenital

anomalies who require additional care

Indicator 3 Rate of severe fetal growth restriction

(FGR) in a singleton pregnancy

undelivered by 40 weeks

Indicator 4a Rate of women who planned for vaginal

birth following a primary caesarean

section

Indicator 4b Rate of women who achieved a

planned vaginal birth following a primary

caesarean

Indicators 5a Perinatal mortality ratio for babies born

and 5b at 22 weeks and 32 weeks or more

(gestation standardised, excluding all

terminations of pregnancy and deathsdue to congenital anomalies) using five

years pooled data

Indicator 6 Rate of women referred to postnatal

domiciliary care or Hospital in the Home

Indicators 7a Rate of women smoking during

and 7b pregnancy (before 20 weeks

and after 20 weeks gestation)

Indicator 8a Rate of breastfeeding initiation for babies

born at 37+ weeks

Indicator 8b Rate of use of infant formula bybreastfed babies born at 37+ weeks

Indicator 8c Rate of final feed being taken exclusively

and directly from the breast by breastfed

babies born at 37+ weeks gestation

Indicator 9 Rate of women attending their first

antenatal visit prior to 12 weeks’

gestation

Indicator 10 Rate of term infants without congenital

anomalies with an Apgar score of


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5

Methods

The data for this report is derived from:

• the Victorian Perinatal Data Collection (VPDC) by calendar year 2012

for indicators 1, 3, 4, 5, 7, 8, 9 and 10

• the Victorian Admitted Episodes Dataset (VAED) by financial year 2012–13 for indicators 2 and 6.

A small number of public health services submit their data on paper forms that are entered manually

into the VPDC by the Department of Health & Human Services.

Data is reported by health services at which the episode of care was completed. This occurs once

the woman and her baby are discharged from the place of birth. The rates reported have not been

standardised for factors such as age, ethnicity or socioeconomic status.

Further information on the data sources and definitions for each indicator can be found in

Appendix 1.

Changes from 2011–12 are detailed in Appendix 2.

Changes for 2012–13

Report name change

The introduction of two new neonatal performance indicators over the past two reporting periods

(Indicator 3: Rate of severe fetal growth restriction (FGR) in a singleton pregnancy undelivered by

40 weeks, and Indicator 10: Rate of term infants without congenital anomalies with an Apgar score

< 7 at five minutes ) increases the number of neonatal indicators to five out of 10. Accordingly, the

title of this report has changed from ‘maternity services performance indicators’ to ‘perinatal services

performance indicators’ to reflect the government’s commitment to monitoring and reporting on

the outcomes and experiences of babies as well as women during pregnancy and childbirth in

Victorian health services.

Refined Indicator 1 a, b, c

For this report improvements to the data search methodology has meant that more maternal medical

conditions and complications of pregnancy reported in text fields have been captured. These cases

have been excluded from the standard primiparae group, making this a more accurate indicator. This may, in part, account for the lower rates of induction of labour and caesarean section in

standard primiparae in 2012 compared with recent years.

Indicator 2: Term infants without congenital anomalies who require additional care

An error in the method used to extract data from the VAED for this indicator has meant that the

results from 2008–09 to 2011–12 are not comparable with the results for 2012–13. This error has

been rectified for this report and the results for 2012–13 are comparable with the 2007–08 reporting

period. These results have been included for ease of comparison.


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New Indicator 10: Term infants without congenital anomalies with an Apgar score

< 7 at five minutes

The Apgar score is an assessment of a newborn’s wellbeing at birth based on five physiological

attributes at one and five minutes (and longer if necessary). It is a validated measure for adverse

long-term outcomes in infants.

Singleton, term infants without congenital anomalies are expected to be born in good condition,

show healthy physiological adaption to birth and not require prolonged resuscitation measures.

An Apgar score less than 7 at five minutes indicates a baby that requires ongoing resuscitation

measures or additional care that may be due to avoidable factors during labour, childbirth or the

immediate period following birth.

This new neonatal indicator has been added to the suite as a proxy outcome measure for the

quality of intrapartum care and to a large extent the quality of resuscitation measures provided

following birth.


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Using this report

This report provides individual hospital (or campus) level data for public health services compared

with the statewide public hospital average and, where available, the statewide private hospital

average. The indicator data is presented in three main ways:

• in graphical format as either bar graphs or caterpillar plots (health service level data)

• radar plots to show associations between clusters of indicators (health service level data)

• tables (statewide trends over five years).

Interquartile ranges are used to identify health services whose performance in relation to a given

indicator is an ‘outlier’, where the lower and upper quartiles are highlighted in either red (for least

favourable results) or green (for most favourable results) depending on whether the result is expected

to be low or high. Results presented within the interquartile range are left orange and are not

considered to be outlying.

In reviewing the data it is important to note the following:

• Hospitals are ordered by level of maternity service capability (Department of Health 2010)

and, within these levels, by decreasing numbers of birthing women. In some figures hospitals

have been grouped into three broader peer groupings: level 6 (tertiary services), levels 4 and

5 (services catering for moderately high risk women and babies) and levels 2 and 3 (low-risk

women and babies).

• Only data where there were a minimum of 10 possible occasions for a given event (denominator)

are reported, for example, 10 or more standard primiparae giving birth in a reporting year (unless

otherwise indicated). A graph with no visible result against a listed hospital represents ‘0%’

(n = 0), not that the denominator was 0.

