{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,3]],"date-time":"2026-06-03T06:30:37Z","timestamp":1780468237800,"version":"3.54.1"},"reference-count":53,"publisher":"BMJ","issue":"6","funder":[{"name":"NIHR PSTRC"},{"DOI":"10.13039\/501100014093","name":"Peter Sowerby Foundation","doi-asserted-by":"crossref","id":[{"id":"10.13039\/501100014093","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2017,4,13]]},"published-print":{"date-parts":[[2017,6]]},"abstract":"<jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>Obstetric care is a high-risk area in healthcare delivery, so it is essential to have up-to-date quantitative evidence in this area to inform policy decisions regarding these services. In light of this, the objective of this study is to investigate the incidence and economic burden of third and fourth-degree lacerations in the English National Health Service (NHS) using recent national data.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We used coded inpatient data from Hospital Episode Statistics (HES) for the financial years from 2010\/2011 to 2013\/2014 for all females that gave birth during that period in the English NHS. Using HES, we used pre-existing safety indicator algorithms to calculate the incidence of third and fourth-degree obstetric tears and employed a propensity score matching method to estimate the excess length of stay and economic burden associated with these events.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Observed rates per 1000 inpatient episodes in 2010\/2011 and 2013\/2014, respectively: Patient Safety Indicator\u2014trauma during vaginal delivery with instrument (PSI 18)=84.16\u2009and 91.24; trauma during vaginal delivery without instrument (PSI 19)=29.78\u2009and 33.43; trauma during caesarean delivery (PSI 20)=3.61\u2009and 4.56. Estimated overall (all PSIs) economic burden for 2010\/2011=\u00a310.7 million and for 2013\/2014=\u00a314.5 million, expressed in 2013\/2014 prices.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Despite many initiatives targeting the quality of maternity care in the NHS, the incidence of third and fourth-degree lacerations has increased during the observed period which signals that quality improvement efforts in obstetric care may not be reducing incidence rates. Our conservative estimates of the financial burden of these events appear low relative to total NHS expenditure for these years.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2016-015463","type":"journal-article","created":{"date-parts":[[2017,6,12]],"date-time":"2017-06-12T20:10:18Z","timestamp":1497298218000},"page":"e015463","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":20,"title":["Estimating the incidence and the economic burden of third and fourth-degree obstetric tears in the English NHS: an observational study using propensity score matching"],"prefix":"10.1136","volume":"7","author":[{"given":"Martina","family":"Orlovic","sequence":"first","affiliation":[{"name":"Department of Surgery and Cancer, Faculty of Medicine, Institute of Global Health Innovation, Imperial College London, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alexander William","family":"Carter","sequence":"additional","affiliation":[{"name":"Department of Surgery and Cancer, Faculty of Medicine, Institute of Global Health Innovation, Imperial College London, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joachim","family":"Marti","sequence":"additional","affiliation":[{"name":"Department of Surgery and Cancer, Faculty of Medicine, Institute of Global Health Innovation, Imperial College London, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elias","family":"Mossialos","sequence":"additional","affiliation":[{"name":"Department of Surgery and Cancer, Faculty of Medicine, Institute of Global Health Innovation, Imperial College London, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2017,6,12]]},"reference":[{"key":"2025121221314678000_7.6.e015463.1","unstructured":"Vincent C . Patient safety London: Elsevier, 2006."},{"key":"2025121221314678000_7.6.e015463.2","unstructured":"WHO. Conceptual framework for the International classification for Patient Safety, Version 1.1, Final Technical Report January 2009. 3. Geneva, 2009."},{"key":"2025121221314678000_7.6.e015463.3","unstructured":"Kohn LT , Corrigan J , Donaldson MS . To Err is human: building a Safer Health System. Washington, D.C.: National Academy Press, 2000."},{"key":"2025121221314678000_7.6.e015463.4","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijnurstu.2013.12.007"},{"key":"2025121221314678000_7.6.e015463.5","doi-asserted-by":"publisher","DOI":"10.1097\/PTS.0b013e3181fd1a00"},{"key":"2025121221314678000_7.6.e015463.6","unstructured":"Darzi A . High quality care for all: NHS next stage review final report. London, 2008."