NHS Digital

Indicator Supporting Documentation

IAP00398 Low birth weight of term babies

FIELD

CONTENTS

IAP Code

IAP00398

Title

Low birth weight of term babies

Published by

NHS Digital

Reporting period

Annual

Geographical Coverage

England

Reporting level(s)

CCG and National

Based on data from

Office for National Statistics (ONS) CCG level extract of the birth characteristics data (linked birth registration and birth notification data) in England and Wales publication.

Contact Author Name

Pam Murray

Contact Author Email

pam.murray2@nhs.net

Rating

Fit for use

Assurance date

13/09/2018

Review date

7/05/2020

Indicator set

CCG Indicator Outcomes Set

Brief Description

[This appears as a blurb in search results]

This indicator measures the proportion of full-term live births with a low birth weight, per 100 live full-term births with a recorded birth weight that occur in the calendar year. The indicator will be reported at the national level, disaggregated by the Clinical Commissioning Group (CCG) of residence.

Purpose

Low birth weight is influenced by maternal lifestyle issues such as smoking and wider maternal health including pre-eclampsia and high blood pressure. Effective maternity services commissioned by Clinical Commissioning Groups (CCGs) can identify and address such issues within pregnancy either directly or by referral. Many of the services that would be the subject of such referrals would also fall within CCG commissioning responsibilities.

Even where the relevant service is not commissioned by a CCG, for example, smoking cessation, the identification and referral of women with a need for such support falls within the role of maternity services commissioned by CCGs.

If the number of full-term live births with a low birth weight within a CCGs area is disproportionately high, CCGs should consider the reasons for this and what actions as commissioners they should take to address it.

Definition

This indicator measures the proportion of full-term live births with a low birth weight, per 100 live full-term births with a recorded birth weight that occur in the calendar year. The indicator will be reported at the national level, disaggregated by the Clinical Commissioning Group (CCG) of residence.

This indicator uses an extract of data held by Office for National Statistics (ONS), where birth registration, notification, and death registrations have been linked. This data is used by ONS to publish low birth weight in the context of infant mortality in the Gestation-specific infant mortality in England and Wales statistical bulletin.

This indicator will use the same definitions as used in the ONS publication. The ONS defines a full-term birth as having a gestation length of greater than or equal to 37 weeks, a low birth weight is defined as being lower than 2,500g.

CCG level data will be aggregated from the Lower Super Output Area (LSOA) of the mother’s home postcode. This will result in the distribution of activity being aggregated based on the resident population of the CCG, as opposed to the usual convention in the CCG Outcomes Indicator Set (OIS) of using the registered population, which is based on GP Practice.

Data Source

Office for National Statistics (ONS) CCG level extract of the birth characteristics data (linked birth registration and birth notification data) in England and Wales publication.

Numerator

Of the denominator, the number with low birth weight

Denominator

The number of full-term live births with a recorded birth weight that occur in a calendar year, by Clinical Commissioning group (CCG) of residence.

Calculation

This indicator is calculated by dividing the numerator by the denominator and multiplying by 100 to provide a percentage indicator value. 95% confidence intervals are then calculated using the Wilson Score method.

Interpretation Guidelines

A low percentage of babies born at a gestational age of greater than or equal to 37 weeks and with a birth weight of less than 2,500g is desirable.

Caveats

It is possible that births that take place at home without a midwife present may suffer from recording issues. However, the percentage of births that take place at home is relatively low. In England and Wales, it was 2.4% in 2011. The proportion of these that took place without a midwife is thought to be small.

The low birth weight figure may be influenced by the number of multiple births, which are known to have a lower birth weight than singleton births.

Application form

Section

Overview

Title

Low birth weight full-term babies

Set or domain

Clinical Commissioning Group Outcomes Indicator Set (CCG OIS)

Topic area

Maternity

Definition

This indicator measures the proportion of full-term live births with a low birth weight, per 100 live full-term births with a recorded birth weight that occur in the calendar year. The indicator will be reported at the national level, disaggregated by CCG of Residence.

This indicator uses an extract of data held by Office for National Statistics (ONS), where birth registration, notification, and death registrations have been linked. This data is used by ONS to publish low birth weight in the context of infant mortality in the Gestation-specific infant mortality in England and Wales statistical bulletin.

This indicator will use the same definitions as used in the ONS publication. The ONS defines a full-term birth as having a gestation length of greater than or equal to 37 weeks, a low birth weight is defined as being lower than 2,500g.

CCG level data will be aggregated from the Lower Super Output Area (LSOA) of the mother’s home postcode. This will result in the distribution of activity being aggregated based on the resident population of the CCG, as opposed to the usual convention in the CCG OIS of using the registered population, which is based on GP Practice.

Indicator owner & contact details

Alison Roe, Senior Service Delivery Manager, HSCIC

ccgois@hscic.gov.uk

Publication status

Not currently in publication

Rationale

Sponsor

Jeff Featherstone, Programme Lead; Commissioning Outcomes and Incentives, NHS England

Purpose

Low birth weight is influenced by maternal lifestyle issues such as smoking and wider maternal health including pre-eclampsia and high blood pressure. Effective maternity services commissioned by CCGs can identify and address such issues within pregnancy either directly or by referral. Many of the services that would be the subject of such referrals would also fall within CCG commissioning responsibilities. Even where the relevant service is not commissioned by a CCG - for example, smoking cessation - the identification and referral of women with a need for such support falls within the role of maternity services commissioned by CCGs. If the number of full-term live births with a low birth weight within a CCGs area is disproportionately high, CCGs should consider the reasons for this and what actions as commissioners they should take to address it.

