Are Current Measures of Neonatal Birth Trauma Valid Indicators of Quality of Care?

P Kumar; L-A Papile; K Watterberg


J Perinatol. 2015;35(11):903-906. 

In This Article

Abstract and Introduction


Neonatal birth traumas are an important cause of morbidity and mortality, and the rates of these events are frequently used as a measure of the quality of obstetric care. The objectives of this clinical report are to review the limitations of using the current definition of birth trauma as an indicator of quality of care and to propose changes to make it a more accurate measure of quality of care.

The reported incidence of birth trauma is highly variable from study to study, with several large population-based studies reporting an incidence ranging between 24 and 37 per 1000 births.[1–3] Although the majority of birth traumas occur in infants with risk factors, some occur in the absence of identifiable risk factors, making the latter challenging to predict and avoid. Because parents often assume birth traumas are preventable, their occurrence can lead to anger, frustration and sometimes litigation. Studies have shown that Obstetrician–gynecologists are the most frequently sued physicians in the United States and shoulder dystocia-related nerve injuries constitute the second highest category of payouts in obstetric malpractice suits.[4,5] It has also been reported that many different factors other than the medical error have a role in parents' decision to sue the providers.[6–8] The objectives of our report are to review the limitations of the current measures of birth trauma as indicators of quality of care and to propose a new framework to evaluate neonatal birth trauma to provide a more reliable measure of quality of care.

The 2000 publication by the Institute of Medicine, 'To Err Is Human: Building a Safer Health System',[9] renewed interest in quality improvement initiatives nationwide. Subsequently, the Agency for Healthcare Research and Quality identified neonatal birth trauma as 1 of 20 hospital-level Patient Safety Indicators and proposed criteria for the diagnosis of neonatal birth trauma.[10] (Supplementary Appendix A and B Since then, the neonatal birth trauma rate has been used by several investigators to measure the quality of perinatal care,[11–13] and is being considered for public reporting. However, before neonatal birth trauma becomes widely adopted as a measure of quality of care, the definitions and the methodology used to calculate the neonatal birth trauma rate need to be accurate, consistent and robust.

A suitable quality of care measure should meet the following four criteria: (1) importance: it must be relevant to a large number of patients, involve a high-risk condition or represent an opportunity for significant improvement. (2) Scientific acceptability: it should have a precise definition, be reliable and valid, be able to discriminate real differences in performance and employ adequate risk adjustment. (3) Feasibility: data for reporting the measure must be feasible to obtain. (4) Usability: the results must be understandable and interpretable by the intended audiences.[14–16] Although there is a general consensus that the goal of reducing birth traumas is important and should be pursued, there are several limitations that call into question the use of birth trauma rate as an appropriate measure of the quality of perinatal care.