Maternal and Child Health Journal

, Volume 19, Issue 12, pp 2688–2697 | Cite as

Feasibility of Implementing a Standardized Clinical Performance Indicator to Evaluate the Quality of Obstetrical Care in British Columbia

  • Jennifer A. HutcheonEmail author
  • Lily Lee
  • K. S. Joseph
  • Brooke Kinniburgh
  • Geoffrey W. Cundiff



To establish the feasibility of implementing a  previously-published clinical standardized performance indicator, the Adverse Outcome Index (AOI), using routinely-collected data in a population-based perinatal database and to examine variation in the indicator over time and between hospitals.


Maternal and newborn medical record data contained in the British Columbia Perinatal Data Registry, 2004–2013, were used to calculate an AOI (a composite of 10 maternal and newborn adverse events) and its severity-weighted scores, the Weighted Adverse Outcome Score and the Severity Index. Temporal trends in the indices were examined by plotting annual risks and weighted risks with 95 % confidence intervals. Hospital-level risks were calculated with 95 % confidence intervals, adjusting for patient case-mix.


Among 410,054 singleton deliveries in British Columbia, the risk of AOI was 5.8 per 100, while the Weighted Adverse Outcome Score and Severity Index were 1.6 and 27.4, respectively. The risk of AOI did not change significantly over the study period, while the Severity Index decreased from 29.3 (95 % CI 26.7–31.9) in 2004 to 23.9 (22.0–25.8) in 2013. Fifteen of 52 hospitals had risks of AOI significantly above the provincial median. The hospitals’ risks of AOI were not correlated with their Severity Indices (r = 0.02).


The AOI can successfully be estimated using data from a population-based database, and used to monitor trends in safety of labour and delivery over time and between hospitals. The low correlation between frequency and severity of adverse events confirms the importance of considering event severity in perinatal population health surveillance.


Quality indicators Obstetrical safety Adverse events Adverse Outcome Index 



JAH is the recipient of New Investigator awards from the Canadian Institutes of Health Research (CIHR) and the Michael Smith Foundation for Health Research. KSJ is supported by an Investigator award from the Child and Family Research Institute and a CIHR Applied Chair award in Reproductive, Child, and Youth Health Services and Policy Research.