This indicator is currently published at national, region, and upper tier local authority level within the Public Health Outcomes Framework (PHOF) indicator 2.01, Low birth weight of term babies; however, this has not been disaggregated at CCG level.

Endorsement

N/A

Evidence base

Babies that are born weighing less than 2,500g are considered to have a low birth weight1, this is regardless of their gestational age. It is estimated that 1 in 14 babies in the UK are born with a low birth weight; this is higher than the average for EU15 and EU 27 countries2.

A number of factors are thought to be related to a low birth weight, these include, genetics, smoking during the pregnancy3, drinking more than a moderate amount of alcohol per day during the pregnancy4, living in an area of income deprivation5, and ethnicity6.

A low birth weight is associated with immediate and longer-term health consequences for babies. Babies born weighing just below the birth weight threshold (2,000g to 2,500g) are five times as likely to die as an infant than those of normal birth weight, and a low birth weight can affect the babies cognitive development8.

1 Determinants of low birth weight: methodological assessment and meta-analysis, World Health Organisation, 1987, http://apps.who.int/iris/bitstream/10665/51680/1/bulletin_1987_65%285%29_663-737.pdf?ua=1

2 Healthy Lives, Healthy People: Our strategy for public health in England, Department of Health, July 2011, https://www.gov.uk/government/publications/healthy-lives-healthy-people-our-strategy-for-public-health-in-england

3 Genetic variation in the 15q25 nicotinic acetylcholine receptor gene cluster (CHRNA5–CHRNA3–CHRNB4) interacts with maternal self-reported smoking status during pregnancy to influence birth weight, Human Molecular Genetics, August 2012, http://hmg.oxfordjournals.org/content/early/2012/09/17/hmg.dds372.full

4 Dose–response relationship between alcohol consumption before and during pregnancy and the risks of low birthweight, preterm birth and small for gestational age (SGA)—a systematic review and meta-analyses, BJOG: An International Journal of Obstetrics & Gynaecology, July 2011, http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2011.03050.x/full

5 Area deprivation, individual factors and low birth weight in England: is there evidence of an "area effect''?, Journal of Epidemiology and Community Health, April 2006, http://openaccess.city.ac.uk/1283/1/Area%20deprivation%2C%20individual%20factors %20and%20low%20birth%20weight%20in%20England.pdf

6 Birthweight and gestational age by ethnic group, England and Wales 2005: introducing new data on births, ONS, August 2008, http://www.ons.gov.uk/ons/rel/hsq/health-statistics-quarterly/no--30--summer-2006/risk-factors-for-low-birthweight-based-on-birth-registration-and-census-information--england-and-wales--1981-2000.pdf

7 Live births, Stillbirths and Infant Deaths: Babies Born in 2009 in England and Wales, Office for National Statistics, June 2012, http://www.ons.gov.uk/ons/rel/vsob1/birth-cohort-tables--england-and-wales/2009/stb-bct-2009.html

Birthweight, postnatal growth and cognitive function in a national UK birth cohort, International Journal of Epidemiology, October 2001, http://ije.oxfordjournals.org/content/31/2/342.full

Policy base (or NICE quality standard), related national incentives or critical business question

This indicator aims to reflect the provision of high quality care as set out in the NICE Quality Standard for Antenatal care (QS22)9 and the NICE Quality Standard for Caesarean section (QS32)10.

These Quality Standards have Quality Statements that refer to assessment of factors that can influence the birth weight of a baby; if these assessments identify a risk; advice to counter these risks is given.

This topic has been included in the Department of Health Business Plan within the context of addressing issues of premature mortality, avoidable ill health, and inequalities in health, particularly in relation to child poverty11.

1 Quality standard for antenatal care, NICE, September 2012, http://www.nice.org.uk/guidance/QS22

2 Quality standard for caesarean section, NICE, June 2013, http://www.nice.org.uk/guidance/qs32

Department of Health Business Plan, Cabinet Office, June 2013, http://transparency.number10.gov.uk/business-plan/3/63

Set or domain rationale, if appropriate

The CCG OIS is an integral part of NHS England’s systematic approach to quality improvement. It is intended to provide clear, comparative information for CCGs, patients and the public about the quality of health services commissioned by CCGs and the associated health outcomes. All of the CCG outcomes indicators have been chosen on the basis that they contribute to the overarching aims of the five domains in the NHS Outcomes Framework and it is intended as a tool for CCGs to drive local improvement and set priorities http://www.england.nhs.uk/ccg-ois/

This indicator fits within Domain 1 of the CCG OIS: Preventing people from dying prematurely.

Data source

ONS. http://www.ons.gov.uk/

The data is taken from an extract of data held by ONS, where birth registration, notification, and death registrations have been linked. This data is used by ONS to publish low birth weight in the context of infant mortality in the Gestation-specific infant mortality in England and Wales statistical bulletin.

Justification of source and others considered

ONS is the official source for birth information and is the only producer of National Statistics on gestation-specific infant mortality in England and Wales. This data source contains data on the number of babies born by gestation length and birth weight.

The ONS publication ‘Gestation-specific Infant Mortality in England and Wales’ contains information on the gestation length and birth weight of babies born. This data source is also used by the PHOF indicator 2.01, Low birth weight of term babies.

No other data sources were considered for this indicator.

Data availability

The underlying record level data is not publicly available. The statistical bulletin and aggregated tables for a given calendar year are published annually about 22 months after the end of the reference year at the following link: http://www.ons.gov.uk/ons/rel/vsob1/child-mortality-statistics--childhood--infant-and-perinatal/index.html.

Special extracts and tabulations of data from the Gestation specific infant mortality in England and Wales statistical bulletin are available to order for a charge (subject to legal frameworks, disclosure control, resources and agreements of costs, where appropriate). Such enquiries should be made to:

Mortality Team,

Health and Life Events Division,

Office for National Statistics,

Cardiff Road,

Newport.

