to Pregnancy Reviews
Audit - Update May 2001
Introduction: There is no 'correct' rate for caesarean
section but there is concern that the rate is rising
in England and Wales (1989-90 11.3%, 1994-95 15.5%
and preliminary estimates for 1997-98 suggest 17%,
DoH 1999). The variations in caesarean section rate
between units are not accounted for by differences
The National Sentinel Caesarean Section Audit represents
a unique collaboration between The Royal College of
Obstetricians and Gynaecologists, the Royal College
of Midwives, the Royal College of Anaesthetists and
the National Childbirth Trust. It is funded by the
Department of Health through NICE.
To evaluate the current role of caesarean sections
in maternity care.
- To determine the frequency of caesarean sections
in all maternity units in England, Wales, Northern
Ireland, the Channel Islands and the Isle of Man.
- To determine the factors associated with variations
in the rates of caesarean section. The focus will
be on the circumstances of delivery, the decision-making
process and women's choice.
- To determine whether these factors are associated
with the rising caesarean section rate.
- To assess the quality of clinical care against
agreed standards, derived from current literature.
- To determine the extent to which maternal request
for caesarean section:
a) Contributes to the elective caesarean section rate.
b) And how frequently patient and clinician reports of maternal request concord.
- To determine the influence of the following on
caesarean section rates:
b) Staff on Delivery Suite
c) Clinicians' threshold in relation to performing a caesarean section
d) Policies on Delivery Suite
- At a national level, the audit has been run by
RCOG CESU. Locally, every maternity unit has a nominated
facilitator/co-ordinator who received ENB-approved
training in audit methodology.
- To determine the frequency of caesarean sections,
denominator data on all deliveries was collected
in every maternity unit on Denominator Data Forms.
- More detailed information on all women having
a caesarean section was collected on Clinical Data
Forms. The focus of enquiry was on the decision-making
process and aspects of the quality of care.
- At a unit level, information on staffing (midwifery,
obstetric and anaesthetic), facilities and equipment
was collected. Staffing levels were verified by diaries
kept at intervals during the study.
- Local audit facilitators validated the data they
sent against a local source (e.g. labour ward/theatre
register) and returned data weekly to RCOG CESU.
- The returned data was checked and discrepancies
in numbers of Clinical Data Forms returned or queries
regarding missing denominator data have been followed
up with audit facilitators in the respective units.
All data entry and analysis is being performed centrally.
Update on Phase One
- Data collection for Phase One is complete (1 May
- 31 July 2000). There has been an excellent response
rate from the 236 NHS units and 4 private sector
units taking part in England and Wales.
- One unit had to be excluded due to failure to
collect data prospectively.
- Denominator Data feedback to all participating
units has now been verified locally and analysis
of the dataset is underway. Twenty-two units highlighted
some discrepancies with the data they received, which
have now been resolved. Amended results were sent
back to them during December and January.
- During February, the eight hospitals with midwifery-led
units that feed into them were sent summaries of
their denominator data which also included deliveries
in the midwifery-led units in the denominator.
- Clinical Data Forms: data entry was completed
in December 2000. Cleaning and analysis is in progress.
Following this process, we hope to send you summaries
of your clinical data in May.
- External validation against birth registration
statistics for England and Wales for the study period
will be undertaken. The percentage of births included
in the data and the ascertainment of stillbirths
will be validated.
- Data entry for the supplementary surveys is complete.
The response rates were as follows:
95% (N=223) Labour ward staffing and facilities
98% (N=232) Staffing diaries
94% (n=204) Anaesthetic questionnaires
Data cleaning and descriptive analysis of both the maternity unit and anaesthetic
surveys is in progress.
- A facilitators' questionnaire was sent out to
all facilitators during December 2000. This provided
an opportunity for them to share their views on the
experience of facilitating the audit, helping to
build a picture of what areas worked well and if
any problems were encountered.
With all the postal difficulties being experienced around the Christmas period,
we are pleased to have received a response rate of 79%.
Update on Phase Two
- 42 units were invited to take part in Phase Two.
These were randomly selected in England, Wales and
Northern Ireland, stratified by their caesarean section
rates, geography and type of hospital (DGH, Teaching
- One unit declined to take part and another failed
to authorise their participation in time, giving
a final sample of 40 units.
- Data collection took place between 1 December
2000 and 28 February 2001.
- Simultaneously, all maternity units in Northern
Ireland, the Channel Islands and the Isle of Man
ran the audit for the first time, including completion
of the supplementary surveys.
Phase Two has three components:
- The 39 hospitals from England and Wales who participated
in Phase Two responded admirably to the task of filling
in Denominator Data and Clinical Data Forms for a
further three month period, and once again the quality
of the data and the commitment shown by staff has
- Similarly, the 16 units in Northern Ireland, the
Channel Islands and the Isle of Man who were collecting
data for the first time also did a great job.
- Complete Phase Two data has now been received
back from all units
Survey of Women's Views in Relation to Mode of
- This was a postal survey using a semi-structured
questionnaire of women over 32 weeks gestation who
had an EDD in January 2001.
- MREC approval was granted in August 2000. Forty
units in England, Wales and Northern Ireland took
part in the maternal survey as part of Phase Two.
They were granted local ethical approval between
13th September and 8th December 2000. All LRECs gave
approval to the study.
- The questionnaire was piloted on volunteers (all
pregnant women), recruited thanks to media publicity,
local facilitators and National Childbirth Trust
- Training days for the facilitators of Phase Two
took place in October 2000.
Once ethical approval was received, invitations to all women in the participating
units who had an EDD in January
- 2001 were despatched by the local facilitators
between 27.11.00 and 15.01.01. A total of 7,873 invitations
were sent out.
- Women who were willing to receive a questionnaire
were asked to return a reply slip to RCOG CESU, who
then despatched a questionnaire to the women. All
women who replied were sent a questionnaire within
a maximum of 2-3 working days of CESU receiving the
- CESU received 2,942 reply slips back from women
- a response rate of 37.4%.
- 2,506 completed questionnaires were returned -
a response rate of 85%.
- Overall 32% of all women invited to participate
Survey of Clinicians' Attitude Towards, and Threshold
For, Performing a Caesarean Section
- The aim of the Clinicians' Survey was to examine
senior clinicians' attitudes towards, and threshold
for, performing a caesarean section. Development
and piloting of this questionnaire took place during
- Clinicians in the participating units were invited
to complete a structured questionnaire about their
policies and attitude relating to performing a caesarean
- A database of Consultants practising obstetrics
in the 40 Phase Two hospitals was compiled during
the first two weeks of January by telephoning each
unit and then verifying this information on the RCOG
database of Fellows and Members.
- Printing of the survey was carried out in-house
and it was despatched to a total 226 clinicians at
the end of January.
- The response rate was 77% (n=174) and there has
been some response from all units.
Regional and national data analysis, along with the
audit report, will be published to coincide with the
launch meeting being held on 26th October 2001 in London.
We would like to sincerely thank everyone who has
contributed to both phases of this audit, including
all those who have filled in forms, local facilitators
and those who have enabled and encouraged their hospital
to take part.
If you have any queries or questions
Jane Thomas, Shantini Paranjothy or Caroline Clark
RCOG CESU, 27 Sussex Place, Regent's Park, London NW1 4RG
T: 020 7772 6342 F: 020 7772 6390 E: email@example.com