The Danish National Quality Database for Births

Background and aim of the DNQDB database

The Danish National Quality Database for Births (DNQDB) started out as a part of the Danish National Indicator Project (DNIP) in 2010.^1,2 The aim of the database is to measure the quality of the care provided during labor and birth through specific indicators. In the context of the database, birth is defined as the time from a woman’s arrival at a maternity unit/labor ward until 2 hours after the birth. Mode of delivery can be either vaginal or by cesarean section.

Study population

All hospital births in Denmark are included in the study’s population. The indicators related both to the woman giving birth and to the child(ren). Births in Denmark are approximately 55,000–60,000 per year, of which 1.5% are home births. The latter are not included in the database at the present time. The accumulated number of births and children included in the database as of August 31, 2015 were 269,597 and 274,153, respectively.

Main variables

Childbirth is a complex clinical situation, sometimes involving specialists from more than one department. Because of this, the indicators and the standards adopted were decided by a group of clinicians that included midwives, obstetricians, a pediatrician, anesthesiologists, and an epidemiologist. To decide which parts of the birth process to cover and include in the DNQDB, a schematic, standardized course of labor and birth (Figure 1) was created. Initially, eight indicators were selected, to fit within the upper limit of 8–10 set by the DNIP. Guiding factors for selection were relevance, scientific evidence, acceptability, and patient safety.^1,2 Further details on the indicators selected and the reasons for excluding other potential indicators are available elsewhere.² Subsequently, some of the indicators were extended, and an additional outcome indicator was included in 2013 concerning the proportion of acute cesarean sections (grade 2) performed under local anesthesia. Data from this indicator are not included in the analyses in Tables 1 and 2 because only 2 years of data have been collected, making it as yet invalid for comparison.

Figure 1 Schematic, standardized course of birth. Note: Reproduced with permission from Kesmodel US, Jølving L. Measuring and improving quality in obstetrics – the implementation of national indicators in Denmark. Acta Obstet Gynecom Scand. 2011;90(10):295–304.2 Copyright © 2011, with permission from John Wiley and Sons. Abbreviations: CTG, cardiotocography; STAN, ST analysis; SBE, standard base excess; BW, birth weight.

Table 1 Process indicators in the Danish National Quality Database for Birth Comparison of results in 2012 and 2015 Notes: Comparison of results in 2012 and 2015. aProportion of birth epidural/birth spinal given within 1 hour from prescription. bProportion of women who continuously have a health care professional in the delivery room during the active phase of birth. cProportion of birthing women giving birth with acute cesarean section within the time recommended from decision to birth. dProportion of birthing women giving birth with acute cesarean section within the time recommended from decision to birth.

Table 2 Outcome indicators in the Danish National Quality Database for Birth Notes: Comparison of results in 2012 and 2015. aProportion of women with first-time births complicated with third or fourth degree lacerations (lacerations involving the anal sphincter muscle). bProportion of women with postpartum hemorrhage ≥1,000 mL. cProportion of births where close contact between the mother and the newborn infant is established within the first 2 hours after the child is born. dProportion of live-born children with neonatal hypoxia. eProportion of uncomplicated births resulting in a healthy child. The complications being cesarean section, episiotomy, severe lacerations, delivery by vacuum extraction, severe hemorrhage, and children with low Apgar score <7.

All the quality indicators are process and outcome indicators concerning care during and after labor. The initial eight indicators are listed in Tables 1 and 2. Further information on the indicators and the data definitions are given in Kesmodel and Jølving.²

All data for the DNQDB are collected from the Danish Medical Birth Registry.³ Registration to the Danish Medical Birth Registry is mandatory for all maternity units in Denmark. After an initial period of inaccuracies in registration and of getting used to new registrations designed for the database, the data completeness is now very high (>90% for the indicators in Tables 1 and 2 with apparently no or little selection bias), and the results are therefore considered reliable.

The maternity units receive monthly reports of their own data/results.

Measuring quality appears to have inspired improvements in performance, locally, within the clinical units, as there has been a great effort to perform well in the areas measured by the database. During the 5 years studied so far, performance has improved in the areas covered by process indicators and also for some of the outcome indicators. The comparison shown in Tables 1 and 2, between data from the second year of the database (2012) and the latest year (2015), reveals a significant reduction in the proportion of first-time deliveries complicated by third and fourth degree lacerations, as well as a significant increase in both the proportion of cesarean sections carried out within the time recommended and the proportion of epidural/spinal given within 1 hour from prescription. Likewise, significantly more women now have continuous support during the active phase of the labor. The indicators will be validated and reevaluated in 2016.