NP10 8XG

Tel: +44 (0)1633 445 898

Email: cim@ons.gsi.gov.uk

ONS have confirmed that CCG level data can be provided for this indicator. However, CCG level data will be aggregated from the Lower Super Output Area (LSOA) of the mother’s home postcode. This will result in the distribution of activity being aggregated based on the resident population of the CCG, as opposed to the usual convention in the CCG OIS of using the registered population, which is based on GP Practice.

CCG level data for 2013 can be requested from ONS from October 2015 using the above extract process. This indicator is due to be included as part of the 2015-16 CCG OIS.

Data quality

ONS birth statistics are based on actual registrations provided by the General Register Office (GRO). These data represent the legal record, making it the best and most complete data source. These data are then supplemented by linking the birth registration to the birth notification (using NHS Numbers for Babies) in order to obtain birth weight data.

All births in England and Wales must be registered within 42 days of occurrence. As well as details of the birth (date, sex, single or multiple birth), information is also collected about the parents for the public register and for statistical purposes, such as the mother’s usual residence and her age at the time of the baby’s birth. Information is collected about the father if the parents are married or if the father is present at the registration (known as joint registration).

The accuracy of the information contained in the draft birth entry is the responsibility of the informant; wilfully supplying false information may render the informant liable to prosecution. It is believed that in general the information supplied is correct. As part of the birth registration process, before data are submitted through the Registration Online system, the registrar asks the informant to verify all the data entered are accurate. The registrar is then able to correct any errors. There are some validation checks built into the registration system to aid the registrar with this process.

In England and Wales in 2011, 173 births that occurred in 2010 were included, 17 births that occurred in 2009 were excluded. ONS has linked birth registrations with NHS birth notification records to allow reporting by gestational age and birth weight. 719,624 of 723,978 (99.4%) records are linked successfully, suggesting that completeness of this dataset is very good.

Despite this, not all births are recorded with a valid birth weight and gestational age, completion of these fields may differ regionally. Gestation length is not routinely recorded at birth registration in England and Wales, the opportunity to obtain this data was provided in 2002 with the introduction of the NHS Numbers for Babies (NN4B) system. Gestation specific data has only been reported by ONS since 2006.

In England and Wales in 2011, gestation length was not recorded for 4,621 (0.6%) live births, 4,525 (0.6%) births with a known gestational age had no birth weight recoded, and 77 births had an inconsistent gestation length and birth weight (gestational length of less than 22 weeks and a birth weight of more than 1,000g). When these data quality exclusions have been considered, the number of live births recorded falls from 719,624 to 710,401 (98.7%).

NN4B is only contracted to run until December 2014, after which equivalent services in the Personal Demographic Service (PDS) will be used. The NHS Number for Babies service is working with suppliers to migrate systems to PDS. Suppliers without a compatible system after NHS Numbers for Babies has concluded will need to revert to a manual birth notification process, which may have implications on the quality of the data.

Transferring this functionality into PDS means that an NHS number will continue to be issued to all new born babies, usually within one hour of birth, supporting seamless care across all NHS organisations. The Birth Notification Application that will be used by organisations that do not migrate to PDS will be used in the event of system failure or if the mother does not have an NHS Number. The feed that supplies data to ONS is the same regardless of which system is used.

If data quality is considered low, is an aim of the indicator to drive up data quality?

No

If yes, please outline the data quality improvement plan below:

Quality assurance

When birth registrations are received by ONS, a number of checks are carried out on records to ensure that they are valid. Checks are more frequent on those records with extreme values for key variables (such as age of mother and age of father) as these have a greater impact on published tables. For example, when looking at multiple births, checks are carried out to ensure that the number of triplets is divisible by three and that there is one maternity recorded for each set of triplets. Any birth records, which appear questionable, are raised with the GRO on a monthly basis for further investigation.

Births Metadata, http://www.ons.gov.uk/ons/guide-method/user-guidance/health-and-life-events/births-metadata.pdf, provides detailed information on the registration, collection and quality of births data in England and Wales.

As part of the production process for this indicator, the national figures reported will be checked against figures from other publications where ONS is the data source, such as the PHOF indicator. In addition, as further years of data are published they will be checked to determine whether the change is in line with changes seen previously. Investigation into the source of any issues will be conducted where necessary.

Data linkage

Birth registration, notification, and death registration data is linked and aggregated to LSOA level by ONS before the extract is provided to HSCIC. The linked data contains details of the gestation length and birth weight of the baby which is not available as part of the birth registration alone.

Quality of data linkage

ONS receives birth notifications data from the NHS for linkage with birth registration records for statistical purposes. The registrar links the birth notification to the registration details at the time of registration. This linkage creates a unique sequence number which is used by ONS to re-link the records for this cohort. A small number of records require ONS to use a probabilistic linkage where this unique identifier is not available. Records linked probabilistically are matched on a number of key variables including the baby's date of birth, the mother’s date of birth and postcode of usual residence of the mother.

Registration data on all deaths occurring in England and Wales are held by ONS. Routine linkage of birth records to death registration records identifies those babies who died before their first birthday. For babies born in 2011, 719,624 live birth registration records were successfully linked to their birth notification records; this represents 99.4% of the registration records of live births (723,978). Of these records 1,443 (0.2%) were probabilistically linked. 3,609 stillbirths were also directly linked to their birth notification using the sequence number, while 104 (2.8%) records were linked probabilistically. For infant deaths, 2,973 death registrations (99.1%) were successfully linked to their corresponding birth record.