• The data for public hospitals includes private patients that were managed in a public hospital.

• The statewide rate presents an average rate for women across Victoria in public and private

hospitals (where data is available), not an optimal or target rate for the indicator.

Although the indicators aim to highlight performance relating to quality of care, variation in hospital

performance can be due to factors unrelated to the clinical care provided to women and their

babies. Differences in casemix and models of service delivery, as well as data collection and

reporting processes, can also contribute to variation across and between hospitals. Ensuring

that data submitted to the Department of Health & Human Services is reliable is part of health

service performance.

Understanding a hospital’s performance should take into account outcomes across all indicators.


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Data and results

Statewide results and highlights

This report highlights the continuing improvement in some indicators – decreasing numbers of

women having labour induced in the absence of a medical intervention and an increasing proportion

of women receiving in-home postnatal care. However, some areas such as the new neonatal

indicators relating to identifying and managing FGR and newborn wellbeing scores need to be

reviewed to understand the areas where improvement can be made. Disparities between the

private and public hospital systems also require further analysis and monitoring.

Key findings

• Rates for induction of labour in selected primiparae (Indicator 1a) are lower in 2012 thanin previous years and there is less variation in public hospitals overall. This is in part due to

improvements in the data extraction method for this low-risk cohort. Importantly, the statewide

private hospital rate is three times higher than the statewide public hospital rate.

• Some hospitals reported a significant decrease in their rates for caesarean section in selected

primiparae (Indicator 1b) in 2012 compared with previous years, although the statewide public

hospital rate decreased only slightly overall. Importantly, the statewide private hospital rate is

twice the statewide public hospital rate.

• There has been an increase in the 2012 statewide public hospital rate for severe perineal trauma

in selected primiparae. The rate (6.8 per cent) is more than double the rate occurring in private

hospitals overall.

• The rates of severe FGR (Indicator 3) are higher than expected across Victorian public hospitals,

and health services will need to plan for performance improvement.

• Women planning a vaginal birth after a caesarean had the highest rates of success across public

hospitals since 2008 (Indicator 4b).

• More women than ever before reported (since 2003–04) have received postnatal in-home care

and support across Victorian public hospitals. There are, however, a few services with low rates

that should be understood and monitored.

• The measures for successful breastfeeding (Indicator 8a, b and c) highlight variation and a

performance improvement priority across the Victorian public and private hospital systems.

At discharge from Victorian public hospitals, 80.1 per cent of term, breastfed babies were

reported to be fed exclusively and directly from the breast; the rates of infant formula use in this

cohort of babies requires attention. Although a larger proportion of women in private hospitals

initiated breastfeeding, there were poorer results in the other breastfeeding indicators, with

almost 40 per cent of breastfed babies given infant formula in private hospitals.

• The proportion of women attending their first antenatal visit by the 12th week of pregnancy

(Indicator 9) is only 25.6 per cent across all Victorian public hospitals compared with 84.4 per

cent in private hospitals. The ability to capture this data accurately for antenatal care occurring

in the community is a challenge; however, health services are expected to plan for performance

improvement in this area.

• Although a new indicator, the results for Apgar scores (Indicator 10) show large variation across

Victorian public hospitals, highlighting potential areas for performance improvement in identifying

and managing higher risk pregnancies, intrapartum care and neonatal resuscitation.

Table 2 provides a summary of the statewide public and private hospital rates for the indicators

2012–13 compared with 2011–12, and the outlier rates for 2012–13.


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Indicator 7a: Smoking during

pregnancy –before 20 weeks14.1% 2.7% ≥ 21.9% ≤ 12% 14.8%

Indicator 7b: Smoking during

pregnancy – after 20 weeks7.6% 0.4% ≥ 15.6% ≤ 6.3% 6.9%

8.0% N/A ≥ 8.7% ≤ 2.7% 8.4%

39.4% 31.9% ≥ 42.7% ≤ 31.4% 39.1%

97.3% N/A ≤ 93.2% ≥ 98.9% 96.2%

Indicator 1a: Inductions in

standard primiparae2.9% 12.6% ≥ 6.1% ≤0.0% 4.2%

Indicator 1b: Caesarean section

in standard primiparae 15.5% 29.6% ≥ 22.6% ≤ 9.5% 16.1%

Indicator 1c: Third- and fourth-degree

perineal tears in standard primiparae 6.8% 2.9% ≥ 9.4% ≤ 1.7% 5.9%

giving birth vaginally

Perinatal indicator Statewide public,

2012 (2012–13

for Ind. 2, 6)

Statewide public,

2011 (2011–12

for Ind. 2, 6)

Statewide

private, 2012

Outlier rate

(poorest)

Outlier rate

(best)

Table 2: Summary of results, 2012–13

Indicator 1a, 1b and 1c: Outcomes for standard primiparae, 2012

Indicator 4a: Women who plannedfor vaginal birth following a primary 29.1% 16.0% ≤ 21.7% ≥ 35.7% 29.4%

caesarean section

Indicator 4b: Women who achieved

a planned vaginal birth following a 53.9% 51.7% ≤ 49.1% ≥ 61.1% 46.0%

primary caesarean section

Indicator 5a: Total perinatal mortality

ratio (gestation standardised,

excluding all terminations of 100 81 ≥138 ≤102 100

pregnancy and deaths due to

congenital malformations)