In addition to reducing complications and improving organizational processes, the act of collecting data for the DNQDB has also resulted in measurements that are more accurate. An example is the exact amount of bleeding during birth. Because of this focus on the accurate measurement of this indicator, we now know that maternal bleeding during birth is more extensive than previously suspected. We assume this not to be due to a real increase but to a new and continuous focus on measuring the bleeding correctly, in this case by objective weighing rather than guessing. Another example, which presents a similar difficulty in the comparison of results from the last 5 years, is the proportion of children with fetal hypoxia. In this indicator, hypoxia is defined as pH <7. 0 or, if pH is not measured, Apgar score <7 after 5 minutes. During the 5-year period, there has been an increase in the proportion of births with umbilical cord pH measurement, which compromises the ability to compare data across the years.

As well as focusing on quality locally, each unit has also been inspired to cooperate with other units and to integrate experience obtained elsewhere. This has been the case when trying to reduce the proportion of severe lacerations. Interestingly, the risk of birth complicated by a severe laceration is now almost the same in all maternity units no matter in which part of Denmark the birth takes place (Table 2).

During the 5 years that the DNQDB database has existed, there have been changes in the measurement of quality in childbirth and pregnancy in Denmark. When the database started, the database of the Danish Healthcare Quality Program (DDKM) included indicators concerning pregnancy and maternity.⁴ However, these DDKM indicators no longer exist. Because of this, new indicators are currently being selected by the group of clinicians behind the DNQDB database. These will measure the quality of care in pregnancy, thereby potentially extending the period covered by this database hitherto. A part of this work is done in cooperation with the National Fetal Medicine Database.⁵ This new cooperation between the two databases is important and can be extended in time. The measurement of quality during maternity will be a subject for indicators in the future.

Follow-up

The group of clinicians involved in the project currently meet every year before publishing the annual national report (available from http://www.kcks-vest.dk/kliniske-kvalitetsdatabaser/foedsler/ or on request from the authors). Every year all the indicators are reevaluated, and the need for new indicators is considered.

Examples of research

Most epidemiologic research concerning birth in Denmark is by tradition based on data collected from the Danish Medical Birth Registry. The service offered by the Danish Medical Birth Registry has changed in recent years, making it more difficult and time consuming to access data for research and quality improvement. Because of this, using data from the DNQDB can be an advantage for researchers. Access to the DNQDB data via the Registry Support Centers of Epidemiology and Biostatistics (South) is not only quicker and easier but the DNQDB data are also refined and analyzed by an epidemiologist before being delivered to the researchers. After 5 years of collecting data, the DNQDB data are now very comprehensive and reliable. This gives the opportunity to plan large-scale projects based on data and experience from the DNQDB. Currently, a national group of clinicians is planning to coordinate these projects. The first step in this process is to get access to more data from the Danish Medical Birth Registry.

Administrative issues and funding

Like most other national clinical quality databases in Denmark, the DNQDB is funded by the five Danish regions that administer and finance the public health care system in Denmark. Key information is reported immediately after birth by the attending midwife to the (national) Danish Medical Birth Registry, administered by the Danish Health and Medicines Authority. Subsequently, relevant data are drawn from the registry by the Registry Support Centres of Epidemiology and Biostatistics (South), which then refines it and performs relevant analyses based on the fixed formulas decided by the database steering committee.

Acknowledgment

This paper was funded by the Program for Clinical Research Infrastructure (PROCRIN) established by the Lundbeck Foundation and the Novo Nordisk Foundation, and administered by the Danish Regions.

Disclosure

The authors report no conflicts of interest in this work.

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References

1.	Kesmodel US. The Danish National Indicator Project, Deliveries – Documentarist’s Report. 2010, 3rd version 2012. Available from: http://www.kcks-vest.dk/siteassets/de-kliniske-databaser/fodsler/ dokumentalistrapport-dkf-januar-2012_211211.pdf. Accessed November 26, 2015. Danish.
2.	Kesmodel US, Jølving L. Measuring and improving quality in obstetrics – the implementation of national indicators in Denmark. Acta Obstet Gynecom Scand. 2011;90(10):295–304.
3.	Knudsen LB, Olsen J. The Danish Medical Birth Registry. Dan Med Bull. 1998;45(3):320–323.
4.	The Danish Healthcare Quality Programme. Available from: http://www.ikas.dk/DDKM.aspx. Accessed November 26, 2015.
5.	National Fetal Medicine Database. Available from: http://www.dfms.dk/cms/index.php/fagligt/db. Accessed November 26, 2015.