},{"key":"2025121221314678000_7.6.e015463.7","unstructured":"HoCH C . Patient safety Sixth Report of session 2008\u201309. vol. 1. London, 2009."},{"key":"2025121221314678000_7.6.e015463.8","unstructured":"Kristensen S , Mainz J , Bartels P . Establishing a set of Patient Safety Indicators: safety Improvement for patients in Europe. Aarhus, Denmark, 2007."},{"key":"2025121221314678000_7.6.e015463.9","unstructured":"TKs Fund. Safe Births:\u00a0everybody\u2019s Business. An Independent Inquiry into the Safety of Maternity Services in England. London, 2008."},{"key":"2025121221314678000_7.6.e015463.10","doi-asserted-by":"crossref","first-page":"129","DOI":"10.1016\/j.ogc.2007.12.004","article-title":"Elements of a successful quality improvement and patient safety program in obstetrics and gynecology","volume":"35","author":"Gambone","year":"2008","journal-title":"Obstet Gynecol Clin North Am"},{"key":"2025121221314678000_7.6.e015463.11","doi-asserted-by":"crossref","first-page":"625","DOI":"10.1016\/j.bpobgyn.2007.02.004","article-title":"Anticipating and responding to obstetric emergencies","volume":"21","author":"Guise","year":"2007","journal-title":"Best Pract Res Clin Obstet Gynaecol"},{"key":"2025121221314678000_7.6.e015463.12","doi-asserted-by":"publisher","DOI":"10.1136\/qshc.2007.026096"},{"key":"2025121221314678000_7.6.e015463.13","doi-asserted-by":"crossref","DOI":"10.1136\/bmj.a1702","article-title":"Patient safety indicators for England from hospital administrative data: case-control analysis and comparison with US data","volume":"337","author":"Raleigh","year":"2008","journal-title":"BMJ"},{"key":"2025121221314678000_7.6.e015463.14","doi-asserted-by":"publisher","DOI":"10.1001\/jama.290.14.1868"},{"key":"2025121221314678000_7.6.e015463.15","unstructured":"Review NM . Better births\u2013improving outcomes of maternity services in England: a five year forward view for maternity care. London, 2016."},{"key":"2025121221314678000_7.6.e015463.16","unstructured":"Draper ES , Kurinczuk JJ , Kenyon S . MBRRACE-UK Perinatal Confidential Enquiry: term, singleton, normally formed, antepartum stillbirth: Leicester, 2015."},{"key":"2025121221314678000_7.6.e015463.17","unstructured":"HoCCoP A . Maternity services in England Fortieth Report of session 2013\u201314. London, 2014."},{"key":"2025121221314678000_7.6.e015463.18","doi-asserted-by":"publisher","DOI":"10.1136\/bmjqs-2012-001109"},{"key":"2025121221314678000_7.6.e015463.19","unstructured":"Hospital Episode Statistics. NHS Digital. 2016."},{"key":"2025121221314678000_7.6.e015463.20","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.329.7476.1207"},{"key":"2025121221314678000_7.6.e015463.21","unstructured":"OECD. Health at a glance: europe 2012. Paris 2012."},{"key":"2025121221314678000_7.6.e015463.22","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1111\/ajo.12014","article-title":"The case for retaining severe perineal tears as an Indicator of the quality of obstetric care","volume":"53","author":"Baghurst","year":"2013","journal-title":"Aust N Z J Obstet Gynaecol"},{"key":"2025121221314678000_7.6.e015463.23","unstructured":"AHRQ. Measures of Patient Safety based on Hospital Administrative Data \u2013 The Patient Safety Indicators.\u00a0Technical Review 5. Rockville, MD, 2002."},{"key":"2025121221314678000_7.6.e015463.24","doi-asserted-by":"publisher","DOI":"10.1111\/j.1475-6773.2008.00882.x"},{"key":"2025121221314678000_7.6.e015463.25","unstructured":"WHO. International statistical classification of diseases and related health problems. 10th revision. Geneva, 2011."},{"key":"2025121221314678000_7.6.e015463.26","unstructured":"WHO. ICD-10 Version:2016. Secondary ICD-10 Version:2016. http:\/\/apps.who.int\/classifications\/icd10\/browse\/2016\/en. 2016."},{"key":"2025121221314678000_7.6.e015463.27","unstructured":"Health and Social Care Information Centre. OPCS Classification of Interventions and Procedures Version 4.7. 2014."},{"key":"2025121221314678000_7.6.e015463.28","doi-asserted-by":"crossref","first-page":"474","DOI":"10.1097\/GCO.0b013e3282ef4142","article-title":"Delivery method, anal sphincter tears and fecal incontinence: new information on a persistent problem","volume":"19","author":"Wheeler","year":"2007","journal-title":"Curr Opin Obstet Gynecol"},{"key":"2025121221314678000_7.6.e015463.29","doi-asserted-by":"publisher","DOI":"10.1016\/j.ajog.2006.06.020"},{"key":"2025121221314678000_7.6.e015463.30","unstructured":"McLennan D , Barnes H , Noble M , et al . The English Indices of Deprivation 2010. London, 2011."