Indicator 5b: Perinatal mortality

ratio for babies born at 32 weeks

or more (gestation standardised, 100 66 ≥132 ≤82 100

excluding all terminations of

pregnancy and congenital anomalies)

Indicator 4a and 4b: Vaginal births after primary caesarean section, 2012

Indicator 5a and 5b: Five-year gestation standardised perinatal mortality ratio, 2008-2012

Indicator 2: Term infants without congenital anomalies who require additional care, 2012–13

Indicator 3: Severe fetal growth restriction (FGR) in a singleton pregnancy undelivered by 40 weeks

Indicator 6: Referral to postnatal domiciliary care or Hospital in the Home, 2012–13

Indicator 7: Smoking during pregnancy (before 20 weeks’ and after 20 weeks’ gestation), 2012


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25.6% 84.4% ≤ 11% ≥ 52.1% 25.6%

1.6% 0.8% ≥ 2% ≤ 0% N/A

Figures 2, 3 and 4 display combined results for (a) the standard primiparae, (b) breastfeeding and

(c) the 32-week gestation standardised perinatal mortality ratio alongside management of FGR

and newborn Apgar scores respectively. These combined results have been provided to allow

comparison across a suite of related measures.

Figures 5 provides a snapshot of statewide performance across the following indicators for

the period 2012-13 compared with 2007-08:

• Indicator 1: Outcomes for standard primiparae

• Indicator 2: Term infants (without congenital anomalies) requiring additional care

• Indicator 4a: Women who planned for a VBAC; 4b: Women who achieved a VBAC

• Indicator 5a: 22+ week GSPMR; 5b: 32+ week GSPMR

• Indicator 6: Referral to postnatal domiciliary care or Hospital in the Home

For each indicator, a comparison of the overall statewide rates, minimum and maximum values

(to highlight differences in variation) and outlier rates based on the interquartile range are

compared between the two time periods. Where available the statewide private hospital rates

have been provided.

N/A = not available

Indicator 8a: Breastfeeding

initiation at 37+ weeks93.9% 96.5% ≤ 91.6% ≥ 95.6% 94.2%

Indicator 8b: Use of infant formula for

breastfed babies born at 37+ weeks 25.2% 36.7% ≥ 27.9% ≤ 9.9% 24.1%

Indicator 8c: Final feed being taken

exclusively and directly from the

breast by breastfed babies born at80.1% 75.2% ≤ 78.6% ≥ 90.4% 82.5%

37 weeks or more

Perinatal indicator Statewide public,

2012 (2012–13

for Ind. 2, 6)

Statewide public,

2011 (2011–12

for Ind. 2, 6)

Statewide

private, 2012

Outlier rate

(poorest)

Outlier rate

(best)

Table 2: Summary of results, 2012–13

Indicator 9: First antenatal visit prior to 12 weeks’ gestation, 2012

Indicator 10: Term infants without congenital anomalies with an Apgar score < 7 at five minutes, 2012

Indicator 8a, 8b and 8c: Breastfeeding, 2012


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Statewide public hospitals

Statewide private hospitals

Direction of desired outcome

1a: Inductions upper quartile

1b: Caesarean upper quartile

1c: 3rd and 4th degree perineal

tears upper quartile

Figure 2: Outcomes for standard primiparae, 2012 (Indicators 1a, b and c)

How to interpret this chart

This radar plot displays the three individual performance indicators relating to Indicator 1: Outcomes for standard

primiparae. Each wedge of the radar provides 2012 results for individual public hospitals for 1a) rate of induction of labour,

1b) rate of caesarean section and 1c) rate of 3rd and 4th degree perineal tears. Public hospitals are sorted clockwise

by their capability level, then number of births. Results for each hospital are shown as a point on the radial axis with

increasingly better outcomes moving towards the centre.

Each indicator is represented by a different coloured point and statewide rates for public and private hospitals are provided

at the top of the radar. The three coloured solid lines represent the least favourable quartile for each respective indicator

(upper quartile). The arrows highlight the direction of the desired outcome; therefore results outside the correspondingupper quartile indicate a least performing outlier relative to its peers and the statewide average.

This graph is not intended to imply a relationship between these outcomes. Only review at the local health service

level can determine the extent to which these outcomes are affected by poor performance or non-avoidable factors.


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8a: Breastfeeding initiated

8b: Given infant formula

8c: Last feed from the breast

Level 6 hospitals



Statewide public hospitals


8a: Breastfeeding initiated lower quartile

8b: Given infant formula upper quartile

8c: Last feed from the breast lower quartile Direction of desired outcome

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40%

60%

20%

80%

100%

Level 2 and 3 Level 4 and 5

L e v e l 6

0%

Figure 3: Breastfeeding in hospital, 2012 (Indicators 8a, b and c)

How to interpret this chart

This radar plot displays the three individual performance indicators relating to Indicator 8: Breastfeeding in hospital.

Each wedge of the radar provides 2012 results for individual public hospitals for 8a) rate of breastfeeding initiated, 8b) rate

of infant formula given and 8c) rate of last feed from the breast. Public hospitals are ordered clockwise by their capability

level, then by number of births. Results for each hospital are shown as a point on the radial axis. Each indicator is represented

by a different coloured point and statewide rates for public and private hospitals are provided at the top of the radar.

