WHA National Collaborative

Reducing harm from third and fourth degree perineal tears 

Women’s Healthcare Australasia is currently conducting a National Collaborative Improvement Project in partnership with the NSW Clinical Excellence Commission (CEC), and with the support of Safer Care Victoria and the Clinical Execellence Division of Queensland Health.

The aim of the Collaborative is reducing by 20% the number of women harmed by a third or fourth degree tear by the end of 2018. This unique partnership brings together experts in improvement science with maternity clinicians and leaders who are passionate about improving outcomes for women.

The National Collaborative draws on improvement methodologies developed by the US Institute for Healthcare Improvement  which have been shown to achieve significant and sustainable improvements in patient safety. The Collaborative commenced in November 2017 and is providing participating teams with intensive support and coaching to reliably implement a bundle of evidence based practices aimed at reducing harm to women from third and fourth degree tears.

Teams from twenty six maternity services from tertiary to rural across Queensland, New South Wales, Victoria, South Australia and Western Australia are participating..  Teams are receiving regular coaching and support to reliably implement a bundle of evidence based practices known to reduce risk harm from tears.  Each team is being supported to undertake small scale changes in their Birth Suite with the aim of quickly identifying successful strategies for improvement.  Access to an online CEC data portal to collect and analyse data on both care processes and outcomes will facilitate rapid cycle tests of change based on real time data. Facilitated discussions with peers are also being used to accelerate change, to hold the gains and embed practices in a manner that will ensure lower rates of harm from tears well beyond the life of this improvement project.


Enrolled Hospitals can access resources and information on the Collaborative improvement pages in the CEC data portal.  


Why is WHA focusing on 3rd or 4th degree perineal tears?

WHA consulted with a range of member groups during October and November 2016, to seek their advice on what the highest priority problem might be on which it would be useful to focus a collaborative improvement project.  This work culminated with the decision was taken to start with a Collaborative focused on reducing harm from 3rd & 4th degree perineal tears.

Third & fourth degree perineal tears can have a lifelong impact on women's physical, psychological & social health and wellbeing. There is clear evidence that some WHA member hospitals are succeeding in minimising this harm to women, and that their success is not simply the underreporting of harm.  WHA is keen to facilitate sharing of learning to assist all member hospitals to minimise this harm to women.

Approximately 73% of women giving birth vaginally experience varying degrees of tear in Australia (AIHW, 2015a). While grazes, first and second degree tears of the anterior vaginal wall are usually associated with little to no morbidity for women, injury to the posterior vaginal wall, muscles or anal sphincter can present an array of physical and psychological morbidities for women many months or years after childbirth (Frohlich & Kettle, 2015).

During 2014, 3.1% (n=6,365) of women having a vaginal birth in Australia experienced a third or fourth degree tear (AIHW, 2016). Women’s Healthcare Australasia (WHA) data for 2016/17 reports that 3.54% (n=3,310) of women experienced a third or fourth perineal degree tear (WHA, 2017). What is of interest is the variation in rates of 3rd and 4th degree tears across hospitals within Australia, and that research has indicated that the rate of severe tears is rising (Priddis, et al., 2013).  

Hospitals supporting more than 500 births per annum participating in the WHA Benchmarking Maternity Care program for 2016/17 reported rates of 3rd and 4th degree tear ranging between 1.3% and 5.6%, with an average of 3.86%.  For hospitals supporting fewer than 500 births per annum the rates varied from 0% to 10%, with an average of 2.51%. Rates of third and fourth degree tear also vary by level of maternity care. Level 1-5 hospitals report an average rate of 3.37%, and level 6 (tertiary) hospitals report an average of 3.86%.


What is a Breakthrough Collaborative?

This project is drawing upon the methodology for collaborative improvement developed over many years by the Institute for Healthcare Improvement (IHI) in the US, and successfully employed by hospitals in Scotland, the UK, the US and other places, to achieve sustained improvements in patient care. For some examples of the use of this methodology & its results overseas see: the Scottish Patient Safety Program.

The IHI describes a breakthrough collaborative as a process that typically involves multiple hospitals working together over a 12-18 month period to support the reliable application of existing knowledge about best practice to a problem of common interest to the group so as to improve patient care and outcomes.  Their methodology usually involves at least 3 face to face Learning Sessions spread over about a 12 month period, plus regular exchange of data and insights between these meetings as each hospital tests its own theories on how best to implement the changes needed to achieve and sustain improvement.

The key criteria to choose the topic for any collaborative are:

  • That the problem affects a significant number of patients or involves significant harm to patients
  • There is a gap between what we do and what the evidence tells us we should be doing
  • There are known, evidence based interventions or changes that, if consistently used, will improve outcomes for women
  • The processes and outcomes are able to be reliably measured
  • There is a business case to make investing in collaborative improvement worthwhile

The IHI is clear that a Breakthrough Collaborative is a resource intensive tool that is not well suited to all improvement problems.  Its strength as a methodology is that it focuses on spread and adaptation of existing knowledge about best practice care to multiple settings to accomplish a common aim – in our case reducing harm to women from 3rd or 4th degree tears.  It is designed to achieve sustained improvement embedded in organisational culture and systems. Teams that participate report feeling buoyed by the momentum of regular peer & expert support to strive for and achieve improved outcomes for patients over the short and longer term.


Response to Rachel Reed ' The Perineal Bundle Midwifery'

Women’s Healthcare Australasia would like to thank Dr Rachel Reed for her blog: https://midwifethinking.com/…/the-perineal-bundle-and-midw…/ This article outlines current work being undertaken by WHA and participating hospitals to reduce rates of third and fourth degree perineal tears in Australia.

WHA welcomes midwives’ interest in reducing the numbers of women in Australia affected each year whose health and wellbeing is affected by the harms associated with third & fourth degree perineal tears.

In response to her blog and social media posts, we would like to direct the Women’s Healthcare Community to view WHA’s response via the following link: https://women.wcha.asn.au/media-release-response-rachel-reed-perineal-bundle-midwifery