Does public reporting of the detection of fetal growth restriction improve clinical outcomes: a retrospective cohort study

Abstract

Objective To assess the impact of publicly reporting a statewide fetal growth restriction (FGR) performance indicator. Design Retrospective cohort study from 2000 to 2017. Setting All maternity services in Victoria, Australia. Population A total of 1 231 415 singleton births at ≥32 weeks of gestation. Methods We performed an interrupted time‐series analysis to assess the impact of publicly reporting an FGR performance indicator on the rate of detection for severe cases of small for gestational age (SGA). Rates of perinatal mortality and morbidity and obstetric intervention were assessed for severe SGA pregnancies and pregnancies delivered for suspected SGA. Main outcome measures Gestation at delivery, obstetric management and perinatal outcome. Results The public reporting of a statewide FGR performance indicator was associated with a steeper reduction per quarter in the percentage of severe SGA undelivered by 40 weeks of gestation, from 0.13 to 0.51% (P = 0.001), and a decrease in the stillbirth rate by 3.3 per 1000 births among those babies (P = 0.01). Of babies delivered for suspected SGA, the percentage with birthweights ≥ 10th centile increased from 41.4% (n = 307) in 2000 to 53.3% (n = 1597) in 2017 (P < 0.001). Admissions to a neonatal intensive care unit for babies delivered for suspected SGA but with a birthweight ≥ 10th centile increased from 0.8 to 2.0% (P < 0.001). Conclusions The public reporting of an FGR performance indicator has been associated with the improved detection of severe SGA and a decrease in the rate of stillbirth among those babies, but with an increase in the rate of iatrogenic birth for babies with normal growth. Tweetable abstract The public reporting of hospital performance is associated with a reduction in stillbirth, but also with unintended interventions.

Increasing obstetric intervention for fetal growth restriction is shifting birthweight centiles: a retrospective cohort study

“…26,27 In particular, the rate of early iatrogenic delivery of babies suspected of SGA has increased. 2 Better detection of SGA allows for timely delivery before the fetus' growth crosses critical centiles. However, this also has the effect of reducing the proportion of babies that fall below the 3rd, 5th or 10th centile.…”

“…It is the result of increasing intervention preferentially removing smaller babies from later gestations. 2,10 This effect is concerning because it is likely to be self-perpetuating. Increasing early intervention to reduce stillbirth 4 will continue to increase the birthweights defining the lower centiles.…”

“…1 If detected and appropriately managed, the risk of stillbirth is 20-fold lower than if the fetus is undetected. 2 Improving the detection and timely delivery of the growth-restricted fetus is therefore central to reducing the rate of stillbirth. [2][3][4] There are now many jurisdictions that audit hospital performance in their detection of the small-for-gestationalage (SGA) fetus.…”

“…2 Improving the detection and timely delivery of the growth-restricted fetus is therefore central to reducing the rate of stillbirth. [2][3][4] There are now many jurisdictions that audit hospital performance in their detection of the small-for-gestationalage (SGA) fetus. [5][6][7][8] Such an approach is particularly well established in Victoria, Australia, where the proportion of severe SGA, defined as a birthweight <3rd centile, born ≥40 weeks' gestation has been publicly reported by named hospital since 2012.…”

Risk factor assessment for fetal growth restriction, are we providing best care?

“…The timely detection of fetal growth restriction (FGR) remains challenging 1 . Over half of growth‐restricted babies remain unrecognised before birth 1,2 .…”