The three coloured solid lines represent the least favourable quartile for each respective indicator (8a; lower quartile, 8b; upper

quartile and 8c; lower quartile). The arrows highlight the direction of the desired outcome, therefore results outside the relevant

quartile and not in the desired direction indicate a least performing outlier relative to its peers and the statewide average.

This graph is not intended to imply a relationship between these outcomes. Only review at the local health service level can

determine the extent to which these outcomes are affected by poor performance or non-avoidable factors.


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Figure 5: Comparison of statewide performance over five years, from 2007-08 to 2012-13

Average

4.8% 2.9% 13.9% 12.6%

Minimum rate

0% 0%Maximum rate

33.3% 20%Lower quartile (best results

are at or below this rate)

0% 0%

Upper quartile (poorest results are

at or above this rate)

8.3% 6.1%

Indicator 1a: Rate of inductions in standard primiparae in Victorian public hospitals

Average

14.8% 15.5% 26.8% 29.6%Minimum rate

3.4% 0%Maximum rate



11.8% 9.5%

Upper quartile (poorest results areat or above this rate)

19.4% 22.6%

Indicator 1b: Rate of caesarean section in standard primiparae in Victorian public hospitals

2007

Statewide public

2012

Statewide public

2007

Statewideprivate average

2012



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Average

5.2% 6.8% 3.3% 2.9%Minimum rate

0% 0%Maximum rate



0% 1.7%



6.4% 9.4%

Indicator 1c: Rate of third- and fourth-degree perineal tears in standard primiparaegiving birth vaginally in Victorian public hospitals

2007

Statewide public

2012

Statewide public

2007


2012


Average

7.1% 8%Minimum rate

0% 15.5%Maximum rate

15.5% 18.5%Lower quartile (best results


2.9% 2.7%

Upper quartile (poorest results areat or above this rate)

8% 8.7%

Indicator 2: Term infants without congenital anomalies who

require additional care in Victorian public hospitals

2007-08

Statewide public

2012-13

Statewide public

2007-08


2012-13



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Average

30.2% 29.1% 19.1% 16%Minimum rate

13% 0%Maximum rate

77.8% 56.2%Lower quartile (poorest results are

at or below this rate)

20.8% 21.7%Upper quartile (best results are


36.5% 35.7%

Indicator 4a: Rate of women who planned for vaginal birth following a primary

caesarean section in Victorian public hospitals

Average

56.6% 53.9% 51.8% 51.7%Minimum rate

33.3% 37.2%Maximum rate

83.3% 83.3%Lower quartile (poorest results are

at or below this rate)

53.2% 49.1%Upper quartile (best results are


67.7% 61.1%

Indicator 4b: Women who achieved a planned vaginal birth following a primary

caesarean section in Victorian public hospitals

2007

Statewide public

2012

Statewide public

2007

Statewide

private average

2012

Statewide

private average


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Average

100 100 86 81Minimum rate

67 61Maximum rate

169 180Lower quartile (best results


102.8 102Upper quartile (poorest results are


147.6 138

Indicator 5a: Perinatal mortality ratio for babies born at 22 weeks or more (gestation standardised,

excluding all terminations of pregnancy and deaths due to congenital anomalies) using five years

pooled data in Victorian public hospitals

Average

100 100 N/A 66Minimum rate

67 55Maximum rate

166 138Lower quartile (best results


93.7 82



135 132

Indicator 5b: Perinatal mortality ratio for babies born at 32 weeks or more (gestation standardised,

excluding all terminations of pregnancy and deaths due to congenital anomalies) using five years pooled

data in Victorian public hospitals

2003-07

Statewide public

2008-12

Statewide public

2003-07

Statewide

private average

2008-12

Statewide

private average


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Average

89.9% 97.3%Minimum rate

0% 52.4%Maximum rate

99.8% 100%Lower quartile (poorest results


76.5% 93.2%Upper quartile (best results

are at or above this rate)

93.1% 98.9%

Indicator 6: Rate of women referred to postnatal domiciliary care

or Hospital in the Home in Victorian public hospitals

2007-08

Statewide public

2012-13

Statewide public

2007-08


2012-13



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Indicators 1a, 1b and 1c: Outcomes for standard primiparae

Purpose and rationale

This suite of indicators captures data on three important outcomes for standard primiparae:

• Indicator 1a: Inductions in standard primiparae

• Indicator 1b: Caesarean section in standard primiparae

• Indicator 1c: Third- and fourth-degree perineal tears in standard primiparae.

The standard primipara represents a woman experiencing an uncomplicated pregnancy.

The intervention and complication rates for this group of women should therefore be low

and broadly consistent across hospitals.

Interhospital comparison of outcomes for standard primiparae (rather than all women giving birth)

controls for differences in complexity of caseloads and increases the validity of any comparisons.

Hospitals that are consistently above the statewide average should review their policies, procedures

and practices to identify areas for improvement.

Clinical significance

Birthing interventions, particularly in women having their first birth, can occur in stages starting

with induction of labour, possibly increasing the risk of instrumental vaginal birth or caesarean

section. Reducing the number of primiparous women who have induced labour may reduce the

number of women progressing through birthing interventions to unnecessarily undergo operative

birth and other interventions.

The standard primipara is a low-risk woman who has had most accepted indications for induction

excluded. The rate for induction in this group should therefore, in most cases, be close to zero.