},{"key":"2025121221314678000_7.6.e015463.31","doi-asserted-by":"publisher","DOI":"10.1245\/s10434-014-3785-4"},{"key":"2025121221314678000_7.6.e015463.32","doi-asserted-by":"publisher","DOI":"10.1093\/intqhc\/mzt088"},{"key":"2025121221314678000_7.6.e015463.33","doi-asserted-by":"publisher","DOI":"10.1542\/peds.2007-2831"},{"key":"2025121221314678000_7.6.e015463.34","doi-asserted-by":"publisher","DOI":"10.1093\/biomet\/70.1.41"},{"key":"2025121221314678000_7.6.e015463.35","first-page":"1","article-title":"Comparing propensity score methods in balancing covariates and recovering impact in small sample educational program evaluations","volume":"18","author":"Stone","year":"2013","journal-title":"Practical Assessment, Research & Evaluation"},{"key":"2025121221314678000_7.6.e015463.36","unstructured":"Department of Health. 2013\/14 Reference costs publication, 2014."},{"key":"2025121221314678000_7.6.e015463.37","unstructured":"Department of Health. 2010\/11 Reference costs publication, 2011."},{"key":"2025121221314678000_7.6.e015463.38","unstructured":"Department of Health. 2011\/12 Reference costs publication, 2012."},{"key":"2025121221314678000_7.6.e015463.39","unstructured":"Department of Health. 2012\/13 Reference costs publication, 2013."},{"key":"2025121221314678000_7.6.e015463.40","unstructured":"Personal Social Services Research Unit. Unit costs of Health and Social Care 2015. Canterbury, 2015."},{"key":"2025121221314678000_7.6.e015463.41","unstructured":"Knight H , Cromwell D , Van der Meulen J , et al . Patterns of maternity care in English NHS hospitals 2011\/12. London, 2013."},{"key":"2025121221314678000_7.6.e015463.42","unstructured":"Van Teijlingen ER , Lowis GW , McCaffery P . Midwifery and the medicalization of childbirth: comparative perspectives. New York: Nova Publishers, 2004."},{"key":"2025121221314678000_7.6.e015463.43","doi-asserted-by":"publisher","DOI":"10.1001\/archsurg.2010.241"},{"key":"2025121221314678000_7.6.e015463.44","doi-asserted-by":"publisher","DOI":"10.1177\/1077558707309611"},{"key":"2025121221314678000_7.6.e015463.45","doi-asserted-by":"publisher","DOI":"10.2307\/2286330"},{"key":"2025121221314678000_7.6.e015463.46","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0153370","article-title":"Establishing a National Maternal Morbidity Outcome Indicator in England: a Population-Based Study using Routine Hospital Data","volume":"11","author":"Nair","year":"2016","journal-title":"PLoS One"},{"key":"2025121221314678000_7.6.e015463.47","doi-asserted-by":"crossref","first-page":"126","DOI":"10.1186\/1471-2288-14-126","article-title":"Identifying complications of interventional procedures from UK routine healthcare databases: a systematic search for methods using clinical codes","volume":"14","author":"Keltie","year":"2014","journal-title":"BMC Med Res Methodol"},{"key":"2025121221314678000_7.6.e015463.48","doi-asserted-by":"crossref","first-page":"715","DOI":"10.1111\/j.1600-0412.2012.01398.x","article-title":"Long-term outcome after obstetric injury: a retrospective study","volume":"91","author":"Sundquist","year":"2012","journal-title":"Acta Obstet Gynecol Scand"},{"key":"2025121221314678000_7.6.e015463.49","doi-asserted-by":"crossref","first-page":"605","DOI":"10.1097\/01.gco.0000191901.69320.a0","article-title":"Short-term and long-term effects of obstetric anal sphincter injury and their management","volume":"17","author":"Fitzpatrick","year":"2005","journal-title":"Curr Opin Obstet Gynecol"},{"key":"2025121221314678000_7.6.e015463.50","doi-asserted-by":"crossref","unstructured":"Weledji EP , Elong A , Verla V . Secondary repair of severe chronic fourth-degree perineal tear due to obstetric trauma. J Surg Case Rep 2014;2014.doi:10.1093\/jscr\/rju034","DOI":"10.1093\/jscr\/rju034"},{"key":"2025121221314678000_7.6.e015463.51","doi-asserted-by":"crossref","first-page":"591","DOI":"10.1186\/s12913-014-0591-4","article-title":"Perinatal staff perceptions of safety and quality in their service","volume":"14","author":"Sinni","year":"2014","journal-title":"BMC Health Serv Res"},{"key":"2025121221314678000_7.6.e015463.52","unstructured":"TKs F , Births S . Supporting Maternity Services to Improve Safety - Report of ThreeRegional Events Held in York. London and Wigan, 2009."},{"key":"2025121221314678000_7.6.e015463.53","unstructured":"Sandall J , Homer C , Sadler E , et al . Staffing in Maternity Units: Getting the Right People in theRight Place at the Right Tim. London, 2011."}],"container-title":["BMJ Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjopen-2016-015463","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,12,13]],"date-time":"2025-12-13T05:31:56Z","timestamp":1765603916000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmjopen.bmj.com\/lookup\/doi\/10.1136\/bmjopen-2016-015463"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2017,6]]},"references-count":53,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2017,6,12]]},"published-print":{"date-parts":[[2017,6]]}},"alternative-id":["10.1136\/bmjopen-2016-015463"],"URL":"https:\/\/doi.org\/10.1136\/bmjopen-2016-015463","relation":{},"ISSN":["2044-6055","2044-6055"],"issn-type":[{"value":"2044-6055","type":"print"},{"value":"2044-6055","type":"electronic"}],"subject":[],"published":{"date-parts":[[2017,6]]}}}