Data fields

ONS will provide pre-calculated denominator and numerator volumes at CCG of Residence level from the birth and birth notifications data. The following fields will be provided to the HSCIC:

CCG of Residence code

CCG of Residence name

Denominator - The number of full-term live births with a recorded birth weight that occur in a calendar year, by CCG of Residence.

Numerator - Of the denominator, the number with low birth weight.

Data filters

The data included is the number of full-term live births with a recorded birth weight, and the number of these births with a low birth weight.

The source data includes all births and infant deaths registered as occurring in the year, linked to birth notification and death registration data.

Births where the gestational length or birth weight was not known and births where the gestation length was inconsistent with the birth weight are excluded. Only births that occurred in an English LSOA will be included.

A full-term baby is defined as having a gestation length of greater than or equal to 37 weeks; low birth weight is defined as weighing less than 2,500g.

Justifications of exclusions & how these adhere to standard definitions

The standard definition of a full-term birth in the UK is having a gestation length of greater than or equal to 37 weeks12. This definition is used in the PHOF indicator 2.01 Percentage of all live births at term with low birth weight13.

Further to this definition is post-term, which includes babies born at 42 weeks and over. This distinction is made in the ONS Gestation-specific Infant Mortality in England and Wales publication14. This indicator will include post-term babies in the data, as they have reached term.

Babies born at full-term are used as the denominator for this indicator as babies born before the term date are more likely to be under weight. In 2011, 61.3% of babies born with a low birth weight were pre-term, 92.8% of babies born with a birth weight of 2,500g or over are born at term. If the indicator was not limited to babies born at full-term, the activity volumes may be driven by the number of births born pre-term rather than low birth weight.

The standard definition of low birth weight is less than 2,500g. This is used by the World Health Organisation (WHO)15, Organisation for Economic Cooperation and Development (OECD)16, the PHOF 2.01 Percentage of all live births at term with low birth weight13 indicator, and the ONS Gestation-specific Infant Mortality in England and Wales publication14.

3 You and your baby at 37-40 weeks pregnant, NHS Choices, February 2013, http://www.nhs.uk/conditions/pregnancy-and-baby/pages/pregnancy-weeks-37-38-39-40.aspx

4 Public Health Outcomes Framework, 2.01 - % of all live births at term with low birth weight, Public Health England, August 2014, http://www.phoutcomes.info/public-health-outcomes-framework#gid/1000042/pat/6/ati/102/page/6/par/E12000004/are/E06000015

5 Gestation-specific Infant Mortality in England and Wales, 2011, ONS, October 2013, http://www.ons.gov.uk/ons/rel/child-health/gestation-specific-infant-mortality-in-england-and-wales/2011/index.html

6 Low birthweight: country, regional and global estimates, WHO, 2004, http://whqlibdoc.who.int/publications/2004/9280638327.pdf

Infant health: Low birth weight’, in Health at a Glance: Europe 2012, OECD, November 2012, http://dx.doi.org/10.1787/9789264183896-12-en

Data processing

The numerator and denominator data at CCG level is provided to HSCIC by ONS. The percentage for each CCG is calculated by HSCIC using the calculation presented in section 4.3.

Numerator

Of the denominator, the number with low birth weight.

Denominator

The number of full-term live births with a recorded birth weight that occur in a calendar year, by CCG of Residence.

Computation

The percentage p is given by:

where:

O is the numerator; the number of babies in the denominator with a birth weight of less than 2,500g;

n is the denominator; the number of full-term live births with a gestational age of greater than or equal to 37 weeks, with a recorded birth weight.

Risk adjustment or standardisation type

None

Justification of risk adjustment type

It is proposed to not risk adjust or standardise this indicator.

This indicator is commonly reported without risk adjustment by ONS (the data source) and in the PHOF indicator on which this is based. Data will be provided to the HSCIC in an aggregated form, risk adjustment for this indicator would require patient level data which will be subject to a Data Sharing Agreement,

It is accepted that there could be value in standardising this indicator, as there are various non-modifiable factors that could influence birth weight. It would be technically possible to standardise this indicator, but difficult due to data access issues. It has been decided on balance, in order to maintain consistency with convention, to not standardise this indicator.

Risk adjustment variables and methodology

N/A

Justification of risk adjustment variables

N/A

Confidence interval / control limit use

Confidence Intervals

Confidence interval / control limit methodology

Using the Wilson Score method17,18, the 100(1– α)% confidence limits are given by:

where:

q is 1–p;

z is the 100(1– α /2)th percentile value from the Standard Normal distribution.

For example, for a 95% confidence interval, α = 0.05 and z = 1.96 (i.e. the 97.5th percentile value from the Standard Normal distribution)19.

Reference

17. Wilson EB. Probable inference, the law of succession, and statistical inference. J Am Stat Assoc 1927; 22: 209–12.

18. Newcombe RG, Altman DG. Proportions and their differences. In Altman DG et al. (eds). Statistics with confidence (2nd edn). London: BMJ Books; 2000: 46–8.

19. Eayres D. Technical Briefing 3: Commonly used public health statistics and their confidence intervals. York: APHO; 2008. Available at http://www.apho.org.uk/resource/item.aspx?RID=48457

Contextual information provided alongside indicator

PHOF indicator 2.01 Percentage of all live births at term with low birth weight could be used for contextual information. This could be included as a link in the indicator metadata.

Justification of contextual information

PHOF indicator 2.01 presents the same information contained in this indicator, but at national, region, and upper tier local authority level. This information can be used to provide contextual information.

Calculation and data source of contextual information

N/A

Use of bandings, benchmarks or targets

None

Justification of bandings, benchmarks or targets used

This indicator is presented without a target or ranking. If a CCG believes their figure to be disproportionately high, the factors contributing to this can be investigated and appropriate action can be taken.