The outcome for otherwise low-risk women is reflected in the rate of caesarean section for

standard primiparae.

Some of the variation between hospitals may reflect differences in casemix related to factors not

reported to the VPDC. However, services that are consistently above the statewide average for

inductions of labour or caesarean birth should audit their policies, procedures and practices to

identify the underlying reasons and identify areas for improvement.

Third- and fourth-degree perineal tears are a significant birth-related complication that may lead

to long-term disability or morbidity. Third- and fourth-degree tear rates may reflect the quality of

intrapartum care or differences in how this data is reported and captured. Hospitals with high rates

are encouraged to review their intrapartum practices, while those with very low rates may need to

ensure that staff are appropriately identifying and classifying perineal tears.


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Observations on the data

Indicator 1a: Inductions in standard primiparae

Standard primiparae in public hospitals were less likely to have labour induced in 2012 compared

with recent years. However, improvements to methods for identifying the exclusion data in 2012

means that caution should be taken when comparing data across years.

Women included in the standard primiparae group are unlikely to have a medical indication for

induction and some hospitals had very low rates of (or no) inductions. The highest rates were in

small hospitals and based on small numbers of standard primiparae. However, there were a number

of hospitals (mostly rural) where five to 10 per cent of standard primiparae had labour induced. These health services should review and address the reasons for these inductions using a quality

performance improvement framework.

Although individual hospital rates are not shown for private hospitals, standard primiparae who gave

birth in private hospitals were substantially more likely to have labour induced than those in public

hospitals, and this is reflected in the significantly higher statewide rate for private hospitals (12.6 per

cent compared with 2.9 per cent in public hospitals) (see Figure 6).

Indicator 1b: Caesarean section in standard primiparae

While there was a small decrease in the statewide proportion of standard primiparae who gave birth

by caesarean section in 2012, several hospitals recorded large decreases. The four hospitals with

the highest rates had fewer than 30 standard primiparae each.

As in previous years, standard primiparae in private hospitals were more likely than those in

public hospitals to give birth by caesarean section (29.6 per cent and 15.5 per cent respectively)

(see Figure 7).

Indicator 1c: Third- and fourth-degree perineal tears in standard primiparae

There was a small increase in 2012 in the statewide proportion of standard primiparae who had a

third- or fourth-degree perineal tear reported. The rate in several individual hospitals has decreased

and in others has moderately or markedly increased. It is not clear to what extent this reflects less

favourable perineal outcomes and how much it reflects better ascertainment that enables referral

and appropriate management.

Fewer third- and fourth-degree lacerations were reported in private hospitals (see Figure 8).

Expectations for performance improvement

Hospitals with results in the upper quartile range (outliers) for Indicators 1a and 1b should ensure

induction of labour and caesarean section is limited to women who have a clear medical indication.

Outliers for Indicator 1c should regularly monitor the knowledge and skills of clinicians to ensure

they are competent in avoiding and correctly identifying severe perineal tears.


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Outlier services are expected to:

• undertake regular multidisciplinary audits and reviews of the indications for inductions and

caesarean section (weekly or monthly, depending on the size of the service)

• ensure the information (verbal and written) provided to women regarding the benefits and

risks of induction and caesarean section are based on scientific evidence

• undertake a review of the local booking, prioritisation and authorisation processes for inductions

and caesarean section, including escalation in the absence of clinical indication.

The Department of Health & Human Service’s Maternity and Newborn Clinical Network (MNCN)

provides a Victorian standard for induction of labour, which is available at .

Consumer summary

Indicators 1a, 1b and 1c: Outcomes for standard primiparae

A standard primipara refers to a woman aged 20–34 years who is giving birth for the first time,

free of medical complications and pregnant with a single baby in the head-first position who is

growing normally and born between 37 and 40 weeks.

This indicator focuses on low-risk, uncomplicated pregnancies. Therefore, medical intervention

and complication rates for this group of women are expected to be lower.

Induced labour and caesarean section can increase the risk of complications and lead to longer

recovery times for women and affect future pregnancies. Therefore, hospitals with levels of

intervention above the statewide rate are encouraged to review their practices and processes.

Complications such as third- and fourth-degree tears after vaginal birth can cause long-term

problems for women. A low rate of third- and fourth-degree tears after vaginal birth is desirable.

The data presented in this report indicates variation in practice between Victorian hospitals. In

general, private hospitals have higher intervention rates (induced labour and caesarean section)

than public hospitals. The rate of third- and fourth-degree tears after vaginal birth is generally

higher in public hospitals than in private hospitals.

Ask your health service about the level of organisational and clinical support providedto low-risk women to avoid unnecessary interventions and complications.

Understanding a hospital’s performance should take into account outcomes across all indicators.


