Beyond the Benchmark: Three Specialist Societies Call for Better Birth Governance

NASOG, together with the Colorectal Surgical Society of Australia and New Zealand and the Urological Society of Australia and New Zealand, has released a joint position statement on severe obstetric perineal injury, together with recommendations to the Australian Commission on Safety and Quality in Health Care calling for stronger governance and independent external review when maternity services become outliers.

If a woman's risk of sustaining a major birth injury changes substantially depending on the hospital in which she gives birth, we need to understand why. Not to apportion blame — to actually look.

This is not a concern held by obstetricians alone. Our colleagues in colorectal surgery and urology share it, particularly regarding the governance response when a maternity service becomes an outlier.

Recent national newspaper headlines have highlighted substantial variation in rates of third- and fourth-degree perineal injury between Australian maternity services. There are legitimate reasons outcomes vary. Maternal age, BMI, diabetes and other medical complexities are changing.

But changing patient risk cannot be the end of the conversation. We also need to ask whether clinician, hospital and system factors are contributing to what we are seeing.

If we are serious about understanding why outcomes differ, we need considerably more detail about what is happening during birth:

• Who actually has their hands on the baby's head at birth?

• Is the perineum being managed hands-on or hands-off?

• Who is conducting the birth — a student, junior clinician, midwife, trainee or specialist?

• Was it an instrumental birth, or was a non-instrumental birth undertaken in a particular birth position?

• Was an episiotomy performed and, if so, what technique was used and who performed it?

• How long had labour continued, and was labour managed in accordance with recommended timeframes?

• What other maternal or neonatal complications occurred?

• Have clinical practices within the unit changed over time?

• When a hospital develops an unusually high rate of major perineal injury, does the organisation recognise it within a reasonable timeframe and have the governance structures necessary to respond promptly?

These are not questions intended to blame individual clinicians. Individual clinicians often work within systems they did not design, with staffing, supervision and resources they do not control. Good governance means understanding both what happened at the birth and the system in which that birth occurred.

From robust to antifragile

There is an interesting comparison at the other end of the reproductive journey.

Australian fertility medicine has built genuinely robust systems of quality assurance, accreditation and outcome reporting — and, importantly, has translated that information into something patients can actually use.

Through the Australian Government-funded YourIVFSuccess website, patients can enter their own characteristics and receive an individualised estimate of their chance of having a baby through IVF based on Australian treatment data. They can also examine success rates across Australian IVF clinics.

Think about what that represents. We have taken complex national reproductive data, independently analysed it and turned it into meaningful information Australians can use when making healthcare decisions.

Birth data should aspire to the same standard of transparency and usefulness.

Leadership within the Fertility Society of Australia and New Zealand has itself acknowledged that even a strong profession should not simply be permitted to mark its own homework.

Through the National Fertility Roadmap, the sector has also recognised the need for stronger governance, safety and transparency.

That evolution is now continuing. Australia is moving from an industry-led accreditation system towards independent national accreditation of assisted reproductive technology services through the Australian Commission on Safety and Quality in Health Care, while existing regulatory responsibilities continue during the transition.

That is significant. A sector that already had sophisticated data, accreditation and quality systems has still been prepared to ask whether its governance could be stronger.

That principle should extend across reproductive healthcare.

The next step beyond robustness is an antifragile healthcare system: one that becomes stronger when weaknesses are exposed. Identifying a problem should not make the person identifying it the problem.

We do not shoot the messenger; we examine the message.

Which raises an uncomfortable question about maternity benchmarking in Australia: where is the external review?

Hospitals collect their own data. Networks compare themselves with other networks. Public services benchmark against public services. Private groups benchmark across their own groups. All of this has value, but who independently looks at the results when something appears wrong?

At what point does benchmarking become another form of marking our own homework?

The danger of measuring the wrong thing

In my previous President's Blog, I discussed postpartum haemorrhage as a possible early indicator that a maternity service may be under pressure. Blood-product utilisation is measurable in close to real time, and an unexpected increase could potentially identify a unit requiring review or additional resources long before national statistics become available.

A colleague subsequently gave me an important cautionary example. They described an attempt to use blood-product utilisation for a similar purpose. The response was not necessarily correction of the underlying problem. Instead, visibility of the blood-product data to clinicians was reduced and transfusion practices changed, including greater utilisation of iron infusion.

The blood-transfusion rate fell, but the underlying rate of postpartum haemorrhage — and the causes driving it — remained unchallenged and unchanged.

If we measure only the response to an adverse outcome, rather than the adverse outcome itself and what caused it, we can improve the metric without improving safety.

When a metric becomes the target, there is a danger that we change the metric rather than change the safety outcome.

So how do we look beyond a tear?

Australia has the data. The problem is using it.

Australia collects an extraordinary amount of information about childbirth. Hospitals collect it, states and territories collect it, and much of it ultimately contributes to national reporting.

The problem is timeliness and accessibility.

For an external researcher, accessing detailed maternity data can require ethics approval, applications to individual state and national data custodians and lengthy approval and linkage processes. National reporting also comes with an inevitable delay. Where access to restricted datasets is granted, governments and data custodians may retain approval requirements around publication.

The result is that important information about the health outcomes of Australian mothers and babies can take years to become publicly visible.

The recent Callander study illustrates the problem simply: when it was published in 2025, the most recent births analysed were from 2019 — already more than five years old.

That is not a criticism of the researchers. It demonstrates the system they were working within.