Banding, benchmark or target methodology, if appropriate

N/A

Evidence of variability

The below figures are taken from PHOF indicator 2.01 Percentage of all live births at term with low birth weight publication. CCG level data for 2013 can be requested from ONS from October 2015.

At the national level in 2011, there were 627,369 eligible live births (full-term and having a recorded birth weight), of which 17,855 were recorded as having a birth weight of lower than 2,500g in England in 2011. When this is broken down into 150 upper tier local authorities (Isles of Scilly has been merged with Cornwall and City of London has been merged with Hackney due to small numbers), the number of eligible births ranges from 301 to 16,224. The number of low birth weight babies ranges from 7 to 729. It is possible that these differences are being influenced by the differing ethnicity make ups in each area.

Although figures at CCG of Residence level are not currently available, it can be inferred from this data that the numbers will generally be of a smaller volume, due to 211 CCGs covering the same area as 150 upper tier local authorities.

 

Level Description

Indicator Value (%)

Lower CI

Upper CI

Denominator

Numerator

UA1

York

1.6

1.1

2.3

1,933

31

UA2

Herefordshire

1.6

1.1

2.3

1,724

28

UA3

North Somerset

1.8

1.3

2.4

2,099

37

UA4

East Sussex

1.8

1.5

2.2

4,962

90

UA5

North East Lincolnshire

1.9

1.3

2.6

1,832

34

UA6

Bracknell Forest

1.9

1.3

2.8

1,457

28

UA7

Darlington

1.9

1.3

2.9

1,193

23

UA8

Redcar and Cleveland

1.9

1.2

3.1

826

16

UA9

Surrey

2

1.7

2.2

13,039

256

UA10

Wokingham

2

1.4

2.7

1,679

33

 

Level Description

Indicator Value (%)

Lower CI

Upper CI

Denominator

Numerator

UA141

Tower Hamlets

4.1

3.5

4.7

4,032

164

UA142

Redbridge

4.3

3.7

4.9

4,205

179

UA143

Blackburn with Darwen

4.3

3.5

5.2

2,147

92

UA144

Brent

4.3

3.8

5.0

4,775

207

UA145

Harrow

4.4

3.7

5.2

3,139

138

UA146

Newham

4.4

3.9

5.0

5,394

238

UA147

Leicester

4.6

4.0

5.2

4,852

221

UA148

Birmingham

4.6

4.3

5.0

15,776

729

UA149

Oldham

4.6

3.9

5.5

2,957

137

UA150

Luton

5.3

4.6

6.1

3,227

171

It would be expected that 95% of data points would be within the 2 standard deviations of the England figure (denoted by Average on the chart above). However, of the 150 upper tier local authorities, 62 (41.3%) are outside the 2 standard deviations limit. This proportion may be reduced through standardisation of the data; however this will go against convention.

Section

Overview

Interpretation guidelines

A low percentage of babies born at a gestational age of greater than or equal to 37 weeks and with a birth weight of less than 2,500g is desirable.

This indicator requires careful interpretation and should not be viewed in isolation, but instead be considered alongside information from other indicators and various sources. When evaluated together, these will help provide a more holistic view of CCG outcomes and provide a more complete overview of the impact of the CCGs processes on outcomes.

When interpreting the results of this indicator, it is important to bear in mind the population makeup of the CCG, as the differing socio-economic and ethnic makeup may influence the reported figures.

Examples of other indicators include PHOF 2.01 ‘Percentage of all live births at term with low birth weight’ and publications from ONS such as the Gestation-specific infant mortality in England and Wales statistics.

Limitations and potential bias

It is possible that births that take place at home without a midwife present may suffer from recording issues. However, the percentage of births that take place at home in England and Wales was 2.4% in 2011. The number of these that took place without a midwife is thought to be small.

A number of factors can influence birth weight; these include ethnicity and social economic status. These factors are not taken into account as part of this indicator, meaning that the number of babies born with a low birth weight at CCGs may be in part due to the differing makeups of ethnicity and social economic status.

The low birth weight figure may be influenced by the number of multiple births. This issue is lessened due to the fact that fewer than half of all twin births go beyond 37 weeks, and hardly any triplet births go beyond this stage20. Overall in England and Wales in 2011, there were 22,796 multiple births, compared to 696,828 singleton births. If this figure is limited to those born at full-term, it reduces to 10,501 (46.1%). For comparison, 623,596 (89.5%) singleton births are born at full-term (these figures are not limited to those with a recorded birth weight). As the multiple births are expected to be born pre-term and the relatively small number of multiple births that occur at full-term, it is recommended to retain these cases in the indicator. This will allow for consistency with the source publication and the PHOF indicator on which this is based.

These limitations will be included in the indicator metadata.

Giving birth to twins or more. NHS Choices, March 2014, www.nhs.uk/conditions/pregnancy-and-baby/pages/giving-birth-to-twins.aspx

Presentation of indicator

The indicator will be presented on the HSCIC Indicator Portal in a consistent format to other CCG OIS indicators. It will be accompanied by an indicator specification and quality statement.

The data is presented with a detailed header including information on the statistic presented, the reporting period, level of coverage, publication date, data source and any further notes to be aware of. The customer is also able to make use of drop-down filtering.

The specific fields presented in the data will be as follows:

· Reporting Period - The period that the data relates to.

· Breakdown - National (Resident in England), CCG of Residence

· Level - CCG of Residence Code

· Level Description - CCG of Residence Name

· Percentage - Percentage of live babies born at full-term with a valid birth weight recorded who weighed less than 2,500g.