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5%0% 10% 15% 20% 25%

5%0% 10% 15% 20% 25%

Yarrawonga District Health Service

Colac Area Health

Kilmore and District Hospital

Western District Health Service (Hamilton)

Swan Hill District Health

Bairnsdale Regional Health Service

Djerriwarrh Health Services

Sandringham and District Memorial Hospital

Casey Hospital

Mercy Werribee Public Hospital

Northeast Health Wangaratta

South West Healthcare Warrnambool

Mildura Base Hospital

Latrobe Regional Hospital (Traralgon)

West Gippsland Healthcare Group

Albury Wodonga Health

Goulburn Valley Health

Bendigo Health Care Group

Ballarat Health Services

Box Hill Hospital

Barwon Health (Geelong)

Frankston Hospital

The Northern Hospital

Sunshine Hospital

Monash Medical Centre Clayton

Mercy Hospital for Women

The Royal Women's Hospital


Statewide public hospitals (n = 132/4,516)

Castlemaine Health 0%

Mansfield District Hospital 0%

Benalla and District Memorial Hospital 0%

Gippsland Southern Health Service (Leongatha) 0%

Bass Coast Regional Health 0%

Echuca Regional Health 0%

Angliss Hospital 0%

Dandenong Hospital 0%

Central Gippsland Health Service 0%

Figure 6: Indicator 1a: Rate of inductions in standard primiparae in Victorian public hospitals, 2012

Statewide rates for public hospitals

2012 (quartiles: lower; upper) 2011 2010 2009 2008

2.9% (0%; 6.1%) 4.2% 4.5% 4.9% 4.2%

Note: The inclusion criteria for this indicator were refined, and the results for 2011 and 2012 may not be comparable to previous years.

Least favourable

Most favourable

Non-outlying

Statewide

public hospitals

Statewide

private hospitals


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10%0% 20% 30% 40% 50% 60%

10%0% 20% 30% 40% 50% 60%

Colac Area Health

Mansfield District Hospital

Benalla and District Memorial Hospital


Bass Coast Regional Health




Echuca Regional Health



Casey Hospital








Angliss Hospital

Dandenong Hospital

Central Gippsland Health Service




Box Hill Hospital


Frankston Hospital


Sunshine Hospital







Yarrawonga District Health Service 0%

Gippsland Southern Health Service (Leongatha) 0%

Figure 7: Indicator 1b: Rate of caesarean section in standard primiparae in Victorian public hospitals, 2012



15.5% (9.5%; 22.6%) 16.1% 16.6% 16.7% 15.6%


Least favourable

Most favourable

Non-outlying

Statewide

public hospitals

Statewide

private hospitals


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Figure 8: Indicator 1c: Third- and fourth-degree perineal tears in standard primiparae giving

birth vaginally in Victorian public hospitals, 2012

5%0% 10% 15% 20% 25%

5%0% 10% 15% 20% 25%

Gippsland Southern Health Service (Leongatha)





Casey Hospital




Mildura Base HospitalLatrobe Regional Hospital (Traralgon)



Angliss Hospital

Dandenong Hospital





Box Hill Hospital


Frankston Hospital The Northern Hospital

Sunshine Hospital







Colac Area Health 0%

Yarrawonga District Health Service 0%

Kilmore and District Hospital 0%

Western District Health Service (Hamilton) 0%

Swan Hill District Health 0%

Djerriwarrh Health Services 0%



6.8% (1.7%; 9.4%) 5.9% 6.4% 5.0% 5.3%


Least favourable

Most favourable

Non-outlying

Statewide

public hospitalsStatewide

private hospitals


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Indicator 2: Term infants without congenital anomalies who

require additional care


This indicator aims to highlight variations in the care required for term infants without congenital

anomalies in Victorian hospitals. As such, it is concerned with the quality of perinatal care, with

a primary focus on adverse events occurring during labour or the immediate neonatal period that

are principally due to avoidable factors. This includes term infants with low five-minute Apgar

scores, birth trauma, early seizures, hypoxic ischaemic encephalopathy, FGR and sepsis. It also

includes some infants with more minor conditions, such as hyperbilirubinaemia.

The indicator is derived from newborn diagnostic-related groups (DRGs) and the Australian

Classification of Health Interventions (ACHI) procedure codes to identify term newborns requiring

more than normal care.


The infants included in this indicator are at least 37 weeks 0 days’ gestation, 2,500 grams or

more and are born without congenital anomalies. As such their need for additional medical

care and treatment should be low. Higher rates may indicate quality of care issues during

labour and childbirth.

An error in the method used to extract data from the VAED for this indicator (and outlined

on page 5) has meant that results from 2008–09 to 2011-12 are not comparable with

2012–13. However, this year’s results are comparable with the 2007–08 reporting period.


Eight per cent of term babies without congenital anomalies were admitted to nursery care

in public hospitals in 2012–13. There was wide variation across hospitals ranging from

around zero to 18 per cent (see Figure 9).


Hospitals with results in the upper quartile range (outliers) should ensure there are adequate

mechanisms to capture, review and report on adverse intrapartum events and outcomes.


• undertake multidisciplinary reviews of adverse events and outcomes to identify areas

for clinical practice or system improvement

• monitor the competency and confidence of their clinicians in fetal surveillance during

labour and in neonatal resuscitation

• review the availability of senior clinicians to both supervise junior staff and to be available

to rapidly escalate care after hours.


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Consumer summary

Indicator 2: Term infants without congenital anomalies who require additional care

Following birth, some babies will develop problems that require more than normal care.

This indicator may reflect the quality of care during labour, birth and the immediate neonatal

period and rates should be reviewed by health services to determine whether there may be

avoidable reasons for the higher need for care for individual or cohorts of babies.

Ask your health service how they review unexpected events during labour and childbirth,

how often this review is undertaken and how they report on service improvement.