  1. 1.
    Public Health Agency of Canada. (2008). Canadian perinatal health report, 2008 (edition), Ottawa.Google Scholar
  2. 2.
    Bailit, J. L. (2007). Measuring the quality of inpatient obstetrical care. Obstetrical and Gynecological Survey, 62, 207–213.CrossRefPubMedGoogle Scholar
  3. 3.
    The Joint Commission. Specifications Manual for Joint Commission National Quality Measures (v2012B). (2012). The joint commission website. Accessed Oct 30 2014.
  4. 4.
    Howell, E. A., Zeitlin, J., Hebert, P. L., Balbierz, A., & Egorova, N. (2014). Association between hospital-level obstetric quality indicators and maternal and neonatal morbidity. JAMA, 312, 1531–1541.PubMedCentralCrossRefPubMedGoogle Scholar
  5. 5.
    Korst, L. M., Fidman, M., Lu, M. C., Mitchell, C ., Lawton, E., Griffin, F., et al. (2014). Monitoring childbirth morbidity using hospital discharge data: Further development and application of a composite measure. American Journal of Obstetrics and Gynecology, 211(3), 268.e1–268.e16. doi: 10.1016/j.ajog.2014.03.011.CrossRefGoogle Scholar
  6. 6.
    Mann, S., Pratt, S., Gluck, P., Nielsen, P., Risser, D., Greenberg, P., et al. (2006). Assessing quality obstetrical care: development of standardized measures. Joint Commission Journal on Quality and Patient Safety, 32, 497–505.PubMedGoogle Scholar
  7. 7.
    Nielsen, P. E., Goldman, M. B., Mann, S., Shapiro, D. E., Marcus, R. G., Pratt, S. D., et al. (2007). Effects of teamwork training on adverse outcomes and process of care in labor and delivery: a randomized controlled trial. Obstetrics and Gynecology, 109, 48–55.CrossRefPubMedGoogle Scholar
  8. 8.
    Frosst, G. O., Hutcheon, J. A., Joseph, K. S., Kinniburgh, B. A., Johnson, C., & Lee, L. (2015). Validating the British Columbia Perinatal Data Registry: A chart re-abstraction study. BMC Pregnancy Childbirth, 15, 123. doi: 10.1186/s12884-015-0563-7.PubMedCentralCrossRefPubMedGoogle Scholar
  9. 9.
    Hanley, G. E., Janssen, P. A., & Greyson, D. (2010). Regional variation in the cesarean delivery and assisted vaginal delivery rates. Obstetrics and Gynecology, 115, 1201–1208.CrossRefPubMedGoogle Scholar
  10. 10.
    Mehrabadi, A., Hutcheon, J. A., Lee, L., Liston, R. M., & Joseph, K. S. (2012). Trends in postpartum hemorrhage from 2000 to 2009: a population-based study. BMC Pregnancy Childbirth, 12, 108.PubMedCentralCrossRefPubMedGoogle Scholar
  11. 11.
    Kelly, S., Sprague, A., Fell, D. B., Murphy, P., Aelicks, N., Guo, Y., et al. (2013). Examining caesarean section rates in Canada using the Robson classification system. Journal of Obstetetrics Gynaecology Canada, 35, 206–214.Google Scholar
  12. 12.
    Joseph, K. S., Kinniburgh, B., Hutcheon, J. A., Mehrabadi, A., Basso, M., Davies, C., & Lee, L. (2013). Determinants of increases in stillbirth rates from 2000 to 2010. Canadian Medical Association Journal, 185, E345–E351.PubMedCentralCrossRefPubMedGoogle Scholar
  13. 13.
    Hutcheon, J., Harper, S., Strumpf , E., Lee, L., & Marquette, G. (2015). Using inter-institutional practice variation to understand the risks and benefits of routine labour induction at 41+0 weeks. BJOG, 122, 973–981. doi: 10.1111/1471-0528.13007.CrossRefPubMedGoogle Scholar
  14. 14.
    Schummers, L., Hutcheon, J. A., Bodnar, L. M., Lieberman, E., & Himes, K. P. (2015). Risk of adverse pregnancy outcomes by prepregnancy body mass index: A population-based study to inform prepregnancy weight loss counseling. Obstetrics and Gynecology, 125(1), 133–143.CrossRefPubMedGoogle Scholar
  15. 15.
    Bailit, J. L., Grobman, W. A., Rice, M. M., Spong, C. Y., Wapner, R. J., Varner, M. W., et al. (2013). Risk-adjusted models for adverse obstetric outcomes and variation in risk-adjusted outcomes across hospitals. American Journal of Obstetrics and Gynecology, 209(5), 446.e1–446.e30. doi: 10.1016/j.ajog.2013.07.019.CrossRefGoogle Scholar
  16. 16.
    Walker, S., Strandjord, T. P., & Benedetti, T. J. (2010). In search of perinatal quality outcome measures: 1 hospital’s in-depth analysis of the adverse outcomes index. American Journal of Obstetrics and Gynecology, 203(4), 336.e1–7. doi: 10.1016/j.ajog.2010.05.024.CrossRefGoogle Scholar
  17. 17.
    Ross, S. (2007). Composite outcomes in randomized clinical trials: arguments for and against. American Journal of Obstetrics and Gynecology, 196(2), 119.e1–119.e6.CrossRefGoogle Scholar
  18. 18.
    California Maternal Quality Care Collaborative. (2007). OB Hemorrhage Toolkit version 2.0. Accessed May 12 2015.

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Jennifer A. Hutcheon
    • 1
    • 2
    Email author
  • Lily Lee
    • 1
  • K. S. Joseph
    • 1
    • 2
    • 3
  • Brooke Kinniburgh
    • 1
  • Geoffrey W. Cundiff
    • 2
  1. 1.Perinatal Services BCProvincial Health Services AuthorityVancouverCanada
  2. 2.Department of Obstetrics and GynaecologyUniversity of British Columbia (UBC)VancouverCanada
  3. 3.School of Population and Public HealthUniversity of British ColumbiaVancouverCanada

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