· Lower CI - Lower confidence interval

· Upper CI - Upper confidence interval

· Denominator - The number of full-term live births, born at a gestational age greater than or equal to 37 weeks with a valid birth weight recorded.

· Numerator - Of the denominator, the number of babies born that weighed less than 2,500g.

Risks and usefulness

Similar existing indicators

A similar indicator is currently published at national, upper tier local authority and county level within the Public Health Outcomes Framework (PHOF indicator 2.01, Percentage of all live births at term with low birth weight).

Differences between proposed and existing indicators

This indicator is to enable comparison on the levels of low birth weight babies between CCGs.

It does not overlap with any other indicator in the IAS Repository. It is linked to the ‘Neonatal mortality and stillbirths’ and ‘admission of full-term babies to neonatal care’ indicators that have also been proposed for inclusion into the CCG OIS for 2015/16. These indicators also use ONS birth data.

Coherence and comparability

The methodology is mostly consistent with that of PHOF 2.01. Both indicators use the number of live births born with a gestational age greater than or equal to 37 weeks with a recorded birth weight in England.

The PHOF indicator is presented differently to the present CCG OIS indicator. The PHOF indicator is reported at upper tier local authority, region, and national level, whereas the CCG OIS indicator will be presented at CCG and national level.

Figures will be checked against the source extract and national level figures will be checked with the PHOF indicator.

Undesired behaviours and/or gaming

Improvement actions

This indicator requires careful interpretation and should not be viewed in isolation, but instead be considered alongside information from other indicators and alternate sources. CCGs can use this indicator in context to identify if improvements are needed in their delivery of service, further investigation will be required in order to determine what, where and how these services should improve, leading to the desirable outcome of an decrease in the number of full-term babies with a birth weight of less than 2,500g.

If a CCG would like to reduce the number of full-term babies born with a low birth weight, it may consider commissioning additional services that are in accordance with NICE Quality Standards 22 and 32.

Approach to indicator review

The time period for when the indicator is to be reviewed will be set by the Indicator Governance Board (IGB). This indicator will be reviewed by the HSCIC Clinical Indicators team in accordance with this timeframe.

User feedback and comments on the indicator are welcomed via HSCIC Enquiries enquiries@hscic.gov.uk or the HSCIC CCG OIS mailbox ccgois@hscic.gov.uk.

Disclosure control

‘Guidance on disclosure control of birth and death registration data’ published by ONS states that disclosure control for the year 2013 onwards is only applicable to populations below 5,000, where values of 0, 1, and 2 are suppressed. Populations of 5,000 and over are not subject to disclosure control. The population in this case refers to the denominator of live births at term, with a recorded birth weight.

Data will be received from ONS with the suppression in place.

Copyright

Users reproducing ONS content should include a source accreditation to ONS – Source: Office for National Statistics, licensed under the Open Government Licence v1.0.

Indicator Assurance Extension Cover Sheet

Date

07/05/2018 

1.  

There is evidence that IGB assured the indicator to a period ending 1st January 2016 or after 

Yes 

 

2.  

Are there any outstanding caveats? List them here: 

 Indicator to be reviewed alongside:

· IAP00397 Neonatal mortality and stillbirths

Yes

3.  

Are there any changes to … 

a. Policy 

No 

b. Data source 

No 

c. Sponsoring organisation 

No 

d. Methodology 

No 

4.  

Are there any issues with data quality? 

No 

5.  

Has the indicator been superseded by another indicator? If yes, what is the new indicator’s reference number and title? 

No 

6.  

Has the indicator been withdrawn by the sponsoring organisation?  

No 

7.  

Are there any patient safety implications? 

No 

8.  

Have there been any complaints of risk associated with this indicator? 

No 

9.  

Primary category 

Pregnancy and neonates 

10.  

Publication reference 

 

Recommendation 

Fit for extension 

Prepared by 

Sue Slade 

IGB decision 

Fit for use

Accreditation period 

Two Years

IGB Approval date 

13/09/2018

Review date 

17/05/2020

Indicator Assurance

Appraisal Summary

Ref

IAP00398

Title

Low birth weight of term babies

Set / Framework

CCG Indicator Outcomes Set

Definition

This indicator measures the proportion of full-term live singleton births with a low birth weight, per 100 singleton live full-term births with a recorded birth weight that occur in the calendar year. The indicator will be reported at the national level, disaggregated by CCG of Residence.

This indicator uses an extract of data held by Office for National Statistics (ONS), where birth registration, notification, and death registrations have been linked.

CCG level data will be aggregated from the Lower Super Output Area (LSOA) of the mother’s home postcode. This will result in the distribution of activity being aggregated based on the resident population of the CCG, as opposed to the usual convention in the CCG OIS of using the registered population, which is based on GP Practice.

Purpose

Low birth weight is influenced by maternal lifestyle issues such as smoking and wider maternal health including pre-eclampsia and high blood pressure. Effective maternity services commissioned by CCGs can identify and address such issues within pregnancy either directly or by referral. Many of the services that would be the subject of such referrals would also fall within CCG commissioning responsibilities. Even where the relevant service is not commissioned by a CCG - for example, smoking cessation - the identification and referral of women with a need for such support falls within the role of maternity services commissioned by CCGs. If the number of full-term live singleton births with a low birth weight within a CCGs area is disproportionately high, CCGs should consider the reasons for this and what actions as commissioners they should take to address it.