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Figure 9: Indicator 2: Term infants without congenital anomalies who require additional

care in Victorian public hospitals, 2012–13

5%0% 10% 15% 20%

5%0% 10% 15% 20%


Seymour District Memorial Hospital

East Grampians Health Service (Ararat)

Benalla and District Memorial Hospital

South Gippsland Hospital

Mansfield District Hospital

Kerang District Hospital

Cohuna District Hospital

Colac Area Health

Maryborough District Health Service

Yarrawonga District Health Service

Kyneton District Health Service

Castlemaine Health

South West Healthcare Camperdown

Portland District Health

Terang and Mortlake Health Service









Casey Hospital

Wimmera Health Care Group






West Gippsland Healthcare Group Albury Wodonga Health

Angliss Hospital

Dandenong Hospital





Box Hill Hospital


Frankston Hospital


Sunshine Hospital




Statewide public hospitals (n = 3,704/46,107)

Kyabram and District Health Service 0%

Orbost Regional Health 0%

Alpine (Bright, Myrtleford and Mt Beauty) 0%


2012-13 (quartiles: lower; upper) 2011–12 2010–11 2009–10 2008–09 2007-08

8.0% (2.7%; 8.7%) 8.4% 8.2% 7.9% 9.0% 7.1%

Note: An error in the method of data collection means that results for 2012–13 are not comparable with 2008–09 to 2011–12.

Least favourable

Most favourable

Non-outlying

Statewide

public hospitals


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pregnancy undelivered by 40 weeks


The purpose of this indicator is to identify the proportion of severely growth restricted singleton

babies who are not born by 40 weeks’ gestation. A baby is considered to be severely growth

restricted when their birthweight is below the third centile for gestation, sex and plurality.


The risk of mortality for a severely growth restricted baby increases as the pregnancy advances.

Severe FGR is associated with increased risk of perinatal mortality and morbidity, admission to

special or neonatal intensive care nurseries and long-term health consequences. These babies

should be identified antenatally to allow medical management and appropriate timing of the birth

before 40 weeks’ gestation. Detection of severe FGR during pregnancy would be expected to

reduce increased mortality and morbidity.


In 2012, 39.4 per cent of singleton babies with severe growth restriction were born at 40 or

more weeks’ gestation in Victorian public hospitals. This high rate across hospitals has remained

unchanged over the past three years. In 2012 there were more babies undelivered at 40 weeks

in public hospitals than private hospitals (see Figure 10).



• report on their detection of FGR at a regular interval (monthly or quarterly depending

on the size of the service), including the possible reasons for the lack of detection

• monitor the competency and confidence of clinicians in assessing fetal wellbeing

during pregnancy

• review management of FGR policies

• ensure women with higher risk pregnancies are referred to the most appropriate level of service.


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Consumer summary

Indicator 3: Severe fetal growth restriction (FGR) in a singleton pregnancy undelivered

by 40 weeks

FGR refers to poor growth of a baby during pregnancy. It is recommended that severely

growth restricted babies are identified and born before 40 weeks’ gestation.

This indicator is concerned with babies with severe FGR who were not born before 40 weeks’

gestation, reflecting poor identification and/or management.

The data presented in this report indicates that a high number of severely growth restrictedbabies (close to 40 per cent) born in public hospitals were not born before 40 weeks’

gestation. This suggests an immediate need to improve methods for identifying and managing

severe FGR in most Victorian hospitals.

Understanding a hospital’s performance should take into account outcomes across all

indicators.

Ask your health service about the risk factors for FGR and let them know if you are

concerned about your baby’s wellbeing during pregnancy.


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Figure 10: Indicator 3: Rate of severe fetal growth restriction (FGR) in a singleton pregnancy

undelivered by 40 weeks in Victorian public hospitals, 2012

10%0% 20% 30% 4 0% 50% 6 0%

10%0% 20% 3 0% 40% 5 0% 6 0%

70%

70%



Casey Hospital









Angliss Hospital

Dandenong Hospital





Box Hill Hospital


Frankston Hospital


Sunshine Hospital







2012 (quartiles: lower; upper) 2011 2010

39.4% (31.4%; 42.7%) 39.1% 39.6%

Least favourable

Most favourable

Non-outlying

Statewide

public hospitals

Statewide

private hospitals


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Indicators 4a and 4b: Vaginal births after primary

caesarean section


This indicator identifies the proportion of women who are offered, and plan for, a vaginal birth

after a primary caesarean section (VBAC) (Indicator 4a) and those who achieve a planned term

vaginal birth (Indicator 4b).

Each woman who has had a previous caesarean section must be assessed to determine if there

are any contraindications to her planning a VBAC for subsequent births. If there are none, and

appropriate clinical support is available and provided by the hospital, women should be encouraged

to plan a VBAC and be offered factual information about the risks and benefits.

Not all hospitals in Victoria offer VBAC, and those that do not have been excluded from the indicator.


Approximately one-third of all babies in Victoria are born by caesarean section. While many of these

procedures are necessary and improve outcomes for women and babies, having a caesarean

section can prolong recovery from the birth, increase the small risk of serious morbidity after the

birth, increase the risk of major complications in subsequent pregnancies (particularly problems

with implantation of the placenta) and require additional resources and costs. Having a caesarean

section for the first birth also greatly increases the risk of needing a caesarean in subsequent births.

Reducing the number of avoidable caesarean sections minimises these problems and there are

two main strategies to achieve this:

• preventing a woman’s first caesarean section

• encouraging women who have had a prior caesarean section to attempt a subsequent

VBAC and supporting them to achieve it.

