The Leeds University maternity audit project

Objectives. To measure levels of and changes in compliance with evidence-based recommendations in obstetrics in the UK. To identify barriers to and factors associated with compliance. Design. A quantitative case-note audit for 1988 and 1996, and a qualitative interview study of key staff. Setting. Twenty maternity units, selected at random from all UK units Subjects. Fifty consecutive cases of pre-term delivery (PTD), Caesarean section (CS), instrumental delivery (ID), and perineal repair (PR) operations in each period in each unit. The lead clinician, midwifery manager, a senior midwife, neonatologist, and middle-grade obstetrician in each unit. Main outcome measures. Maternal steroid use in PTD, antibiotic use in CS, use of the ventouse (vacuum extractor) rather than forceps as instrument of first choice for ID, and use of polyglycolic acid (PGA) sutures for PR in each time period. Facilities for implementing, staff attitudes to, and the degree of planning to follow each recommendation. Main results. The median proportion of ventouse as instrument of first choice in each unit was 8% (range 0‐32%) in 1988, rising to 64% (range 0‐98%) in 1996. PGA use for PR was 0% (range 0‐30%) in 1988, and 72% (range 0‐100%) in 1996. Steroid use for eligible PTD was median 0% (range 0‐23%) in 1988, rising to 82% (range 63‐95%) in 1996. Antibiotic use for CS was 7% (range 0‐25%) rising to 84% (range 10‐100%) in 1996. There was no relationship between unit size, type of unit, facilities, staff attitudes or degree of planning, and compliance with the recommendations, nor was the level of adherence to one standard typically correlated with adherence to the others. However, there was a positive correlation (R = 0.6, P < 0.005) between local availability of the Cochrane database of perinatal trials and unit compliance with the audit standards in the latter time period. Conclusions. We have documented a massive shift in practice in line with the evidence, although many units still have substantial room for improvement. About 2000 wound infections, 200 deaths due to prematurity, nearly 8000 women in pain from catgut sutures, and 1500 cases of severe perineal trauma from forceps remain preventable. The reasons why units vary remain obscure, although the qualitative interviews often revealed local factors such as key enthusiastic staff. There was no sign of evidence being positively driven into practice by any systematic managerial process. The relationship between Cochrane availability and high-standard care may be simply a marker of commitment to the evidence, but it remains plausible that if senior staff make Cochrane available for their juniors, audit compliance improves.