Assurance Details:

Reviewing Body

HSCIC Indicator Assurance Service

Application Date

05/01/2015

Peer Review

Reviewers:

No peer review undertaken at present

Methodological Review

Review Group

HSCIC Methodology Review Group (MRG)

Discussion Dates

15/01/2015,

Minutes Available

Yes

Appraisers:

Chris Roebuck (Chair)

HSCIC, Director, Benefits and Utilisation

Chris Dew

PHE Programme Manager, Clinical Indicators

Paul Fryers

HSCIC Deputy Director, East Midlands Knowledge and Intelligence Team

Jonathan Hope

HSCIC Section Head, Statistical Response Unit

Paul Iggulden

HSCIC Interim Head of Clinical Analysis, Research & Development

John Sharp*

HSCIC Head of Data Quality

Julie Stroud (chair)

HSCIC Interim Head of Profession (Statistics)

Conflicts of interest: None Declared

Indicator Governance Board

Discussion Dates

24/03/15, 07/05/2015

Minutes Available

Yes, Yes

Summary of Assurance Discussions

Methodology Review:

Statement of Recommendation

15/01/15 – MRG felt that this was a good indicator and would recommend it for inclusion in the Library on the condition that evidence of significant variability is supplied and minor changes to the application form are made.

27/02/15 – MRG pre-meet update: Chair of MRG was satisfied with the changes made to the application and felt there was enough variation for the indicator to be of use.

Indicator Governance Board:

Review Period Set

3 Years

Rationale

It was agreed the indicator (including multiple births) be assured for a period of 3 years. However, the applicants should review the effect of excluding multiple births on the results as CCG level data becomes available, reporting back to IGB if significant variance is identified. These results should be included as part of the future review considerations. As the indicator follows the methodology used in an equivalent PHOF indicator, both indicators should be reviewed together.

Level of Assurance

[determined at meeting]

Assured

Basis of Decision

It was agreed the indicator (including multiple births) be assured for a period of 3 years. However, the applicants should review the effect of excluding multiple births on the results as CCG level data becomes available, reporting back to IGB if significant variance is identified. These results should be included as part of the future review considerations. As the indicator follows the methodology used in an equivalent PHOF indicator, both indicators should be reviewed together.

Sign-off Date

07/05/2015

NICE inherited this indicator and all its supporting documentation from NHS Digital on 1 April 2020

1

IAP00075 Supporting documentationCopyright © 2019 NHS Digital1

Appraisal Log

No

Issue or recommendation

Raised By/Date

Action Status* Assigned

Response / Action taken (if appropriate)

Response date

Resolved

Checked by / Date

Criterion: CLARITY

1a

It would be desirable to make clear throughout the documentation, but specifically in the numerator and denominator, that the resident population is being used for this indicator, as opposed to the registered population that is usually used in the CCG OIS.

MRG

15/01/15

Recommended

Updated references to CCG to CCG of Residence and updated references to National to National (Resident in England), where applicable.

17/02/15

MRG Chair27/02/15

1b

Some typos were identified which would be forwarded to the applicant.

MRG

15/01/15

Recommended

The definition section has been reworded in accordance with the comments made on the Neonatal Mortality and Stillbirths indicator. A number of slight amendments have been made throughout the document based on comments received.

17/02/15

MRG Chair27/02/15

Criterion: RATIONALE

2a

IGB asked for a clearer rationale of why the indicator is to be produced and what organisations are meant to do with them. In the instance IGB members felt the specific purpose was too vague to assess the appropriateness of excluding multiple births.

IGB

24/03/15

Required

The rationale used in the application is provided by Jeff Featherstone (Programme Lead; Commissioning Outcomes and Incentives, NHS England)

The indicator is to provide information to CCGs on their low birth weight rates so they can determine whether they need to amend their commissioning practice.

The rationale for the equivalent PHOF indicator on which this indicator has been based aims to reflect inequalities in lifestyle issues of mothers and/or issues with maternity services.

This NICE rationale for this CCG OIS indicator aims to provide an indication of maternal health and development factors in new born babies.

15/04/15

Criterion: DATA

3a

Clarity is needed on completeness of gestational age and the applicant is asked to revisit section 3.4 (Data Quality) to ensure the accuracy of the statement “gestational length is not routinely collected…”. MRG would like to see a percentage completeness for gestational age.

MRG

15/01/15

Required

This statement has been clarified to state that gestation length is not recorded at the birth registration but is available through linkage to the NHS Numbers for Babies (and the Patient Demographic Service replacement), which was available from 2002 and has been reported by ONS since 2006. Percentages have been added to figures.

17/02/15

MRG Chair27/02/15

3b

An update is required regarding the migration of data collection following the close of Numbers for Babies to assure the group that this will not cause a problem.

MRG

15/01/15

Required

The NHS Numbers for Babies migration team has been contacted and have confirmed that the data supplied to ONS will be the same, regardless of the system used.

17/02/15

MRG Chair27/02/15

Criterion: CONSTRUCTION

4a

MRG recommended excluding twins from the indicator, due to their legitimate lower birth weight and differing rates of IVF (increasing risk of twins) across the country. The applicant is asked to approach ONS in the first instance to check feasibility. Work will have to be shared with PHE as it will affect the corresponding PHOF indicator(s).

MRG

15/01/15

Recommended

ONS have stated that it is possible to remove multiple births from the indicator. The data filter and limitation sections of the document have been updated to reflect this.

17/02/15

MRG Chair27/02/15

4b

Members of IGB challenged the rationale to exclude multiple births from the indicator on the basis that more understanding was required as to the purpose of the indicator, for instance if the purpose of the indicator is simply for information then why would they be taken out? (see point 2a)

IGB

24/03/15

Required

As per recommendation 2a

15/04/15

Criterion: INTERPRETATION

5a

MRG noted the information provided by the applicant as evidence of variability (form section 5.7), however felt it did not sufficiently demonstrate significant variability in the indicator. It was appreciated by the Group that the current paperwork does not make it explicitly clear that this is the intent of the form and apologised to the applicant.