The safety of women and babies is paramount and sound clinical judgement is required to

differentiate the avoidable from the unavoidable first caesarean section and to assess women

with a prior caesarean section for whom a plan for a VBAC is appropriate.


In 2012 there was a small statewide decrease in the proportion of women planning a vaginal birth

following a primary caesarean section in public hospitals. However, there was wide variation across

hospitals from zero to 57 per cent. As in previous years, fewer women in private hospitals planned

a VBAC than in public hospitals (16.0 per cent and 29.1 per cent respectively) (see Figure 11).

There was an increase in the proportion of women in public hospitals who achieved a vaginal birth

after caesarean (53.9 per cent), with a similar result in private hospitals (51.7 per cent). In public

hospitals, the rate ranged widely from around 38 per cent to 82 per cent (see Figure 12).


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Consumer summary

Indicator 4: Vaginal births after primary caesarean section

Caesarean sections can be life-saving procedures. However, they are associated with greater

health risks for both the woman and her baby and should be considered when medically

indicated. Having a caesarean section for the first birth also greatly increases the risk of

needing a caesarean in subsequent births.

For women who have had a previous caesarean section, it is important to determine whether

it is medically safe to attempt a vaginal birth. This indicator looks at the rate of women who

plan a vaginal birth after a caesarean section and actually do give birth vaginally.

The data presented in this report indicates variation in the number of women who plan avaginal birth after a caesarean section in both public and private Victorian hospitals. There

is also variation in the number of women who went on to achieve a vaginal birth after a

caesarean section.

Public hospitals have a higher rate of women planning and achieving a vaginal birth after

a previous caesarean section compared with private hospitals overall.

Understanding a hospital’s performance should take into account outcomes across

all indicators.

Ask your health service about the level of organisational and clinical support provided

to women wishing to safely follow the VBAC pathway.



• report on the capability of the service to offer a VBAC to women without contraindications

• undertake a review of the VBAC pathway offered and report on identified deficiencies to

accessing facilities or specialists and/or standards of care

• ensure that the information (verbal and written) provided to women regarding the benefits

and risks of VBAC are based on scientific evidence.


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Figure 11: Indicator 4a: Rate of women who planned for vaginal birth following a primary

caesarean section in Victorian public hospitals, 2012

10%0% 20% 30% 40% 50% 60%

10%0%

0%

20% 30% 40% 50% 60%



Casey Hospital








Colac Area Health

East Grampians Health Service (Ararat)

Seymour District Memorial Hospital




Western District Health Service Hamilton





Angliss Hospital

Dandenong Hospital





Box Hill Hospital


Frankston Hospital


Sunshine Hospital





Statewide public hospitals (n = 1,317/4,529)



29.1% (21.7%; 35.7%) 29.4% 30.2% 30.3% 29.9%

Least favourable

Most favourable

Non-outlying

Statewide

public hospitals

Statewide

private hospitals


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Figure 12: Indicator 4b: Rate of women who achieved a planned vaginal birth following

a primary caesarean section in Victorian public hospitals, 2012

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%












Angliss Hospital

Dandenong Hospital




Box Hill Hospital


Frankston Hospital


Sunshine Hospital








53.9% (49.1%; 61.1%) 46.0% 44.4% 53.5% 62.1%

Least favourable

Most favourable

Non-outlying

Statewide

public hospitals

Statewide

private hospitals


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Indicators 5a and 5b: Five-year (2008–2012) gestation

standardised perinatal mortality ratio


The gestation standardised perinatal mortality ratio (GSPMR) is a measure of perinatal mortality

which compares the observed perinatal mortality rate of individual hospitals with what would be

expected, taking into account the gestation of the babies born there. It is a partially risk adjusted

calculation, enabling hospitals with higher proportions of low gestation infants (and therefore

higher likelihood of perinatal mortality) to be validly compared with hospitals that have a different

casemix. Pooling the data over five-year periods adds stability to the data and reduces the riskof over-interpretation of chance fluctuations.

Indicator 5a provides a broad comparative measure of perinatal mortality rates across hospitals and

can identify variations and outliers. Indicator 5b captures the GSPMR for those babies born at 32

or more weeks’ gestation, which may be more meaningful for non-tertiary hospitals that would not

normally care for babies born before 32 weeks’ gestation or be expected to have the capability to

care for babies born at earlier gestations beyond the provision of immediate emergency care and

transfer to a higher capability service.

Any deaths related to congenital anomalies and terminations of pregnancy are excluded from this

data to better represent deaths that may be avoidable.

A high GSPMR should prompt hospitals to identify preventable factors related to care that may have contributed to adverse outcomes.

A GSPMR of 100 indicates that the observed number of perinatal deaths at that hospital is

exactly what would be expected, considering the gestation of babies born there.

It is important to note that, for this indicator, the statewide rate does not necessarily represent

the optimal or clinically appropriate rate for perinatal mortality.

The graph provides a visual representation of the variation in perinatal mortality occurring

across Victorian public hospitals when compared with the statewide public hospital rate.


Variation in GSPMR may be due to differences in the health and/or socioeconomic status of womenbut may also relate to the quality of care and care delivery systems. While the cause of a persistently

high GSPMR is likely to be multifactorial, it is expected

victorian perinatal services performance indicators 2012–13

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