We cannot wait five years to identify a problem in maternity care. The important point is that our hospitals already hold much of the information we need.

Look beyond the tear

There is a limit to what a headline rate of third- or fourth-degree tears can tell us.

Major perineal injury is recorded within the woman's hospital episode. For coded reporting purposes, that outcome follows the specialist obstetrician-gynaecologist under whom the patient is discharged. It does not necessarily follow the clinician who conducted the birth, and it is not an intention-to-treat measure of the care pathway through which the woman entered labour or birth.

A major perineal injury appearing against the discharging specialist's episode does not establish that the specialist had their hands on the baby's head when the injury occurred.

Many of the individual facts surrounding a birth are known. We can determine whether a woman transferred between services or locations. We know whether the birth was instrumental, whether an episiotomy was performed and who conducted the birth.

What we do not routinely do is bring those variables together with rates of major perineal injury and ask what associations exist.

When one maternity service has a substantially different major perineal injury rate from another, the number alone cannot explain why. We need to pair that outcome with patient risk factors and the clinician and hospital factors surrounding the birth: who conducted it and their level of experience, birth position, hands-on or hands-off perineal management, instrumental and episiotomy practices, labour duration, supervision, staffing and other relevant features of the service.

Only then can we start to understand why the rates differ.

The tear is the outcome. The important governance question is what factors are associated with it.

Alongside our joint position statement, NASOG, CSSANZ and USANZ have released specific recommendations to the Australian Commission on Safety and Quality in Health Care. Our message is simple: when a maternity service becomes an outlier for major perineal injury, look beyond the tear.

Examine patient risk factors, certainly. But examine what is happening inside the birth suite as well. Are instrumental birth or episiotomy practices changing? Are labour duration or birth positions changing? Who is conducting the births and what supervision is available? Are postpartum haemorrhage, low Apgar scores, neonatal admissions or other adverse outcomes changing at the same time?

A pattern that is difficult to recognise when outcomes are viewed separately may become much clearer when they are considered together.

Our colorectal and urological colleagues share these concerns because major perineal injuries can ruin the remaining quality of life for a woman after childbirth. They can affect family planning, intimate relationships and sexual function, and result in faecal or urinary incontinence, pelvic organ prolapse, pelvic floor dysfunction and chronic pain.

These are not simply numbers recorded at discharge. For some women, they are lifelong injuries.

Beyond benchmarking

Benchmarking remains valuable, but it has limitations.

If you only look to your left and your right, and everybody is walking towards the same cliff, benchmarking tells you that you are keeping up. It does not tell you to stop walking.

A hospital may sit comfortably within its benchmark and still have an absolute outcome that warrants closer examination. Being similar to other services does not, by itself, establish that an outcome is acceptable.

Where is the independent external review sitting above the benchmarking system? Who looks beyond whether a hospital resembles its peers and asks whether the outcome itself is acceptable?

If the same organisations collect the data, benchmark the data and determine the response, we should be willing to ask: are we all just marking our own homework?

We should not need to become an outlier before we become curious.

Look at your own numbers

NASOG encourages every public and private maternity unit in Australia to examine its own outcomes over time — not just third- and fourth-degree tears, but the pattern underneath them.

This does not require an enormous research department. Ask a keen medical student looking for a worthwhile project. Ask a trainee needing an audit or quality-improvement activity. Bring obstetricians, midwives, urologists, colorectal surgeons and governance teams together and examine what is already sitting within your service.

If the information is being collected, use it. If it is not being collected, ask for it to be.

Look over three years. Look over five years. Look at absolute rates as well as benchmarks. Pair the outcome with the circumstances of the birth and ask whether anything is changing.

If the trend is reassuring, that is worth knowing. If it is not, it is better to know before the service becomes an outlier.

The question should not simply be, “Are we an outlier?”

It should be, “Are our outcomes changing — and do we understand why?”

Governance must ultimately serve the community

Independent review is not about finding someone to blame. It is about identifying what can be improved.

Governance is not blame, but nor should it mean inaction. Individual clinicians often work within systems they did not design, with staffing, supervision and resources they do not control. Good governance means recognising when outcomes are changing, asking why and ensuring the system responds appropriately and in a timely way.

Benchmarking is the beginning of governance, not the end of it. We should be able to ask whether an outcome is changing, what factors are associated with that change and what can be done differently.

But ultimately, this information should not belong only to hospitals, governments or researchers.

It should belong to the community.

Women should be able to understand their risk of a major, potentially life-altering birth injury when choosing a hospital or health service. As our data improves, they should also be able to understand whether their probability of injury differs according to relevant factors such as model of care, birth position, birth technique, instrumental delivery or other aspects of their care.

A statistic can never predict exactly what will happen to an individual woman. But meaningful probabilities allow people to make genuinely informed decisions.

We already accept this principle in fertility care. Through YourIVFSuccess, Australians can use their individual characteristics and national data to better understand the probability of success from fertility treatment.

Why should a woman have access to sophisticated outcome information when deciding where to conceive, but not when deciding where to give birth?

NASOG believes Australia should aspire to maternity data that is timely, independently scrutinised and sufficiently detailed to improve care inside our birth suites — and sufficiently transparent to inform the women and families who use them.

Look beyond the benchmark. Look beyond the tear. Understand what is associated with the outcome — and make that information available to the community whose lives depend upon it.

See the Position Statement and Recommendations