It was put forward that it is likely there is significant variance however this needed to be evidenced. It was identified that this should be through the provision of a funnel plot.

If variability is not identified, the indicator will require further consideration at a future MRG meeting.

If significant variability is identified, MRG are content that the indicator would not require further discussion on this point by the group.

In addition, the information provided in section 7 of the form should be deleted to avoid confusion.

MRG

15/01/15

Required

Confidence intervals have been added to the table.

A funnel plot has been added to this section.

17/02/15

MRG Chair27/02/15

5b

It is worth stressing throughout the interpretation section the effect ethnicity can have on results and that this should be considered when interpreting results.

MRG

15/01/15

Recommended

References have been added to this section stating that low birth weight may be influenced by ethnicity and socio-economic factors.

17/02/15

MRG Chair27/02/15

5c

It was determined that as a general rule where issues are identified which result in discussion around whether to exclude or not, information around the subject of exclusion should be provided and presented as contextual information. In this case it would be easier for users to interpret the indicator if they were able to see information on multiple births (on the basis that they are excluded from the main indicator) if they were to be presented as additional information. Alternatively, the indicator could be presented including multiple births with a contextual indicator showing the results excluding them.

IGB

24/03/15

Recommended

This information will be provided in future if possible, although the applicant is unable to provide the information at present (in support of the application) without the requirement to commission an extract of CCG level data.

15/04/15

5d

It was suggested that the results being presented (in section 5.7 of the application form) appear to represent a non-normal distribution. Members asked whether MRG had determined whether other statistical process that may present a more “normal” distribution had been considered in the development process. Members noted that similar issues had been raised as part of the assessment of the Summary level Hospital Mortality Indicator (SHMI), e.g. in terms of how the developers approached over dispersion and suggested the outcomes of those discussion may provide learning in this instance.

IGB

24/03/15

Recommended

The inclusion of a funnel plot in the application was provided with the purpose of demonstrating variability in the indicator. It is not the intention to publish the funnel plot as part of the final product.

15/04/15

Criterion: RISKS AND USEFULNESS

6a

MRG felt that the information contained in Section 6.4 regarding undesired behaviours and/or gaming was unnecessary.

MRG

15/01/15

Recommended

This information has been removed,

17/02/15

MRG Chair27/02/15

6b

IGB need to understand the rationale and purpose of the equivalent PHOF indicator, as the implication of having exclusions in one indicator that are not in the other is either there is a clear difference in purpose or the other indicator is wrong.

IGB

24/03/15

Required

The rationale for the PHOF indicator is as follows:

“Low birth weight increases the risk of childhood mortality and of developmental problems for the child and is associated with poorer health in later life. At a population level there are inequalities in low birth weight and a high proportion of low birth weight births could indicate lifestyle issues of the mothers and/or issues with the maternity services.

This indicator is in line with the Government's direction for public health on starting well through early intervention and prevention. It has also been included in the Department of Health Business Plan within the context of addressing issues of premature mortality, avoidable ill health, and inequalities in health, particularly in relation to child poverty”

Taken from: http://www.phoutcomes.info/public-health-outcomes-framework#gid/1000042/pat/6/ati/102/page/6/par/E12000004/are/E06000015

The CCGOIS is intended to align with the PHOF indicator and as to provide information to CCGs on their low birth weight rates in order that they can determine whether they need to amend their commissioning practice.

15/04/15

6c

IGB members recommended a useful way to resolve the concern around excluding multiple births would be to see the results presented for both approaches (including and excluding). If the results are not significantly different it was suggested that it would seem less sensible to exclude multiple births and therefore introduce inconsistency in approach with other frameworks.

IGB

24/03/15

Required

CCG level figures are not currently available for analysis until October 2015. A special extract from ONS ahead of this time would incur charges.

National level data currently available shows:

· In England and Wales in 2011, multiple births accounted for 3.2% of total births (696,828 singleton births, compared to 22,796 multiple births).

· Multiple births are often delivered pre-term and as such would be removed by the filters already in place on this indicator.

· When the multiple births figure is limited to those born at full-term, it reduces to 10,501 (46.1% of total multiple births).

· For comparison, 623,596 (89.5%) of singleton births are delivered at full-term.

In response to the MRG recommendation to exclude twins from the indicator due to their legitimate lower birth weight and differing rates of IVF (increasing risk of twins) across the country, it is assumed that this follows the hypothesis that rates of IVF treatment are typically higher in affluent areas. However, the results presented in section 5.7 of the application would seem to indicate that a number of the Local Authorities reporting the lowest scores are areas with low levels of deprivation. However, the Local Authorities reporting the highest proportions of full-term live births with a low birth weight are those that typically have higher levels of deprivation. In addition, these Local Authorities also tend to have above average populations who’s ethnicity is South-East Asian, suggesting that the main confounders for the indicator are Deprivation and Ethnicity.

On this basis it is proposed to retain multiple births in the indicator. This will allow the present indicator to remain consistent with the PHOF indicator on which is has been based.

In both indicators reference is made to low birth weight may be influenced by ethnicity and socio-economic factors.

15/04/15

*The description of the states given to each recommendation are as follows:

Action required: The group concerned is of the opinion that the indicator is not ready to go into the library of Quality Assured Indicators, based on the point raised.

Action recommended: The group concerned recommend action is undertaken in the particular area in order to increase the quality and rating of the indicator, however, do not feel this would prevent its inclusion in the Library of Quality Assured Indicators.

See our accessibility statement if you’re having problems with this document.

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England, 2.8

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Upper tier local authority

% low birth weight

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2SD 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full-term births with a recorded birth weight

Cases as a Percentage of Population